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 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

Objectives. Nonunion is one of the most troublesome complications to treat in orthopaedics. Former authors believed that atrophic nonunion occurred as a result of lack of mesenchymal stem cells (MSCs). We evaluated the number and viability of MSCs in site of atrophic nonunion compared with those in iliac crest. Methods. We enrolled five patients with neglected atrophic nonunions of long bones confirmed by clinical examinations and plain radiographs into this study. As much as 10 ml bone marrow aspirate was obtained from both the nonunion site and the iliac crest and cultured for three weeks. Cell numbers were counted using a haemocytometer and vitality of the cells was determined by trypan blue staining. The cells were confirmed as MSCs by evaluating their expression marker (CD 105, CD 73, HLA-DR, CD 34, CD 45, CD 14, and CD 19). Cells number and viability were compared between the nonunion and iliac creat sites. Results. After three weeks, numbers of 6.08×10. 6. cells (. sd. 2.07) and 4.98×10. 6. cells (. sd. 1.15) were obtained from the nonunion site and the iliac crest, respectively, with viability of 87.1% (81.7% to 90.8%) and 89.8% (84.7% to 94.5%), respectively. No differences was found between the two sources of MSCs regarding cells number (p = 0.347) and viability (p = 0.175). Conclusions. Our findings showed the existence of MSCs in the site of atrophic nonunion, at a similar number and viability to those isolated from the iliac crest

Introduction. Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to attempt to treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity, and problems associated with potential graft harvest sites. Matrix associated stem cell transplantation (MAST) is one such treatment described for larger lesions >15mm2 or failed alternative therapies. This cohort study describes a medium-term review of the outcomes of talar lesions treated with MAST. Methods. A review of all patients treated with MAST by a single surgeon was conducted. Preoperative radiographs, MRIs and FAOS outcome questionnaire scores were conducted. Intraoperative classification was undertaken to correlate with imaging. Postoperative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment and progression to arthritis/fusion surgery. Results. 58 MAST procedures in 57 patients were identified in this cohort. The mean follow up was 5 years. There were 20 females and37males, with a mean age of 37 years (SD 9.1). 22 patients had lateral OCLS were and 35 patients had medial OCLs. Of this cohort 32patients had previous surgery and 25 had this procedure as a primary event. 15 patients had one failed previous surgery, 9 patients had two, four patients had three previous surgeries and three patients had four previous surgeries. 12 patients had corrective or realignment procedures at the time of surgery. In terms of complications 3 patients of this cohort went on to have an ankle fusion and two of these had medial malleolar metal work taken out prior to this, 5 patients had additional procedures for arthrofibrotic debridements, 1 patient had a repeat MAST procedure, 1 additional patients had removal of medial malleolar osteotomy screws for pain at the osteotomy site, there were 2 wound complications one related to the ankle and one related to pain at the iliac crest donor site. Conclusion. MAST has demonstrated positive results in lesions which prove challenging to treat, even in a “ failed microfracture” cohort. RCT still lacking in field of orthobiologics for MAST. Longer term follow up required to evaluate durability

Aims. The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria. Patients and Methods. Between January 2012 and January 2015, 14 consecutive patients were treated for an infected nonunion of the tibia with a gap and were included in the study. During stage one, a radical debridement of bone and soft tissue was undertaken with the introduction of an antibiotic-loaded cement spacer. At the second stage, the tibia was stabilized using a long lateral locked plate and a six-pin monorail fixator on its anteromedial surface. A corticotomy was performed at the appropriate level. During the third stage, i.e. at the end of the distraction phase, the transported fragment was aligned and fixed to the plate with two to four screws. An iliac crest autograft was added to the docking site and the fixator was removed. Functional outcome was assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. Patient-reported outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score. Results. The mean age of patients was 38.1 years (. sd. 12.7). There were 13 men and one woman. The mean size of the defect was 6.4 cm (. sd. 1.3). the mean follow-up was 33.2 months (24 to 50). The mean external fixator index was 21.2 days/cm (. sd. 1.5). The complication rate was 0.5 (7/14) per patient. According to the classification of Paley, there were five problems and two obstacles but no true complications. The ASAMI bone score was excellent in all patients. The functional ASAMI scores were excellent in eight and good in six patients. The mean MSTS composite score was 83.9% (. sd. 7.1), with an MSTS emotional acceptance score of 4.9 (. sd. 0.5; maximum possible 5). Conclusion. Composite fixation (rail-plate) decreases fixator time and the associated complications, in the treatment of patients of infected nonunion tibia with a segmental defect. It also provides good anatomical and functional results with high emotional acceptance. Cite this article: Bone Joint J 2018;100-B:1094–9

Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions. Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis. Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia

Background. The aim of the study was to assess the outcome of internal fixation using two ordinary plates with autogenous bone grafting in the management of non-union of femoral shaft fractures over a period of eleven years. Method. A retrospective study of double plating and autogenous bone grafting for un-united femoral shaft fractures performed by the two Senior Authors between 1996 and 2007. During this period, twenty-one cases were carried out. Details of preoperative, intra-operative, and postoperative findings were assessed. Postoperative follow up was recorded over a period of minimum two years. The procedure was performed using two ordinary plates; a broad lateral and narrow anterior plates. Autogenous cancellous grafts from iliac crest were used in all of the cases, and in some, half fibulas were inserted through the medullary canal of the femur. Results. A total of twenty-one patients were included in the study. All of them received previous treatment. The primary treatment was by intramedullary nailing in thirteen patients, uni-plating in four, external fixator in three, and traction in one. The average age was 32 (range from 16 to 52). The average interval between the initial fracture and the treatment of the non-unions was 13 months (range from 6 to 28 months). All wounds, both at fracture site and the graft donor site, healed primarily except one. That was at an iliac crest graft donor site, where superficial infection occurred, and was treated with antibiotics and healed 6 weeks later. All patients achieved union on an average of 16 weeks (range from 12 to 28 weeks). There has been no failure in implants. The average lower limb shortening was 0.75 cm (range from 0.5 to 1.0 cm). No one requested shoe raise. All the patients regained the preoperative range of motion at the hip and knee joints except four, who had limited flexion to 100 degrees. Conclusion. We conclude that double plating with autogenous bone grafting is not only a convenient method to treat non-union of femoral shaft fractures as it requires minimal instrumentation and equipment, but it should also be considered as a safe and accepted treatment method as postoperatively patients can be discharged early on crutches, with a high success rate. It is less expensive, an important consideration in developing countries

We treated 19 patients with established nonunion of the radius and/or ulna by the excision of avascular bone and the grafting of blocks of corticocancellous bone from the iliac crest, augmented by rigid plate fixation under compression. This allowed early mobilisation, and bony union was achieved between three and 24 months after operation in all but one of the patients. The single failure was attributed to the excessive length of the defect (100 mm) and inadequate fixation

Common cell based strategies for treating bone defects require time-consuming and expensive isolation and expansion of autologous cells. We developed a novel expedited technology creating gene activated muscle grafts. We hypothesized that BMP-2 activated muscle grafts provide healing capabilities comparable to autologous bone grafting, the clinical gold standard. Two male, syngeneic Fischer 344 rats served as tissue donors. Muscle tissue was harvested from hind limbs and incubated with an adenoviral vector carrying the cDNA encoding BMP-2. Bone tissue was harvested from the iliac crest. Segmental bone defects were created in the right femora of 12 rats and were filled with either BMP-2 activated muscle tissue or bone grafts. After 8 weeks, femora were evaluated by radiographs, microCT, and biomechanical tests. BMP-2 activated muscle grafts and autologous bone grafts resulted in complete mineralization and healing, as documented by radiographs and microCT. Bone volume in the muscle graft defects (33+/-12mm3) was similar to autologous bone graft defects (39+/-5mm3). Torque at failure of the two groups was statistically indistinguishable (240+/-115 Nmm vs. 232+/-108Nmm). In previous experiments we demonstrated that the large segmental defect model in this study will not heal with either empty defects or non-activated muscle grafts. Our findings therefore demonstrate that BMP-2 gene activation of muscle tissue effectively stimulates defect healing similar to autologous bone grafts

Introduction. Scaphoid nonunions remain controversial with regard to optimal management. The objective of this article is to compare our clinical experience in the treatment of patients with scaphoid nonunion using distal radius non vascularised bone graft with that of iliac crest bone graft. Material & Methods. We conducted a prospective randomized study comparing the clinical, functional and radiographic results of 42 patients treated for scaphoid nonunion using a non-vascularised bone graft from the dorsal and distal aspect of the radius (group I), relative to 46 patients treated by means of a conventional non-vascularised bone graft from the iliac crest (group II). All nonunions were stabilized with single Herbert screw. Results. Bone fusion was achieved in 87.1% of group I and 86.5% of group II patients. Functional results were good to excellent in 76.0% of the patients in group I and 72.5% in group II. The average grip power, as well as wrist flexion and extension were similar in both groups. However, the donor site morbidity was much higher in group II (4 cases of hematoma, 6 cases of chronic pain and 1 anterior superior iliac spine avulsion) fracture. No complication was seen in group I. Conclusion. We conclude that nonvascularized distal radius bone grafting yields similar union rate as well as functional outcome as compared to iliac crest bone graft with no donor site morbidity

Between 1993 and 1999, we treated ten patients with comminuted fractures of the olecranon by multiple tension-band wiring and a graft from the iliac crest. Their mean age was 35 years (19 to 56). The mean follow-up was for 28.5 months (15 to 46) and the mean time to union of the fractures was four months (3 to 7). No patient reported difficulties with activities of daily living or symptoms of instability of the elbow. The mean flexion was to 135° (125 to 145) with a mean flexion contracture of 15° (10 to 30). The mean pronation was 70° (60 to 80) and mean supination 79° (70 to 90). Only three patients had mild pain and loss of strength. Five patients had excellent and five good results with a mean Broberg and Morrey index score of 94.5 points (84 to 100). Our results compare favourably with those previously reported and the technique is thought to be a practical alternative to plate fixation in fractures with extreme comminution

Introduction. This study reports the results of percutaneous autologous bone marrow grafting in 62 patients with corticosteroids treatment who had one hip osteonecrosis treated with bone marrow (BM) injection and the other contralateral hip osteonecrosis with core decompression (CD) alone. Only patients with bilateral symptomatic osteonecrosis and with those hips at stage I or II (as defined by Steinberg) were included in this study. Material and Methods. Between 1988 and 1995, 62 consecutive patients (28 males and 34 females) were included in this study. These patients had a mean age of 31 years (range 18 to 34 years) at the time of the onset of symptoms. The average follow-up was 17 years (range, 15 to 20 years). An average of 152 + 16 milliliters of marrow was aspirated from the iliac crest. The number of stroma progenitor that was transplanted was estimated by counting the Fibroblast Colony Forming Units which express type I and type III collagen. The bone marrow graft obtained after concentration contained average 4889 + 716 progenitors per cubic centimeter (range 3515 to 6293 per cubic centimeter). Each hip received a mean number of thirty cubic centimeters of bone marrow graft (range 27 to 35 cubic centimeters). The average total number of CFU-F injected in each hip was therefore 147 × 103 cells (range 119 × 103 to 195 × 103 cells). Results. Clinical results were determined by the change in Harris hip scores from preoperative evaluation to the last follow-up visit, by the change in the radiographic progression and by the need of subsequent total hip arthroplasty. Bone marrow grafting afforded better reduction in pain, effected a reduction with time in the number of hips that progressed to collapse, and delayed the need for total hip replacement. Ten hips had collapsed and needed arthroplasty at the most recent follow-up after bone marrow grafting, compared to 45 after core decompression. For hips with collapse, the mean survival time before collapse was 71.2 months (43.35- 60.96; 95% CI) for the bone marrow graft group and 38.5 months for the control group (13.2–39.74; 95% CI). With the number available, there was a positive correlation (Spearman's test) between the duration of clinical survival before collapse and the number or concentration of CFU-F and CFU-GM in the graft in the CD group. These results are explained by the fact that bone marrow injection improved the repair process on MRI and on histology. Overall, 10 hips with bone marrow injection showed a total regression of the signal, 59 hips showed a partial reduction (42 with BM and 17 with CD) and 55 hips did not show a significant reduction (10 with BM and 45 with CD). Conclusion. Bone marrow grafting afforded better reduction in pain, reduction in the number of collapses, delayed the need for total hip replacement, and improved the repair process on MRI and on histology

Aims

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

Introduction. The combined incubation of a composite scaffold with bone marrow stromal cells in a perfusion bioreactor could make up a novel hybrid graft material with optimal properties for early fixation of implant to bone. The aim of this study was to create a bioreactor activated graft (BAG) material, which could induce early implant fixation similar to that of allograft. Two porous scaffold materials incubated with cells in a perfusion bioreactor were tested in this study. Methods and Materials. Two groups of 8 skeletally mature female sheep were anaesthetized before aspiration of bone marrow from the iliac crest. For both groups, mononuclear cells were isolated, and injected into a perfusion bioreactor (Millenium Biologix AG, Switzerland). Scaffold granules Ø∼900–1500 μm, ∼88% porosity) in group 1, consisted of hydroxyapatite (HA, 70%) with -tricalcium-phosphate (−TCP, 30%) (Danish Technological Institute, Denmark). The granules were coated with poly-lactic acid (PLA) 12%, in order to increase the mechanical strength of the material (Phusis, France). Scaffold granules Ø∼900–1400 μm, 80% porosity) in group 2 consisted of pure HA/-TCP (Fin Ceramica, Italy). For both groups, cells were incubated in the bioreactor for 2 weeks. Fresh culture medium supplemented with dexamethasone and ascorbic-acid was added every third or fourth day. Porous titanium alloy implants with diameter=length=10mm (Biomet, USA) were inserted bilaterally in each of the distal femurs of the sheep; thus 4 implants in each sheep. The concentric gap (2 mm) surrounding the implant was filled with 1) BAG (autogenous), 2) granules, 3) granules+bone marrow aspirate (BMA, autologous) or 4) allograft. The sheep were euthanized after 6 weeks. Distal femurs were removed and implant-bone samples were divided in two parts. The superficial part was used for mechanical testing and micro-CT scanning, and the profound part for histomorphometry. Push-out tests were performed on an 858 Bionix MTS hydraulic materials testing machine. Shear mechanical properties between implant and newly generated bone were calculated to assess implant fixation. Results were assessed by One-way ANOVA. P-values less than 0.05 were considered significant. Results. One sheep in group 1 had to be euthanized after 4 weeks (excluded). One implant in each group was loosened and could not undergo push-out test (excluded). Group 1: No significant differences regarding failure energy (kJ/m2, p=0.44) or ultimate shear strength (MPa, p=0.17) could be seen. Shear stiffness (MPa) was significantly higher for the allograft group (p=0.04). Group 2: No significant differences regarding failure energy (p=0.11) or shear stiffness (p=0.52) could be seen. Ultimate shear strength was significantly higher for allograft (p=0.04). Results from μ-CT scanning and histomorphometry are pending. Discussion and Conclusion. The present study shows a possible effect of bioreactor activated bone substitute on early implant fixation. We are currently working on bone microarchitecture surrounding implant and histomorphometry. These results will aid in determining if BAG could make up a promising alternative for allograft as bone graft material

Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

Aims

To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

Aims

This study describes the use of the Masquelet technique to treat segmental tibial bone loss in 12 patients.

Unstable pelvic injuries in young children with an immature pelvis have different modes of failure from those in adolescents and adults. We describe the pathoanatomy of unstable pelvic injuries in these children, and the incidence of associated avulsion of the iliac apophysis and fracture of the ipsilateral fifth lumbar transverse process (L5-TP). We retrospectively reviewed the medical records of 33 children with Tile types B and C pelvic injuries admitted between 2007 and 2014; their mean age was 12.6 years (2 to 18) and 12 had an immature pelvis. Those with an immature pelvis commonly sustained symphyseal injuries anteriorly with diastasis, rather than the fractures of the pubic rami seen in adolescents. Posteriorly, transsacral fractures were more commonly encountered in mature children, whereas sacroiliac dislocations and fracture-dislocations were seen in both age groups. Avulsion of the iliac apophysis was identified in eight children, all of whom had an immature pelvis with an intact ipsilateral L5-TP. Young children with an immature pelvis are more susceptible to pubic symphysis and sacroiliac diastasis, whereas bony failures are more common in adolescents. Unstable pelvic injuries in young children are commonly associated with avulsion of the iliac apophysis, particularly with displaced SI joint dislocation and an intact ipsilateral L5-TP.

Cite this article: Bone Joint J 2015; 97-B:696–704.

Objectives

Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs.

Aims

Recent studies of nonoperatively treated displaced midshaft clavicular fractures have shown a high incidence of nonunion and unsatisfactory functional outcome. Some studies have shown superior functional results and higher rates of healing following operative treatment. The aim of this study was to compare the outcome in these patients after nonoperative management with those treated with fixation.