Occipital calvarial bone graft in posterior occipitocervical fusion

STUDY DESIGN: Dorsal occipitocervical fusion is associated with a high rate of fusion failure and requires an additional surgical site for donor bone graft harvesting. In this series, an autologous occipital calvarial bone graft obtained from the same occipitocervical incision with contoured metal loops was used in 25 adults to achieve craniovertebral stabilization and fusion. OBJECTIVES: To study the use of autologous occipital calvarial bone grafts in occipitocervical fusion. SUMMARY OF BACKGROUND DATA: Cranial bone grafts have been used successfully in craniofacial reconstruction with good long-term results. In the plastic surgery literature, there are claims that membranous bone grafts are superior to endochondral bone grafts in fusions because of decreased resorption. In recent studies, results have shown successful use of calvarial bone in fusing the upper cervical spine in children. The use of autologous occipital bone in posterior occipitocervical fusions avoids many of the problems associated with traditional donor sites and provides a sufficient quantity of good quality bone for the fusion. This is especially true in the fragile rheumatoid arthritis patient with cranial cervical instability. METHOD: Split-thickness, autologous calvarial bone grafts with contoured loop and cable instrumentation were used for posterior occipitocervical stabilization and fusion in 25 patients, most of whom had rheumatoid arthritis. The calvarial bone graft was harvested from the occipital skull, using a microair impactor, and was secured next to the loop construct. After surgery, all patients were immobilized with external orthoses. RESULTS: None of the patients had hardware failure or complications from the occipital graft procurement. In 22 patients, good alignment, stability, and bony fusion were shown on radiographs. CONCLUSIONS: Occipital calvarial bone graft appears to work as well as other autologous corticocancellous bone grafts routinely used in posterior occipitocervical fusions.     

A comparative study of ethylene oxide and ionizing radiation for sterilizing bone grafts

To find a good way for sterilization and disinfection of bone grafts, we compared the sterilization capacity of gaseous ethylene oxide (EO) and cobalt-60 gamma radiation. The bone chips were contaminated with 10(7) bacteria per milliliter of Staphylococcus aureus ATCC 25923, Bacillus subtilis globigii 8017 and Bacillus cereus 4001, then sterilized with various doses of gaseous EO or cobalt- 60 gamma radiation. The sterilization effect of EO was more stronger and faster than that of 60Co gamma radiation. The application of moderate doses of EO for sterilizing particulate bone grafts was recommended.     

A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects

PURPOSE: This study compared vascularized and nonvascularized bone grafts for the reconstruction of segmental defects of the mandible. PATIENTS AND METHODS: The results in 39 patients having vascularized bone grafts (38 fibulas and one iliac crest) and 29 patients having nonvascularized bone grafts (26 iliac crest [22 corticocancellous block grafts, four cancellous bone grafts in a tray] and three rib grafts) for segmental mandibular reconstruction were evaluated in terms of overall success rate, total number of surgeries performed, total blood loss, total number of hospital days, and total number of hours in the operating room. RESULTS: Of 39 vascularized bone grafts, two failed (95% success rate), whereas of 29 nonvascularized bone grafts, seven failed (76% success rate). Failure for the nonvascularized bone grafts was closely correlated to the length of the defect. Nonvascularized bone graft patients underwent an average of one more surgical procedure for total reconstruction than vascularized bone graft patients, including osseointegrated implants. However, vascularized bone graft patients spent a mean of over 14 additional days in the hospital for all of their reconstructive procedures and an additional 3 hours in the operating room as compared with nonvascularized bone graft patients. Blood loss was similar in both groups (1,100 mL). Only 20% to 24% of patients in each treatment group have completed reconstruction to include osseointegrated implants. CONCLUSIONS: The success rate for vascularized bone grafting is high and is the treatment of choice when primary reconstruction is required, when the patient has been previously irradiated, or when simultaneous replacement of soft tissue is required. Vascularized bone grafts are also the treatment of choice for mandibular replacements over 9 cm in length. Nonvascularized bone grafts create a better contour and bone volume for facial esthetics and subsequent implant insertion, and may be the treatment of choice for secondary reconstruction of defects less than 9 cm in length.     

Endosseous implant and autogenous bone graft reconstruction of mandibular discontinuity: a 12-year longitudinal study of 31 patients

Surgical, medical, and prosthodontic records of 61 consecutively treated patients with mandibular discontinuity were reviewed retrospectively. All 61 patients had undergone discontinuity reconstruction with autogenous bone grafts; 31 of 61 had also received endosseous dental implants and a dental osseoprosthesis. Of these 31 implant-reconstructed patients, 23 had free autogenous nonvascularized and 8 had vascularized bone grafts. The surgical-prosthetic protocol consisted primarily of secondary, free autogenous nonvascularized bone graft reconstruction and secondary root-form endosseous implant and fixed prosthesis dental reconstruction. Vascularized bone (8 patients) or soft tissue (4 patients) grafts were utilized selectively for severely compromised patients after extensive oncologic resection, avulsive trauma, or after previous radiation treatment. Endosseous implant survival (95.5% in 31 patients), autogenous bone graft success (98.4% in 61 patients), and dental osseoprosthesis success (100% in 31 patients) were favorable. A high incidence (9.1%) of nonfunctioning (sleeping) implants was recorded for this patient population. The need to remove the titanium mesh tray for various reasons (17.6%) and the need to reconstruct soft tissue in the irradiated patient (12%) were noteworthy.     

The Ranawat Award. Histology of nine structural bone grafts used in total knee arthroplasty

The cross section radiographs and histology of nine bone grafts were examined to determine whether grafts are durable enough to support a total knee implant when the load is shared by host bone, graft bone, and a stemmed component. All cases had cemented total knee arthroplasties with stemmed components adjacent to bulk grafts. The cases included autografts and allografts, which had been in situ for an average of 41 months (range, 20-62 months). Seven of the grafts were retrieved postmortem from three patients (four knees), and two were retrieved at revision surgery from one patient. The allografts all were intact, but had not revascularized. The autografts were viable bone. New bone was being laid down on the dead graft bone at the periphery of the allografts. No change in the bone to cement interface, no graft collapse, no development of radiolucent lines, and no component loosening occurred in these cases. The promising clinical results of bone grafts in total knee arthroplasties were confirmed by the examination of these grafts at the cellular level. Using stemmed components in bone grafted knee reconstructions may have increased graft durability and protected the grafts from fatigue failure.     

A double-blind, randomized, controlled trial of the effects of two eggs per day in moderately hypercholesterolemic and combined hyperlipidemic subjects taught the NCEP step I diet

BACKGROUND: Thirty-three patients with nontuberculous pyogenic thoracic and lumbar vertebral osteomyelitis were treated surgically. Indications for surgery were either progression of disease despite adequate antibiotic therapy, neurologic deficit, or both. The most common initial symptom was back pain. Seven patients had diabetes, seven patients were intravenous drug users, two patients were receiving immunosuppressive therapy, and seven patients had a debilitating disease. Eleven had infections elsewhere in their bodies. Prior to surgery organisms were grown from blood in 10 patients and at surgery in 15 patients. METHODS: Infection was evident on plain films in all patients, and either a CT scan or MRI was obtained in each. The lateral extracavitary approach was used for resection of granulation tissue and infected bone ventral to the dura. Interbody bone grafts were placed in 19 patients, usually when bone resection was extensive. Posterior instrumentation was placed in 17 patients at a second procedure 10 days-2 weeks following initial operation. Intravenous antibiotics were administered for 4-6 weeks following surgery, and solid fusion was obtained in all patients. RESULTS: Neurologic deficit was present in 28 patients prior to surgery and was functionally significant in 18 patients. Of the 11 patients with severe paraparesis, 10 achieved good functional recovery. These patients were able to walk, three with assistance and seven without, and all those who were unable to void regained this ability. CONCLUSIONS: Surgical debridement, interbody fusion, and posterior instrumentation is a safe and effective treatment for vertebral osteomyelitis and is indicated when neurologic deficit or bone destruction progress despite adequate antibiotic therapy.     

Incidence of urolithiasis in northeast Thailand

We performed an anterior spinal fusion using a vascularized fibular bone graft combined with posterior fusion for a patient with severe cervical kyphosis due to neurofibromatosis. The kyphosis was corrected from 85 degrees preoperatively to 38 degrees postoperatively. A vascularized fibular bone graft is a useful surgical procedure in selected patients to obtain successful bony union.     

Revision of failed lumbar fusions. A comparison of anterior autograft and allograft

STUDY DESIGN: The radiographic and clinical results of two different anterior structural grafts were compared in 38 patients who had combined anterior-posterior revision surgery for failed lumbar fusion. OBJECTIVES: Failed lumbar fusion surgery, such as pseudarthrosis or flatback deformity, may result in disabling pain. The optimum revision technique has yet to be defined. The authors of the current study sought to determine which of two different types of anterior graft yields the best results. SUMMARY OF BACKGROUND DATA: Posterior procedures for revision of a failed lumbar fusion have not yielded reliably successful results. A combined anterior-posterior approach may be effective in restoring sagittal balance and enhancing fusion rates. Recent studies have shown femoral ring allografts to be effective in lumbar fusion revision, but no studies have compared these with other types of structural grafts. METHODS: Thirty-eight patients with pseudarthrosis were treated with combined anterior-posterior lumbar spine fusion using either femoral ring allografts (26 patients) or tricortical iliac autografts (12 patients). Radiographic follow-up examination and retrospective patient self-assessment questionnaires were used to evaluate outcomes. Results were assessed by independent reviewers after a mean follow-up period of 35 months. RESULTS: Radiographic follow-up examination revealed acceptably low pseudarthrosis rates for structural autografts (0%) and allografts (6%). The questionnaires revealed significant improvement in pain for both groups. Allograft patients showed greater improvement in function, less pain medication usage, and higher overall success rates (83%) than autograft patients (64%). CONCLUSIONS: Femoral ring allografts are as effective, clinically and radiographically, as tricortical iliac autografts when used as an anterior structural element in revision lumbar spine fusion in patients who have undergone multiple surgical procedures for pseudarthrosis or flatback deformity. The slightly greater improvement for the allograft group needs to be confirmed in a larger study.     

Use of demineralized bone matrix in hindfoot arthrodesis

Fifty-five patients considering a hindfoot fusion performed by the senior author over a 5-year period were given the choice of having the fusion augmented by either iliac crest bone graft or demineralized bone graft in a study of the relative efficacy of these 2 methods of bone grafting. Eleven patients underwent subtalar fusion (average age, 40.1 +/- 14.0 years), and 44 had a triple arthrodesis (average age, 54.6 +/- 19.2 years). The most common indications for surgery were posterior tibial tendon insufficiency and traumatic arthritis. There were no significant differences between groups regarding underlying disease, medications, or associated medical conditions. In isolated subtalar fusions, all 3 patients who received an iliac crest bone graft experienced healing, as did 7 of 8 patients who received demineralized bone graft. The eighth patient had a radiographic non-union without clinical symptoms. Complete healing of triple arthrodeses was achieved in 13 of 15 patients who received an iliac crest bone graft and in 29 of 29 patients receiving a demineralized bone graft. There were no intergroup differences in the time to union, which generally was between 3 and 4 months. Intraoperative blood loss was significantly less with demineralized bone graft (33 +/- 25 ml) than with iliac crest bone graft (206 +/- 192 ml). This study demonstrated that demineralized bone graft aids arthrodesis at least as well as does iliac crest bone graft, without the increased blood loss, cost, and postoperative pain associated with iliac crest bone harvest.     

Vascularized bone grafts for congenital pseudarthrosis of the tibia

Eight vascularized fibula grafts and two vascularized rib grafts were used for the treatment of 10 Boyd's Type II congenital pseudarthrosis of the tibia. All but one vascularized fibula graft united within 4 months. The two vascularized rib grafts did not unite until receiving a conventional bone graft. Nine spontaneous fractures were seen in four patients; all were subsequently treated successfully with cast or conventional bone graft. Corrective osteotomies were done in two patients. Follow-up averaged 8 years and 5 months (range, 5 years and 1 month to 14 years and 4 months). Average age at end of follow-up was 13 years and 6 months (range, 7 years and 10 months to 20 years and 4 months). After bony union was achieved, shortening of the affected leg averaged 3.8 centimeters, flexion deformity averaged 20 degrees, and valgus deformity averaged 24 degrees. In three patients, whose leg discrepancy averaged 4.9 centimeters, the leg was lengthened at an average patient age of 13 years and 9 months (age range, 11 years and 7 months to 15 years and 2 months). The resulting limb length discrepancy averaged 2.2 centimeters. Vascularized bone grafting is a reliable technique for achieving bony union in congenital pseudarthrosis of the tibia. Residual shortening may be corrected later by limb lengthening.     

A paradigm of experimentally induced mild hyperthyroidism: effects on nitrogen balance, body composition, and energy expenditure in healthy young men

OBJECTIVE: To conceptualize, with fine needle aspiration cytology (FNAC), the early cellular events occurring in and around fresh autogenous and allogenic bone grafts during the first 40 postimplantation days. STUDY DESIGN: Forty-eight cases of bone grafts were studied by FNAC at serial intervals of 10, 20, 30 and 40 postimplantation days. Twenty patients were recipients of autogenous grafts, 16 received 0.6N HCI partially decalcified allogenic bone implants, and 4 received combined autogenous and allogenic bone grafts (included in the allograft group). There were eight control cases of closed fracture shaft femur, which were managed conservatively. RESULTS: The initial cellular responses in autogenous grafts, allografts and controls appear to be a part of the nonspecific reparative process followed by a more specific phase, with a steady increase in relative lymphocyte count from the 20th day onwards. Osteogenesis, as judged by osteoblasts and osteoclasts, was also comparable. CONCLUSION: Partially decalcified allografts appear to be a good substitute for autogenous bone grafts in clinical practice when adequate autogenous material is not available. FNAC is a good technique for studying bone graft responses without interfering with graft uptake. It is helpful in the early detection of subclinical infection or any other pathology at the graft site.     

Video-assisted thoracoscopic discectomy and fusion

Anterior discectomies and fusions are performed on patients who have anteriorly herniated discs. Fusions are accomplished using bone grafts harvested from the patient or by using cadaveric bone grafts that are inserted into the disc space for stability. This procedure traditionally has been performed through an open incision, but now can be accomplished using a video-assisted thoracoscope. The benefits of this minimally invasive technique for patients include decreased blood loss, less postoperative pain, and a shorter hospital stay.     

Structural allograft in two-stage revisions for failed septic hip arthroplasty

We report 11 patients having revision of total hip arthroplasty using massive structural allografts for failure due to sepsis and associated bone loss. All patients had a two-stage reconstruction and the mean follow-up was 47.8 months (24 to 72). Positive cultures were obtained at the first stage in nine of the 11 patients, with Staphylococcus epidermidis being the most common organism. The other two patients had draining sinuses with negative cultures. There was no recurrence of infection in any patient. The mean increase in the modified Harris hip score was 45 and all the grafts appeared to have united to host bone. Two patients required additional procedures, but only one was related to the allograft. Complications included an incomplete sciatic nerve palsy and one case of graft resorption. Our results support the use of massive allografts in failed septic hip arthroplasty in which there is associated bone loss.     

Acetabular reconstruction with impacted morselized cancellous allografts in cemented hip arthroplasty: a histological and biomechanical study on the goat

Bone defects in total hip arthroplasty revision surgery can be restored with different types of bone graft. The use of impacted morselized allograft chips in combination with cement is the treatment of our choice. To establish the incorporation capacity of the grafts and mechanical stability of the implant, an animal model in the goat was developed. An acetabular defect was created and restored with morselized grafts and a cemented cup. Postoperative performance of the reconstruction was followed both histologically and biomechanically. Histology showed that consolidation of the graft with the host bone bed had occurred within 3 weeks. In the following period a front of vascular sprouts infiltrated the graft. Graft resorption, woven bone deposition, and subsequent remodeling resulted in a new trabecular structure. This structure contained only scarce remnants of the original dead graft material. At the graft-cement interface, graft resorption and new bone formation had resulted in areas of direct vital bone-cement contact. Locally, a soft tissue interface was present. After longer follow-up periods, progressive interface formation and loosening of the cups were found in most animals. Mechanical testing showed that the stability of the reconstruction increased during the first 12 postoperative weeks. Thereafter, the stability decreased, probably by soft-tissue interface formation at the graft cement interface. We conclude that cemented morselized allografts have a high capacity to incorporate. Initial cup stability is adequate to provoke graft incorporation with decreasing stability after the incorporation process has been completed.     

Split calvarial graft cranioplasty for the prevention of headache after retrosigmoid resection of acoustic neuromas

OBJECTIVE: This study describes the technique and efficacy of split calvarial graft cranioplasty for the reconstruction of retrosigmoid/suboccipital defects following surgery for acoustic neuromas. STUDY DESIGN: A prospective study of the technique of split calvarial graft cranioplasty, its postoperative healing, and incidence of postoperative headache. METHODS: The technique requires splitting of the craniotomy bone flap into outer and inner table bone grafts. The combination of both bony grafts allows the coverage of a wider area of posterior fossa dura. This technique was used in 18 patients. All patients were followed for a minimum of 6 months. Eleven of 18 patients were followed for 1 year or longer. Four patients had three-dimensional computed tomography of their skull and area of split calvarial bone graft. RESULTS: One of 18 patients had a persistent disabling headache at 1 year postoperatively. A natural contour of the retrosigmoid area was achieved in all patients. Three-dimensional computed tomography scan, obtained 6 months postoperatively, showed total coverage of the retrosigmoid area and fusion of the bone flap to the surrounding skull. CONCLUSION: The technique of split calvarial grafting of posterior fossa defects is a feasible, safe, and effective way of separating the nuchal musculature and posterior fossa dura. The technique also allows the restoration of the contour and bony covering of the retrosigmoid area. The technique is a simple alternative to other types of cranioplasties aimed at reducing the incidence of postoperative headache in patients with acoustic neuromas.     

Bladder pseudotumor in childhood

The application of frozen and radiation sterilized allogenic bone grafts for reconstructions in orthopaedic operations is described. Analysis of results of treatment of 1125 patients was performed. It was found that use of preserved bone allows to reduce the extend and duration of surgery. Nearly total substitution of grafts may be seen in 3 to 8 months after surgery.     

Idiotype vaccination strategies against a murine B-cell lymphoma: dendritic cells loaded with idiotype and bispecific idiotype x anti-class II antibodies can protect against tumor growth

BACKGROUND: Following extensive resections of head and neck tumors, re-establishing speech and masticatory function are of crucial importance for the patient. METHODS: In 23 patients with vascularised jejunal grafts for reconstruction of the intraoral mucosa, tongue and floor of mouth, a speech intelligibility test was performed, tongue and floor of mouth mobility was investigated using a 3.5 MHz ultrasound scanner. In another 18 patients with vascularised bone grafts for reconstruction of the mandible, masticatory function was analysed using a T-scan system and a miniature pressure transducer. RESULTS: Speech results with jejunal grafts in the lateral floor of mouth/tongue region may attain 91.4%, in anterior floor of mouth reconstructions 63.4%. Patients with implant-bone dentures and vascularised bone grafts prefer the non-reconstructed side for chewing. Masticatory force is significantly diminished compared to a control group. DISCUSSION: Lack of neurosensitive feedback mechanisms may be responsible for diminished chewing pressure and also for inferior speech results despite good floor-of-mouth/tongue mobility. CONCLUSIONS: Despite complex microvascular tissue reconstructions, severe functional impairments remain and necessitate further investigations on improvement of postoperative speech, swallowing and chewing function.     

Posterior C1-C2 transarticular screw fixation for atlantoaxial arthrodesis

OBJECTIVE: To assess the outcomes associated with C1-C2 transarticular screw fixation. METHODS: The clinical outcomes of 121 patients treated with posterior C1-C2 transarticular screws and wired posterior C1-C2 autologous bone struts were evaluated prospectively. Atlantoaxial instability was caused by rheumatoid arthritis in 48 patients, C1 or C2 fractures in 45, transverse ligament disruption in 11, os odontoideum in 9, tumors in 6, and infection in 2. RESULTS: Altogether, 226 screws were placed under lateral fluoroscopic guidance. Bilateral C1-C2 screws were placed in 105 patients; each of 16 patients had only one screw placed because of an anomalous vertebral artery (n = 13) or other pathological abnormality. Postoperatively, each patient underwent radiography and computed tomography to assess the position of the screw and healing. Most screws (221 screws, 98%) were positioned satisfactorily. Five screws were malpositioned (2%), but none were associated with clinical sequelae. Four malpositioned screws were reoperated on (one was repositioned, and three were removed). No patients had neurological complications, strokes, or transient ischemic attacks. Long-term follow-up (mean, 22 mo) of 114 patients demonstrated a 98% fusion rate. Two nonunions (2%) required occipitocervical fixation. In comparison, our C1-C2 fixations with wires and autograft (n = 74) had an 86% union rate. CONCLUSION: Rigidly fixating C1-C2 instability with transarticular screws was associated with a significantly higher fusion rate than that achieved using wired grafts alone. The risk of screw malpositioning and catastrophic vascular or neural injury is small and can be minimized by assessing the position of the foramen transversaria on preoperative computed tomographic scans and by using intraoperative fluoroscopy and frameless stereotaxy to guide the screw trajectory.     

Alternative treatments for a traumatic bone cyst: a longitudinal case report

A patient presented with a large, multilocular, refractory traumatic bone cyst. The radiolucency had increased in dimension since her last recall. Over 11 years, therapy had included needle aspiration biopsies followed by simple curettage and closure, the most common therapy for traumatic bone cysts. However, all treatment had proved unsuccessful for this patient. It was decided to treat the patient with a slightly unique method. After curettage of the lesion, the traumatic bone cyst was packed with a mixture of autogenous blood, harvested autogenous bone chips, and hydroxyapatite.     

Neuroendocrine differentiation and prognosis in prostatic adenocarcinoma

OBJECTIVES: To assess the prognostic importance of neuroendocrine differentiation in conventional (non-small cell) prostatic adenocarcinoma. MATERIALS AND METHODS: Ninety-two samples from patients with prostatic adenocarcinoma were studied retrospectively. The immunohistochemical analysis of chromogranin A and neuron-specific enolase in formalin-fixed, paraffin wax embedded prostatic tissue chips was related to other prognostic variables and patient survival. RESULTS: Neuroendocrine differentiation was detected in 48 cases; there was a significant correlation with worsening tumour differentiation, the presence of bone metastases and with worsening survival, but no independent effect of neuroendocrine differentiation on survival. CONCLUSION: The detection of neuroendocrine differentiation in conventional prostatic adenocarcinoma is not an independent indicator of prognosis.