4 years of follow-up study on 27 patients who had biological reverse total shoulder replacement 12 patients who had Bio-RSA by using Tonier Aequalis reversed implants with bone graft extracted from the head of humerus before humeral shaft was prepared. The average age of this group of patients is 77. The average pre-operative shoulder abduction on the affected side is 52 degrees and forward flexion of 90 degrees. Indication for surgery in all those cases are due to cuff tear. The average post-operative abduction is 90 degrees and forward flexion of 97 degrees. The average follow-up period is 9 months with a range from 4 to 18 months. Two patients from this group failed to make an improvement in the range of their shoulder movements post-operatively. 15 underwent Bio-RSA by using Delta XTEND reverse shoulder system without bone graft. The average age of this group of patients is 73. The average pre-operative shoulder abduction is 35 degrees and forward flexion of 37 degrees. Indication for surgery again in most of the cases is due to cuff tear, except one case was due to proximal humeral fracture. The average post-operative abduction is 96 degrees and forward flexion of 101 degrees. The average follow-up period is 19 months with a range of 4–42 months. Only one patient failed to make an improvement post-operatively. This is the patient who had Bio-RSA due to a proximal humeral fracture. 6 patients out of this group also had previous resurfacing which has failed in comparison to the bone graft group which none had previous resurfacing surgery. Conclusion. Overall, the average post-operative range of movements in both groups is not very significant different. Bio-RSA without bone graft seems to make a larger improvement when compared with per-operative range of motion. Howver, whether a much longer follow-up period and younger patients have an impact on the outcome is debatable

Aims. Large acetabular bone defects encountered in revision total hip arthroplasty (THA) are challenging to restore. Metal constructs for structural support are combined with bone graft materials for restoration. Autograft is restricted due to limited volume, and allogenic grafts have downsides including cost, availability, and operative processing. Bone graft substitutes (BGS) are an attractive alternative if they can demonstrate positive remodelling. One potential product is a biphasic injectable mixture (Cerament) that combines a fast-resorbing material (calcium sulphate) with the highly osteoconductive material hydroxyapatite. This study reviews the application of this biomaterial in large acetabular defects. Methods. We performed a retrospective review at a single institution of patients undergoing revision THA by a single surgeon. We identified 49 consecutive patients with large acetabular defects where the biphasic BGS was applied, with no other products added to the BGS. After placement of metallic acetabular implants, the BGS was injected into the remaining bone defects surrounding the new implants. Patients were followed and monitored for functional outcome scores, implant fixation, radiological graft site remodelling, and revision failures. Results. Mean follow-up was 39.5 months (36 to 71), with a significant improvement in post-revision function compared to preoperative function. Graft site remodelling was rated radiologically as moderate in 31 hips (63%) and strong in 12 hips (24%). There were no cases of complete graft site dissolution. No acetabular loosening was identified. None of the patients developed clinically significant heterotopic ossification. There were twelve reoperations: six patients developed post-revision infections, three experienced dislocations, two sustained periprosthetic femur fractures, and one subject had femoral component aseptic loosening. Conclusion. Our series reports bone defect restoration with the sole use of a biphasic injectable BGS in the periacetabular region. We did not observe significant graft dissolution. We emphasize that successful graft site remodelling requires meticulous recipient site preparation. Cite this article: Bone Jt Open 2022;3(12):991–997

Objective. To determine differences in fracture stability and functional outcome between synthetic bone graft and allograft/autograft with internal fixation of tibia plateau metaphyseal defects. Patient & Methods. Between 2007- 2008, 84 consecutive cases of internal fixation of tibia plateaux were identified from our theater logbook. 29 patients required additional autologous, allogenic bone graft, or synthetic bone graft substitute to ensure fracture stability. 5 patients were excluded due to lost to follow up leaving a cohort of 24 patients. Hydroxyapatite calcium carbonate synthetic bone graft was utilised in 14 patients (6 male and 8 female). Allograft/autograft were utilised in the remaining 10 patients (6 male and 4 female). All 24 patients had closed fractures, classified using the AO and Schatzker classification. Roentograms at presentation, post-operatively and regular follow-up till 12 months were analysed for maintenance of reduction, early and late subsidence of the articular surface. Functional outcomes such as knee range of movement and WOMAC Knee scores were compared between groups. Results. There was no significant statistical difference between groups for post-operative joint reduction, long term subsidence, and WOMAC scores. The degree of subsidence was not related to age or fracture severity. Maintenance of knee flexion was found to be better in the allograft/autograft group (p=0.015) when compared between groups. Multivariate analysis compared graft type, fracture severity, postoperative reduction, subsidence rate, range of movement and WOMAC score. The only finding was a statistical significant (p=0.025) association with the graft type and range of movement. Conclusion. Allograft/autograft may allow better recovery of long-term flexion, possibly due to reduced inflammatory response compared with synthetic bone graft. However, all other parameters such as maintenance of joint reduction and subjective outcome measures were comparable with the use of hydroxyapatite calcium carbonate bone graft. This study shows that synthetic bone graft is a suitable option in fixation of unstable tibia plateau fractures, avoiding risk of viral disease transmission with allograft and donor site morbidity associated with autograft

Introduction. The purpose of this study was to analyse the efficacy and complications associated with the use of Calcium Sulphate synthetic bone graft in a paediatric population. There are no published articles on the use in children. Materials & Methods. A retrospective review was undertaken of the notes, microbiology, and X-Rays of 17 cases (in 15 patients) of calcium sulphate use in paediatric patients. As well as patient demographic data, data collected included indication, use of additional agents (antibiotics), return to theatre, and wound complications. Major complications were also assessed for. Results. There were 17 cases, in 15 patients, in our case series where calcium sulphate synthetic bone graft was used. The average patient age was 12.0 years (range 5 years – 17 years). Indications for use included likely infection (12), possible infection (3), and 2 elective finger cases (enchondroma and osteotomy). The humerus was the most common target site (5), followed by the femur (4), tibia (3), calcaneum (2), finger (2) and metatarsal (1) also included. There were positive intra-operative microbiology samples for eleven cases (Staphylococcus aureus and Staphylococcus epidermidis). Antibiotics were used in all cases except the elective finger surgery, and choice ranged between vancomycin, gentamicin, or a combination of both. Two patients required return to theatre for management of ongoing deep infection, although one case was later deemed to be non-infective osteomyelitis. Seven patients had undergone debridements prior to the definitive one with calcium sulphate (5 without Calcium Sulphate, 2 with Calcium Sulphate). Three patients experienced wound issues in the form of discharge/leakage, all were managed with dressings and did not require return to theatre. Conclusions. Calcium Sulphate synthetic bone graft, with addition of antibiotics, is an efficacious treatment in the paediatric population and is not associated with any major complications. Wound discharge should be observed for, and patients/parents warned about this, but only as per the adult population

Aims. Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre. Methods. Included in this retrospective cohort study were 48 patients (12 females; mean age 55.79 years (SD 8.94)) who were diagnosed with cervical OPLL, received treatment in our centre, and were followed up for 10.22 to 15.25 years. Of them, 24 patients (six females; mean age 52.88 years (SD 8.79)) received ADF, and the other 24 patients (five females; mean age 56.25 years (SD 9.44)) received PLF. Clinical data including age, sex, and the OPLL canal-occupying ratio were analyzed and compared. The primary outcome was Japanese Orthopaedic Association (JOA) score, and the secondary outcome was visual analogue scale neck pain. Results. Compared with the baseline, neurological function improved significantly after surgery in all patients of both groups (p < 0.001). The JOA recovery rate in the ADF group was significantly higher than that in the PLF group (p < 0.001). There was no significant difference in postoperative cervical pain between the two groups (p = 0.387). The operating time was longer and intraoperative blood loss was greater in the PLF group than the ADF group. More complications were observed in the ADF group than in the PLF group, although the difference was not statistically significant. Conclusion. Long-term neurological function improved significantly after surgery in both groups, with the improvement more pronounced in the ADF group. There was no significant difference in postoperative neck pain between the two groups. The operating time was shorter and intraoperative blood loss was lower in the ADF group; however, the incidence of perioperative complications was higher. Cite this article: Bone Jt Open 2024;5(9):768–775

Aims. We wanted to evaluate the effects of a bone anabolic agent (bone morphogenetic protein 2 (BMP-2)) on an anti-catabolic background (systemic or local zoledronate) on fixation of allografted revision implants. Methods. An established allografted revision protocol was implemented bilaterally into the stifle joints of 24 canines. At revision surgery, each animal received one BMP-2 (5 µg) functionalized implant, and one raw implant. One group (12 animals) received bone graft impregnated with zoledronate (0.005 mg/ml) before impaction. The other group (12 animals) received untreated bone graft and systemic zoledronate (0.1 mg/kg) ten and 20 days after revision surgery. Animals were observed for an additional four weeks before euthanasia. Results. No difference was detected on mechanical implant fixation (load to failure, stiffness, energy) between local or systemic zoledronate. Addition of BMP-2 had no effect on implant fixation. In the histomorphometric evaluation, implants with local zoledronate had more area of new bone on the implant surface (53%, p = 0.025) and higher volume of allograft (65%, p = 0.007), whereas implants in animals with systemic zoledronate had the highest volume of new bone (34%, p = 0.003). Systemic zoledronate with BMP-2 decreased volume of allograft by 47% (p = 0.017). Conclusion. Local and systemic zoledronate treatment protects bone at different stages of maturity; local zoledronate protects the allograft from resorption and systemic zoledronate protects newly formed bone from resorption. BMP-2 in the dose evaluated with experimental revision implants was not beneficial, since it significantly increased allograft resorption without a significant compensating anabolic effect. Cite this article: Bone Joint Res 2021;10(8):488–497

Aim. This retrospective study evaluated the outcome of treatment for unhealed fracture-related infections (FRI). Methods. We identified a consecutive, single-centre cohort of patients having treatment for an FRI Consensus confirmed FRI. All fractures were unhealed at the time of treatment. Patients were followed up for at least one year. Successful outcome was a healed fracture without recurrent infection. Lack of union, persistent infection and/or unplanned reoperation defined failure. Results. Demographics: 183 patients (184 FRIs) with mean age 52.1 years (range 17-96) were treated and followed up for a mean of 2.8 years (range 1-9.4). Mean duration of FRI was 1.1 years with 65 (35.5 %) presenting within 6 months of injury. 118 patients had established infected non-union. FRI was most frequent in the tibia (74), femur (48) and humerus (24). 171 patients were BACH Complex. 75.5% of FRIs were culture positive, with Staph. aureus being the most frequent organism. Polymicrobial infection and Gram negative cultures were common (25.5% and 33.6%). Treatment: 98.3% of surgeries were performed in one stage with just 3 planned 2-stage procedures (2 endoprosthetic replacements and 1 free fibular flap). No bone graft was used in any surgery and all wounds were closed at first operation. 48 cases (26%) required flap coverage (29 free flaps and 19 local flaps). Local antibiotics were used in 124 cases (67.4%) of primary surgeries. All patients had sampling, debridement, systemic antibiotics and wound closure. 40 (21.7%) had DAIR, 31 (16.8%) had new internal fixation and 105 (57.1%) had external fixation (including 79 Ilizarov fixators). Outcomes: After primary surgery, 84.6% of all patients were infection-free and 77.2% had united. After further surgery, 98.8% were infection-free and 98.1% had united. External fixation techniques achieved infection eradication in 89.1% compared to 71.7% with any internal fixation (p=0.005). Primary internal fixation achieved union in 81.7% compared to 74.3% with external fixation (p=0.27). Secondary surgery after external fixation was mainly docking site fixation. Conclusion. Unhealed FRIs present a difficult challenge for treatment. This large series demonstrated that single-stage treatment, without bone grafting, gave acceptable results with few reoperations. Primary external fixation gave more certainty of infection eradication but required more reoperations to secure union. However, this difference in reoperation was not statistically significant. We strongly advocate managing these patients with a multidisciplinary team which can treat all aspects of the condition

Problems associated with allograft are well known. The addition of hydroxyapatite (HA) to allograft has various mechanical advantages, especially within revision arthroplasty. The mixing of bone and HA results in mechanical properties different from the individual parts. However, at present the changes in material properties the mix have not been fully investigated and the optimum mixing ratio not characterized. A compressive uniaxial chamber was used to investigate the change in mechanical properties occurring with the addition of HA in varying proportions to morcellised bone graft (MBG). Materials and methods. MBG was prepared using femoral heads donated from patients undergoing total hip replacement surgery using a bone mill in a standard manner. Non porous HA (npHA) was prepared using a precipitation method of Calcium Carbonate and Orthophosphoric acid. The porous HA, (pHA) is a 60% macroporosity HA commercially prepared. Chamber. The uniaxial compression chamber was a 30mm diameter, steel chamber. Holes were drilled to allow fluid drainage. Loads were applied using a 10 kN load cell. Specimens were prepared in the volumetric proportions pure HA, pure MBG, 2:1, 1:1, 1:2 ratio of MBG to HA. The samples were subjected to compressive forces of incrementally increasing loads of up to 2 KN for 60 cycles. The sample was then allowed to creep under a stress of 2 kN. MBG was also tested up to forces of 7 kN. The mechanical parameters that were examined were the stiffness of the sample at the 60th cycle, (Ec60), and creep. Statistical analysis. The different bone: HA mixes were compared by Mann Whitney U tests. The parameters analysed were the Ec60 and creep for the different mixes. All samples were also compared to MBG compacted with higher forces. Results. Apparent stiffness. The Ec60 of the MBG increased with increasing axial stress. The Ec60 of the different proportions of MBG and both npHA and pHA lay between the values of the MBG and HA individually and were significantly different from one another (p<0.05). MBG:npHA were significantly stiffer than the comparative mixes of MBG:pHA. (p<0.05). Creep rate. With increasing axial stress the creep rate for pure MBG decreased up to a precycling stress of 4 MPa. Subsequent increases in stress had no significant effect. Pure npHA and all of the mixes of MBG:npHA demonstrated significantly less creep than the comparable mixes of MBG:pHA (p=0.01). Applicability of results. The increase in apparent stiffness associated with an increase in the volume fraction of HA is accompanied by a concomitant decrease in the creep rate. Comparison of the mechanical response of the MBG at the high precycling stresses (4 - 7 MPa) to the mechanical response of the MBG:HA mixes at 3 MPa demonstrated an overlap in the mechanical response of the pure MBG at high stress and both the MBG:npHA and MBG: pHA mixes. Conclusions. Greater proportions of HA in the mix led to improvement in the mechanical response without the need for increased force of impaction. These improvements can be quantified by using a uniaxial compression test. The results raise the interesting possibility of tailoring bone graft mixtures to specific patient requirements dependent upon their weight and the quality of their bone stock

Biphasic calcium phosphate (BCP) with a characteristic needle-shaped submicron surface topography (MagnetOs) has attracted much attention due to its unique bone-forming ability which is essential for repairing critical-size bone defects such as those found in the posterolateral spine. Previous in vitro and ex-vivo data performed by van Dijk LA and Yuan H demonstrated that these specific surface characteristics drive a favorable response from the innate immune system. This study aimed to evaluate and compare the in vivo performance of three commercially-available synthetic bone grafts, (1) i-FACTOR Putty. ®. , (2) OssDsign. ®. Catalyst Putty and (3) FIBERGRAFT. ®. BG Matrix, with that of a novel synthetic bone graft in a clinically-relevant instrumented sheep posterolateral lumbar spine fusion (PLF) model. The novel synthetic bone graft comprised of BCP granules with a needle-shaped submicron surface topography (MagnetOs) embedded in a highly porous and fibrillar collagen matrix (MagnetOs Flex Matrix). Four synthetic bone grafts were implanted as standalone in an instrumented sheep PLF model for 12 weeks (n=3 bilateral levels per group; levels L2/3 & L4/5), after which spinal fusion was determined by manual palpation, radiograph and µCT imaging (based on the Lenke scale), range-of-motion mechanical testing, and histological and histomorphological evaluation. Radiographic fusion assessment determined bilateral robust bone bridging (Lenke scale A) in 3/3 levels for MagnetOs Flex Matrix compared to 1/3 for all other groups. For µCT, bilateral fusion (Lenke scale A) was found in 2/3 levels for MagnetOs Flex Matrix, compared to 0/3 for i-FACTOR Putty. ®. , 1/3 for OssDsign. ®. Catalyst Putty and 0/3 for FIBERGRAFT. ®. BG Matrix. Fusion assessment for MagnetOs Flex Matrix was further substantiated by histology which revealed significant graft resorption complemented by abundant bone tissue and continuous bony bridging between vertebral transverse processes resulting in bilateral spinal fusion in 3/3 implants. These results show that MagnetOs Flex Matrix achieved better fusion rates compared to three commercially-available synthetic bone grafts when used as a standalone in a clinically-relevant instrumented sheep PLF model

Aims. Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures. Methods. A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout. Results. Six studies involving 353 fractures were identified from 3,078 records. Following ROB2 assessment, five studies (representing 338 fractures) were appropriate for meta-analysis. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference -0.45 mm, p = 0.25, 95%confidence interval (CI) -1.21 to 0.31, I. 2. = 0%) and long-term (> six months, standard mean difference -0.56, p = 0.09, 95% CI -1.20 to 0.08, I. 2. = 73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, and defect site pain at long-term follow-up, perioperative blood loss, duration of surgery, occurrence of surgical site infections, and secondary surgery. Mean blood loss was lower (90.08 ml, p < 0.001, 95% CI 41.49 to 138.67) and surgery was shorter (16.17 minutes, p = 0.04, 95% CI 0.39 to 31.94) in synthetic treatment groups. All other secondary measures were statistically comparable. Conclusion. All studies reported similar methodologies and patient populations; however, imprecision may have arisen through performance variation. These findings supersede previous literature and indicate that, despite perceived biological advantages, autologous bone grafting does not demonstrate superiority to synthetic grafts. When selecting a void filler, surgeons should consider patient comorbidity, environmental and societal factors in provision, and perioperative and postoperative care provision. Cite this article: Bone Jt Open 2022;3(3):218–228

Bone defects require implantable graft substitutes, especially porous and biodegradable biomaterial for tissue regeneration. The aim of this study was to fabricate and assess a 3D-printed biodegradable hydroxyapatite/calcium carbonate scaffold for bone regeneration. Materials and methods:. A 3D-printed biodegradable biomaterial containing calcium phosphate and aragonite (calcium carbonate) was fabricated using a Bioplotter. The physicochemical properties of the material were characterised. The materials were assessed in vitro for cytotoxicity and ostegenic potential and in vivo in rat intercondylar Φ3mm bone defect model for 3 months and Φ5mm of mini pig femoral bone defects for 6 months. The results showed that the materials contained hydroxyapatite and calcium carbonate, with the compression strength of 2.49± 0.2 MPa, pore size of 300.00 ± 41mm, and porosity of 40.±3%. The hydroxyapatite/aragonite was not cytotoxic and it promoted osteogenic differentiation of human umbilical cord matrix mesenchymal stem cells in vitro. After implantation, the bone defects were healed in the treatment group whereas the defect of controlled group with gelatin sponge implantation remained non-union. hydroxyapatite/aragonite fully integrated with host bone tissue and bridged the defects in 2 months, and significant biodegradation was followed by host new bone formation. After implantation into Φ5mm femoral defects in mini pigs hydroxyapatite/aragonite were completed degraded in 6 months and fully replaced by host bone formation, which matched the healing and degradation of porcine allogenic bone graft. In conclusion, hydroxyapatite/aragonite is a suitable new scaffold for bone regeneration. The calcium carbonate in the materials may have played an important role in osteogenesis and material biodegradation

Cervical and lumbar spine fusion procedures are increasing every year. Nonetheless, these procedures are associated with high infection rates, resulting in additional cost burden. The conundrum of achieving efficient spinal fusions with minimum complications requires an ideal bone graft with osteoconductive, osteoinductive, osteogenic and structural characteristics. Synthetic bone graft substitutes with or without autograft, allograft or synthetic bone substitutes have been commonly used for fusion procedures. We carried out a meta-analysis of comparative studies and prospective case series (n = 29) with cervical and lumbar fusion procedures using synthetic bone graft substitutes, autograft or allograft and other biologics. Synthetic bone graft substitutes analysed included HA (Hydroxyapatite), β-TPC (Tri Calcium Phosphate), β-TSC (Tri Calcium Sulfate), PMMA (Polymethylmetacrylate), Surgibone, BOP (Biocompatible Osteoconductive Polymer). The analysis revealed suboptimal evidence for the efficacy and safety of synthetic products used in spinal fusion procedures. Further studies are needed to determine beneficial effects of synthetic substitutes. However, the infection rate could be highly decreased with surface and composition modification of widely used polyether ether ketone (PEEK) implants. Laser modification of surface characteristics and collagen fleeces with micro and nano pore structures can prove to be excellent surface for increased osteoblasts cell proliferation and vitality

Post-traumatic osteonecrosis of the femoral head (ONFH) is a major complication of femoral neck fractures that require numerous solutions. The purpose of the current study is to investigate the effects of platelet-rich plasma (PRP) incorporated autologous granular bones graft for the treatment of pre-collapse stages (ARCO stage II-III) of post-traumatic ONFH. A total of 46 patients were eligible and enrolled into the study. 24 patients were treated with core decompression and PRP incorporated autologous granular bones graft (treatment group: 9 females and 15 males, age range, 16–39 years), and 22 patients with core decompression and autologous granular bones graft (control group: 6 females and 16 males, age range, 18–42 years. During a minimum duration of follow-up of 36 months, multiple imaging techniques including X-ray and computed tomography (CT) scanning were used to evaluate the radiological results, and Harris hip score (HHS) and the visual analogue scale (VAS) were chosen to assess the clinical results. Both treatment group and control group had a significant improved HHS (P < 0.001). The minimum clinically important difference (MCID) for HHS was reached in 91.7% of treatment group and 68.2% of control group (P = 0.0449). HHS in treatment group was significantly higher than control group at the last follow-up (P = 0.0254). VAS score was significantly declined in treatment group when compared with control group (P = 0.0125). Successful clinical results were achieved in 21 of 24 patients (87.5%) in treatment group compared with 13 of 22 patients (59.1%) in control group (P = 0.0284). Successful radiological results were achieved in 19 of 24 patients (79.2%) in treatment group compared with 11 of 22 patients (50%) in control group (P = 0.0380). The survival rates using requirement for further hip surgery as an endpoint were higher in treatment group in comparison to control group (P = 0.0260). The PRP incorporated autologous granular bones graft is a safe and effective procedure for the treatment of pre-collapse stages (ARCO stage II-III) of post-traumatic ONFH

Purpose. The aim of this study was to assess the clinical and radiological result of the usage of chip bone graft in non-contained type bone defect in primary or revision total knee arthroplasty patients. Subjects and Methods. We investigated 32 patients who had underwent primary or revision total knee arthroplasty from March, 2014 to February, 2017 in our hospital, who had non-contained type of defect. The mean age was 73.1 years. 5 of them were males, while 27 of them were females. 7 of them were primary total knee arthroplasty patients, while 25 of them were revision patients. 8 of them had chip bone graft used both in the femur and tibia. 9 of them had chip bone graft used only in the tibia. The other 15 had chip bone graft used only in the femur. Wire-mesh was used in the 9 patients who had chip bone graft used only in the medial side of the tibia. We used KOOS (Knee injury and osteoarthritis outcome score), HSS (Hospital for Special Surgery knee service rating system) and WOMAC scores to assess the clinical result, before the surgery and at the last follow-up. In addition, we had follow-up x-rays and 3D CT done for the patients to check the mean bone union period. In addition, overall radiologic imaging studies were used for complications such as loosening, osteolysis and lesions with radiolucency. Result. The Mean follow-up period was 2.7 years (range; 2.1 to 5). The Mean preoperative KOOS was 102.8 (range; 47 to 132), while it became 31.8 postoperatively (range; 20 to 45). The mean HSS was 13.1 (range; 6 to 35), while it became 35.9 postoperatively (range; 24 to 64). The mean WOMAC was 82.9 (range; 62 to 92), while it became 22.5 postoperatively (range; 13 to 30). According to follow-up x-ray and CT, the mean bone union period was 10.6 months (range: 10 to 13). In follow-up 3D CT of all cases, we could check cortical healing and new bone formation, seen as medium to high-attenuating conglomerate. The graft-host junction showed trabecular ingrowth, while the medullary canal showed fibrous ingrowth. Radiologically, there was no complication such as loosening, osteolysis, migration and radiolucent lines around the stems or cement mantles. In addition, there was no complication such as infection. Conclusion. Chip bone graft is not a commonly used method for bone defect in total knee arthroplasty. According to the result of the usage of chip bone graft in primary or revision total knee arthroplasty with non-contained type of bone defect, it showed favorable result for the subject patients. Therefore, we can consider it as one of the effective methods to manage non-contained bone defect in knee arthroplasty. Keywords. Revision TKA, chip bone graft, wire-mesh, non-contained bone defect. For any figures or tables, please contact authors directly

Abstract. Background. Scaphoid non-union can result in pain, altered wrist kinematics leading to a Scaphoid Non-union Advance Collapse, ultimately to symptomatic radio-carpal arthritis. Open techniques have their limitations. We describe the rationale, surgical technique and outcomes of our series of arthroscopic bone-grafting (ABG) and fixation of scaphoid non-union. Methods. We performed a prospective single-surgeon series of 22 consecutive patients with clinico-radiologically established scaphoid non-union between March 2015 and April 2019. Data was collected from Electronic Patient Records, Patient Archived Computer system (PACS) and hand therapy assessments. We collected demographic data including age, hand-dominance, occupation and mechanism of injury. The Disabilities of the Arm, Shoulder and Hand Score (Quick DASH), Mayo wrist score, Patient Rated Wrist Evaluation (PRWE) and grip-strength measurements were collected preoperatively and at follow-up appointments. Results. There was an improvement in all outcome measures when comparing preoperative and postoperative results. The Quick DASH score improved by a mean of 24 points, Mayo wrist and PRWE scores improved by 15.1 and 29.7 points, respectively. Grip-strength analysis also improved by 6.1 kgf (Right) and 3.3kgf (Left). Follow-up computerised tomography scans revealed union in 18/22 patients with 2 patients lost to follow-up. One patient required revision ABG procedure to achieve union. Conclusion. Arthroscopic bone grafting and fixation of scaphoid non-union allows a minimally invasive method of managing these injuries. It has advantages of minimal morbidity and accurate articular reduction resulting in less postoperative stiffness and increased functional outcomes. It is an effective alternative to conventional open treatment of established scaphoid non-union

Introduction. Acetabular reconstruction of a total hip arthroplasty (THA) for a case with severe bone loss is most challenging for surgeon. Relatively high rate of failure after the reconstruction surgery have been reported. We have used Kerboull-type acetabular reinforcement devices with morsellised or bulk bone allografts for these cases. The purpose of this study was to examine the midterm results of revision THA using Kerboull-type acetabular reinforcement devices. Patients and methods. We retrospectively reviewed 20 hips of revision THA (20 patients) between February 2002 and August 2010. The mean age of the patients at the time of surgery was 67.4 years (range 45–78). All of the cases were female. The mean duration of follow-up was 6.5 years (range 2.1–10.4). The reasons of revision surgeries were aseptic loosening in 10 hips, migration of bipolar hemiarthroplasty in 8 hips, and rheumatoid arthritis in 2 hips. We classified acetabular bone defects according to the American Academy of Orthopaedic Surgeons (AAOS) classification; we found two cases of Type II and eighteen cases of Type III. In terms of bone graft, we performed both bulk and morsellised bone grafts in 6 hips and morsellised bone grafts only in 14 hips. We assessed cup alignment using postoperative computed tomography (CT) and The post-operative and final follow-up radiographs were compared to assess migration of the implant. We measured the following three parameters: the angle of inclination of the acetabular device (Fig. 1); the horizontal migration (Fig. 2a); and vertical migration (Fig. 2b). Substantial migration was defined as a change in the angle of inclination of more than 3 degrees or migration of more than 3 mm. The pre- and postoperative hip functions were evaluated using the Japanese Orthopaedic Association (JOA) hip score. Results. The mean cup inclination and anteversion were 38.4 degrees and 10.6 degrees, respectively. The mean change in the angle was 1.9 degrees in inclination of the device. The average horizontal migration was 1.0 mm, and the vertical migration was 2.0 mm. Only one hip showed substantial migration with breakage of the device. This failure case represented a large amount of posterior pelvic tilt in standing position postoperatively. The mean JOA hip score was increased from 46.7 to 74.8. Discussion. Poor outcome using Kerboull-type reinforcement plate with morsellised bone graft only has been demonstrated by many reports. In these literatures, bulk bone graft was recommended particularly in the case of large bone defect such as larger than half of the rounded plate of the device or more than 2 cm of thickness. In our case series, acetabular reconstruction using a Kerboull- type acetabular reinforcement device and bone graft gives satisfactory mid-term results even with morsellized bone graft only. One possible interpretation is that most of our cases had relatively small bone defect according to the staging of severity of the superior segmental bone loss made by Kawanabe et al. We suggest that the progressive posterior pelvic tilt should be considered to be a risk of poor outcome of the acetabular reconstruction using this device. To view tables/figures, please contact authors directly

Aim. Bone and implant-associated infections caused by microorganisms that grow in biofilm are difficult to treat because of persistence and recurrence. Systemic administration of antibiotics is often inefficient because the poor vascularization of the site of infection. This issue has led to the development of biomaterials capable to locally deliver high doses of therapeutic agents to the injured bone with minimal systemic effects. In this context, calcium sulphate/hydroxyapatite (CS/HA) bone graft substitutes are widely used being safe, osteoconductive and resorbable biomaterials that can be easily enriched with consistent amounts of antibiotics. In this in vitro study, the capability of the eluted antibiotics to select the tested bacterial strains for antibiotic resistance was evaluated to confirm the safe use of the product. Method. S. aureus, S. epidermidis and P. aeruginosa isolated in our Institute from bone and joint infection with different resistance phenotypes were used. 6 × 2.5 mm CS/HA discs were generated by pouring the antibiotic loaded formulations in a mold and were used as a modified disk diffusion test. The resistance selection was evaluated by subculturing cells growing on the edge of the zone of inhibition (ZOI) for seven days. Minimum inhibitory concentrations (MICs) of gentamicin and vancomycin were determined by broth microdilution method before and after the selection of resistance assay. In addition, MICs were assessed after seven day passage on antibiotic free agar plates to evaluate if eventual decrease of antibiotic susceptibility was stable or only transient. Results. Commonly, no adaptation in presence of both CS/HA formulations was observed by analysing ZOI on agar medium. The kinetic of decrease of the ZOI was similar between the strains, with the exception of gentamicin resistant staphylococci in presence of gentamicin loaded CS/HA, which was faster with respect to the susceptible strains. Conclusions. The present study shows that elution of gentamicin and vancomycin from CS/HA bone graft substitutes did not induce a decrease in susceptibility to these antibiotics in an in vitro setting, suggesting the safe use of the product

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

Objectives. Our principle is to bring the socket back to the true acetabulum position. A large structural bone graft is required for severe subluxation. We obtained good long-term results with structural bone grafts. It is necessary to evaluate the bone graft 3 dimensionally, not 2 dimensionally. M and M. We evaluated our 305 primary THAs operated from April 2010 to Mar 2014. Structural bone grafts were utilized on the acetabulum in 39 cases (12.8%). We measured the CE angle on post-operative plain coronal x-rays. 3D-CT evaluation was carried out on the cases with CE angles of 0 degrees or less. We checked the position of the graft and see how much surface area the graft occupies of the total area that receives the load. Result. Mean CE angle on the post-op plain coronal x-rays was −1.5°. 15 cases (38.5%) had 0 degree or less CE angles on the post-op plain coronal x-rays. 11 cases (−15°≤CE<0°), and 4 cases (−30°≤CE<−15°). Mean CE angle was +3.7° on coronal CT of the apex of the socket. Graft position on the acetabulum on 3D-CT was anterosuperior in 13 cases and posterosuperior in 2 cases, wile none showed wide positioning from anterosuperior to posterior. Conclusion. The contact surface area between the graft and the socket is not necessarily large 3 dimensionally, even if the CE angle is 0 degrees in the plain coronal X-rays. Depending on the graft position, sufficient support is considered to be obtained, even though a large size graft is used

Lateralization of the reverse arthroplasty may be desirable to more effectively tension the remaining rotator cuff, decrease scapular notching, improve the cosmetic appearance of the shoulder, and improve stability as well as the arc of motion prior to impingement. There are two primary options to lateralise a reverse shoulder arthroplasty: bone graft with a long post (BIO-RSA) vs. using metal. The two metal options generally include a thicker glenosphere or a thicker glenoid baseplate. Potential benefits of a BIO-RSA include lateralization of the glenoid center of rotation but without placing the center of rotation lateral to the prosthetic-bone interface. By maintaining the position of the center of rotation, the shear forces at the prosthesis-bone interface are lessened and are converted to compressive forces which will minimise glenoid failure. Edwards et al. performed a prospective study on a bony increased offset reverse arthroplasty. Among the 18 shoulders in the BIO-RSA group, the incidence of notching was 78% compared to controls 70%. The graft completely incorporated in 12 (67%), partially incorporated in 4 (22%), and failed to incorporate in 2 (11%). Frankle et al. reported on the minimum 5-year follow-up of reverse arthroplasty with a central compression screw and a lateralised glenoid component. The survivorship was 94% at 5 years. There were seven (9%) cases of scapular notching and no patient had glenoid baseplate loosening or baseplate failure. The authors noted that the patients maintained their improved function and radiographic results at a minimum of five years. In summary, lateralisation of the glenosphere is an attractive option to improve the outcome of reverse arthroplasty. Benefits of lateralisation with metal rather than bone graft include elimination of concern over bone graft healing or resorption. In addition, the procedure has the potential to be more precise with the exact offset amount known pre-operatively as well as improved efficiency of the procedure. Preparing the graft takes additional OR time and there is variable quality of the bone graft