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Fischer C, Schipper S, Langwald S, Klauke F, Kobbe P, Mendel T, Hückstädt M. [Modified Masquelet technique : Technique of the induced membrane in the course of time]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:729-737. [PMID: 39110137 PMCID: PMC11420378 DOI: 10.1007/s00113-024-01474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/19/2024] [Indexed: 09/26/2024]
Abstract
The reconstruction of long bone defects as a result of primary traumatic, secondary infection or tumor-related loss of substance continues to represent a surgical challenge. Callus distraction via segment transport, vascularized bone transfer and the induced membrane technique (IMT) are established methods of reconstruction. In recent decades IMT has experienced increasing popularity due to its practicability, reproducibility and reliability. At the same time, the original technique has undergone numerous modifications. The results are correspondingly heterogeneous. This overview is intended to explain the basic principles of IMT and to provide an overview of the various modifications and their complications.
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Affiliation(s)
- C Fischer
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland.
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland.
| | - S Schipper
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - S Langwald
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
| | - F Klauke
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - P Kobbe
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - T Mendel
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - M Hückstädt
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
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Halvachizadeh S, Teuben M, Lempert M, Kalbas Y, Cesarovic N, Lipiski M, Benninger E, Cinelli P, Pfeifer R, Pape HC. Protective effects of new femoral reaming techniques (Reamer irrigator aspirator, RIA I and II) on pulmonary function and posttraumatic contusion (CT morphology) - results from a standardized large animal model. Injury 2021; 52:26-31. [PMID: 33046248 DOI: 10.1016/j.injury.2020.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The effects of reaming for preparation of intramedullary fixation in long bone fractures have been widely studied. We compared pulmonary and systemic effects between conventional reaming with reamer irrigator aspirator and unreamed nailing in an acute porcine trauma model with a standardized femur fracture. MATERIALS AND METHODS In a standardized porcine model, (moderate blunt chest trauma, abdominal injury and femoral shaft fracture), the femur was submitted to intramedullary nailing after resuscitation and normalization of pulmonary function. The treatment groups included 3 reamer types (Group RFN: conventional reaming with Synream; group RIA1; reamer irrigator aspirator, version 2005; group RIA 2; reamer irrigator aspirator, version 2019) and were compared to unreamed femoral nailing (Group UFN). Pulmonary function measurements included arterial partial carbon-dioxide pressure (paCO2 [kPa]) (baseline, post reaming, 2,4,6 h) and volumetric measures of contusion in chest computer tomography (CT) (at 6 hrs.). Systemic inflammatory response was measured at baseline and every second hour until six hours after trauma. RESULTS This study included 24 male animals, mean weight 50.76 ± 4.1 kg n = 6 per group). Group RFN developed a significantly higher partial CO2 (pCO2) at one hour after reaming when compared with all other groups (7.4 ± 0.4 kPa versus 5.4 ± 0.6 RIA 1, 5.6 ± 0.4 RIA 2, and 5.5 ± 0.5 UFN, p < 0.001), along with a had lower pO2 (12.3 ± 1.3 kPa versus 17.2 ± 1.9 RIA 1, 17.4 ± 1.6 RIA 2, and 16.4 ± 0.7 UFN, p < 0.001) and the degree of pulmonary hyperdense changes in the CT analysis was higher in RFN (485.2 ± 98.5 cm3 versus 344.4 ± 74.4 cm3 RIA 1 and 335.2 ± 58.1 cm3 RIA 2, p < 0.01). The inflammatory reaction was lowest in both RIA groups when compared with group RFN or UFN (p < 0.001). CONCLUSION Both RIA 1 and RIA 2 protect the lung from reaming induced dysfunction and have no systemic inflammatory effects, while the negative effects were more sustained after reamed or unreamed nailing. Both RIA 1 and RIA II appear to be of value in terms of a Safe Definitive Surgery (SDS) strategy.
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Affiliation(s)
- Sascha Halvachizadeh
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland; University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Michel Teuben
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland; University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Max Lempert
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - Yannik Kalbas
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - Nikola Cesarovic
- University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Miriam Lipiski
- University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Emanuel Benninger
- Cantonal hospital Winterthur, Department of Orthopaedics and Trauma, Brauerstrasse 15, 8400 Winterthur, Switzerland.
| | - Paolo Cinelli
- University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Roman Pfeifer
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland; University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
| | - Hans-Christoph Pape
- University Hospital Zurich, Department of Trauma, Raemistrasse 100, 8091 Zurich, Switzerland; University of Zurich, University Hospital Zurich, Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma research, Sternwartstrasse 14, 8091 Zurich, Switzerland.
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Kobbe P, Laubach M, Hutmacher DW, Alabdulrahman H, Sellei RM, Hildebrand F. Convergence of scaffold-guided bone regeneration and RIA bone grafting for the treatment of a critical-sized bone defect of the femoral shaft. Eur J Med Res 2020; 25:70. [PMID: 33349266 PMCID: PMC7754593 DOI: 10.1186/s40001-020-00471-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/04/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Critical-sized bone defects, mainly from trauma, infection or tumor resection are a challenging condition, often resulting in prolonged, complicated course of treatment. Autografts are considered as the gold standard to replace lost bone. However, limited amount of bone graft volume and donor-site morbidity have established the need for the development of alternative methods such as scaffold-based tissue engineering (TE). The emerging market of additive manufacturing (3D-printing) has markedly influenced the manufacturing of scaffolds out of a variety of biodegradable materials. Particularly medical-grade polycaprolactone and tricalcium phosphate (mPCL-TCP) scaffolds show appropriate biocompatibility and osteoconduction with good biomechanical strength in large preclinical animal models. This case report aims to show first evidence of the feasibility, safety, and efficacy of mPCL-TCP scaffolds applied in a patient with a long bone segmental defect. CASE PRESENTATION The presented case comprises a 29-year-old patient who has suffered a left-sided II° open femoral shaft fracture. After initial external fixation and subsequent conversion to reamed antegrade femoral nailing, the patient presented with an infection in the area of the formerly open fracture. Multiple revision surgeries followed to eradicate microbial colonization and attempt to achieve bone healing. However, 18 months after the index event, still insufficient diaphyseal bone formation was observed with circumferential bony defect measuring 6 cm at the medial and 11 cm at the lateral aspect of the femur. Therefore, the patient received a patient-specific mPCL-TCP scaffold, fitting the exact anatomical defect and the inserted nail, combined with autologous bone graft (ABG) harvested with the Reamer-Irrigator-Aspirator system (RIA-Synthes®) as well as bone morphogenetic protein-2 (BMP-2). Radiographic follow-up 12 months after implantation of the TE scaffold shows advanced bony fusion and bone formation inside and outside the fully interconnected scaffold architecture. CONCLUSION This case report shows a promising translation of scaffold-based TE from bench to bedside. Preliminary evidence indicates that the use of medical-grade scaffolds is safe and has the potential to improve bone healing. Further, its synergistic effects when combined with ABG and BMP-2 show the potential of mPCL-TCP scaffolds to support new bone formation in segmental long bone defects.
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Affiliation(s)
- Philipp Kobbe
- Department of Orthopaedic Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Markus Laubach
- Department of Orthopaedic Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
- Centre for Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - Dietmar W Hutmacher
- Centre for Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - Hatem Alabdulrahman
- Department of Orthopaedic Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Richard M Sellei
- Department of Trauma Surgery and Orthopaedics, Sana Klinikum, Offenbach, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
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Naruka V, Nardini M, McVie J, Dunning J. The Reamer-Irrigator-Aspirator technique for manubriosternal non-union repair†. Interact Cardiovasc Thorac Surg 2019; 29:327–328. [PMID: 30848816 DOI: 10.1093/icvts/ivz001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/12/2018] [Accepted: 01/06/2019] [Indexed: 11/13/2022] Open
Abstract
Autologous bone graft is used in the treatment of fracture non-unions. A novel approach to treat painful manubriosternal non-unions is described with bone graft harvested from the femur and plating.
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Affiliation(s)
- Vinci Naruka
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Marco Nardini
- Department of Thoracic Surgery, University Hospital Policlinico of Catania, Catania, Italy
| | - James McVie
- Department of Trauma and Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
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Femoral marrow cavity bone harvesting used for arthroscopic refilling of misplaced or enlarged bone tunnels in revision ACL surgery: an arthroscopically supported technique with antegrade intramedullary bone harvesting by a reamer-irrigator-aspirator (RIA) system. Knee Surg Sports Traumatol Arthrosc 2015; 23:808-15. [PMID: 24682491 DOI: 10.1007/s00167-013-2736-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 10/14/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE In anterior cruciate ligament (ACL) revision surgery, refilling of misplaced or enlarged tunnels frequently requires bone harvesting from the iliac crest. Unfortunately, donor-site pain displays a relevant complication. In order to optimize patients' comfort, we developed a procedure combining minimally invasive intramedullary bone harvesting from the femur with arthroscopic tunnel refilling. METHODS Patients with ACL reconstruction failure that were not eligible for one-step revision surgery but required tunnel refilling prior to the next ACL reconstruction were enrolled prospectively. Cancellous bone was harvested intramedullarily from the ipsilateral femur using the reamer-irrigator-aspirator system in a minimally invasive manner. Afterwards, the femoral and tibial tunnels were arthroscopically refilled using cones and push rods. Computer tomography (CT) analyses were carried out before and after the filling procedure. Pain levels were assessed during the entire follow-up. Patients undergoing iliac crest bone harvesting for other reasons served as a control group. Finally, the quality of the newly formed bone stock was evaluated in the subsequent ACL reconstruction procedure. RESULTS Five patients were included during a 6-month period. Prior to refilling, tunnel analysis revealed a mean tunnel volume of 7.9 cm(3) at the femur [SD ± 5.3 cm(3)] and of 6.7 cm(3) [SD ± 5.1 cm(3)] at the tibia. The CT analyses further revealed that graft failure was predominantly caused by tunnel misplacement. Post-operatively, pain levels due to intramedullary bone harvesting were significantly lower compared to iliac crest bone harvesting at every analysed time point. Three to five months after tunnel filling, CT analyses showed sufficiently incorporated bone stocks with filling rates of 75 % femoral and 94 % tibial. ACL revision surgery was performed 4-5 months after tunnel filling without any complication. CONCLUSION Intramedullary bone harvesting from the ipsilateral femur combined with arthroscopic refilling of the bone tunnels ensures a high-quality bone stock for further ACL reconstruction. The clinical relevance is shown by the feasibility of this technique and the significantly reduced pain levels during post-operative recovery.
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Grote S, Prall W. Revision einer VKB-Plastik. ARTHROSKOPIE 2014. [DOI: 10.1007/s00142-014-0828-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Conway JD, Shabtai L, Specht SC, Herzenberg JE. Sequential harvesting of bone graft from the intramedullary canal of the femur. Orthopedics 2014; 37:e796-803. [PMID: 25350622 DOI: 10.3928/01477447-20140825-56] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/30/2014] [Indexed: 02/03/2023]
Abstract
The effectiveness of using the Reamer/Irrigator/Aspirator (RIA) System (Synthes, Inc, West Chester, Pennsylvania) to obtain bone graft from the intramedullary canal of long bones for the treatment of bone defects and nonunions has been previously documented. However, there is nothing in the literature discussing the potential for reaming the same canal at subsequent surgeries. The authors detail their experience of 8 instances of sequential reaming in 7 patients. Six patients were harvested twice, and 1 patient was harvested 3 times. In each patient, the bone graft was obtained from the same canal. The main outcome measurements were time interval between reamings, reamer head size, indication for reaming, volume of harvested bone graft, and complications. Average volume of graft obtained in the first reaming procedure was 34 mL (range, 25-50 mL). After an average of 9 months (range, 3-16 months), the subsequent reaming was performed. Average volume of graft obtained in the second procedure was 45 mL (range, 28-65 mL). In the authors' series, no reaming-related complications were observed. The graft volume was the same or increased during the subsequent intramedullary reaming in all but 1 case, suggesting that the intramedullary canal is a potentially renewable source for bone graft. There were no complications related to the sequential reaming procedure. Overall, the authors' data suggest that sequential reaming with the RIA has the potential to safely and effectively provide a large quantity of bone graft on multiple occasions.
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Massen F, Baumbach S, Volkmer E, Mutschler W, Grote S. Pathologic fracture of the distal radius in a 25-year-old patient with a large unicameral bone cyst. BMC Musculoskelet Disord 2014; 15:202. [PMID: 24925068 PMCID: PMC4064816 DOI: 10.1186/1471-2474-15-202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 06/06/2014] [Indexed: 01/30/2023] Open
Abstract
Background Distal radius fractures (DRF) are often referred to as osteoporosis indicator fractures as their incidence increases from age 45. In the group of young adults, distal radius fractures normally result from high-energy trauma. Wrist fractures in young patients without adequate trauma thus raise suspicion of a pathologic fracture. In this report we present the case of a fractured unicameral bone cyst (UBC) at the distal radius in a young adult. To the author’s best knowledge, this is the first detailed report in an UBC at the distal radius causing a pathologic DRF in an adult patient. Case presentation A 25-year-old otherwise healthy male presented to our Emergency Department after a simple fall on his right outstretched hand. Extended diagnostics revealed a pathologic, dorsally displaced, intra-articular distal radius fracture secondary to a unicameral bone cyst occupying almost the whole metaphysis of the distal radius. To stabilize the fracture, a combined dorsal and volar approach was used for open reduction and internal fixation. A tissue specimen for histopathological examination was gathered and the lesion was filled with an autologous bone graft harvested from the ipsilateral femur using a reamer-irrigator-aspirator (RIA) system. Following one revision surgery due to an intra-articular step-off, the patient recovered without further complications. Conclusions Pathologic fractures in young patients caused by unicameral bone cysts require extended diagnostics and adequate treatment. A single step surgical treatment is reasonable if fracture and bone cyst are treated appropriately. Arthroscopically assisted fracture repair may be considered in intra-articular fractures or whenever co-pathologies of the carpus are suspected.
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Affiliation(s)
- Felix Massen
- Department of Trauma Surgery, Ludwig-Maximilians-University, Nussbaumstrasse 20, 80336 Munich, Germany.
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Donor site morbidity with reamer-irrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single centre 204 case series. Injury 2013; 44:1263-9. [PMID: 23845569 DOI: 10.1016/j.injury.2013.06.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 05/08/2013] [Accepted: 06/08/2013] [Indexed: 02/02/2023]
Abstract
Donor site morbidity and complication rate using the reamer-irrigator-aspirator (RIA) system for intramedullary, non-structural autogenous bone graft harvesting were investigated in a retrospective chart and radiographic review at a University affiliated Level-1 Trauma Centre. 204 RIA procedures in 184 patients were performed between 1/1/2007 and 12/31/2010. RIA-indication was bone graft harvesting in 201 (98.5%), and intramedullary irrigation and debridement in 3 (1.5%) cases. Donor sites were: femur - antegrade 175, retrograde 4, tibia - antegrade 7, retrograde 18. Sixteen patients had undergone two RIA procedures, two had undergone three procedures, all using different donor sites. In 4 cases, same bone harvesting was done twice. Mean volume of bone graft harvested was 47 ± 22ml (20-85 ml). The complication rate was 1.96% (N=4). Operative revisions included 2 retrograde femoral nails for supracondylar femur fractures 6 and 41 days postoperatively (antegrade femoral RIA), 1 trochanteric entry femoral nail (subtrochanteric fracture) 17 days postoperatively (retrograde femoral RIA) and 1 prophylactic stabilization with a trochanteric entry femoral nail for intraoperative posterior femoral cortex penetration without fracture. In our centre, the RIA technique has a low donor site morbidity and has been successfully implemented for harvesting large volumes of nonstructural autogenous bone graft.
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Haugen HJ, Monjo M, Rubert M, Verket A, Lyngstadaas SP, Ellingsen JE, Rønold HJ, Wohlfahrt JC. Porous ceramic titanium dioxide scaffolds promote bone formation in rabbit peri-implant cortical defect model. Acta Biomater 2013; 9:5390-9. [PMID: 22985740 DOI: 10.1016/j.actbio.2012.09.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/07/2012] [Accepted: 09/10/2012] [Indexed: 11/25/2022]
Abstract
Titanium oxide (TiO₂) scaffolds have previously been reported to exhibit very low mechanical strength. However, we have been able to produce a scaffold that features a high interconnectivity, a porosity of 91% and a compressive strength above 1.2 MPa. This study analyzed the in vivo performance of the porous TiO₂ scaffolds in a peri-implant cortical defect model in the rabbit. After 8 weeks of healing, morphological microcomputed tomography analyses of the defects treated with the TiO₂ scaffolds had significantly higher bone volume, bone surface and bone surface-to-volume ratio when compared to sham, both in the cortical and bone marrow compartment. No adverse effects, i.e. tissue necrosis or inflammation as measured by lactate dehydrogenase activity and real-time reverse transcription polymerase chain reaction analysis, were observed. Moreover, the scaffold did not hinder bone growth onto the adjacent cortical titanium implant. Histology clearly demonstrated new bone formation in the cortical sections of the defects and the presence of newly formed bone in close proximity to the scaffold surface and the surface of the adjacent Ti implant. Bone-to-material contact between the newly formed bone and the scaffold was observed in the histological sections. Islets of new bone were also present in the marrow compartment albeit in small amounts. In conclusion, the present investigation demonstrates that TiO₂ scaffolds osseointegrate well and are a suitable scaffold for peri-implant bone healing and growth.
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Giannoudis PV, Ahmad MA, Mineo GV, Tosounidis TI, Calori GM, Kanakaris NK. Subtrochanteric fracture non-unions with implant failure managed with the "Diamond" concept. Injury 2013; 44 Suppl 1:S76-81. [PMID: 23351877 DOI: 10.1016/s0020-1383(13)70017-2] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Subtrochanteric femoral non-unions in the setting of failed metalwork pose a challenging clinical problem. This study assessed the clinical outcome of patients treated according to the principles of the "Diamond" concept. METHODS Between 2007 and 2011 all patients presented with a subtrochanteric atrophic aseptic non-union in the setting of metalwork failure (broken cephalomedullary reconstruction nail), and treated in a single tertiary referral unit were included to this study. The hypertrophic and the non-unions of pathologic fractures were excluded. The revision strategy was based on the "Diamond concept"; optimisation of the mechanical and the biological environment (implantation of growth factor (rhBMP-7), scaffold (RIA bone graft from contralateral femur) and concentrated mesenchymal stem cells (MSCs) harvested from the iliac crest). The minimum follow up was 26 months (16-48). RESULTS Fourteen patients met the inclusion criteria. A specific sequence of metalwork failure was noted with initial breakage of the distal locking screws followed by nail breakage at the lag screw level. The intraoperative examination of the removed nails revealed no gross structural damage indicative of inappropriate drilling at the time of the initial intramedullary nailing. Varus mal-alignment was present in the majority of the cases, with an average of 5.2 degrees (0-11). The average time to distal locking screw failure was 4.4 months (2-8.5) and nail failure was 6.5 months (4-10). The time to union after the revision surgery was 6.8 months (5-12). Complications included two deaths in elderly patients (due to unrelated causes), one pulmonary embolism, one myocardial infarction, one below the knee deep vein thrombosis and one blade plate failure that required further revision with double plating and grafting. CONCLUSION Varus mal-alignment must be avoided in the initial stabilisation of subtrochanteric fractures. Distal locking screw failure is predictive of future fracture non-union and nail breakage. In the absence of sepsis, a single stage procedure based on the "Diamond concept" that simultaneously optimizes the mechanical and biological environment is a successful method for managing complex subtrochanteric atrophic non-unions with failed metalwork.
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Affiliation(s)
- Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK.
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Guerado E, Andrist T, Andrades J, Santos L, Cerván A, Guerado G, Becerra J. Spinal arthrodesis. Basic science. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012. [DOI: 10.1016/j.recote.2012.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Guerado E, Andrist T, Andrades JA, Santos L, Cerván A, Guerado G, Becerra J. [Spinal arthrodesis. basic science]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012; 56:227-44. [PMID: 23594811 DOI: 10.1016/j.recot.2012.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 01/19/2012] [Indexed: 01/01/2023] Open
Abstract
Spinal arthrodesis consists of a combination of a system of mechanical stabilisation of one or more vertebral segments with a biological substance that promotes osteoneogenesis, with aim of achieving the permanent fusion between areas more or less the same size of these segments. In spinal arthrodesis, the biological support par excellence is the autograft. However, obtaining this involves a high incidence of morbidity and, in cases of arthrodesis of more than one intervertebral space, the quantity available is usually insufficient. The extraction and implantation time prolongs the surgery, increasing the exposure to and risk of bleeding and infection. For these reasons, there is a search for substances that possess the properties of the autograft, avoiding the morbidity and added surgical time required to extract the autograft. The biomechanical-biological interaction in vertebral arthrodesis has been studied in this article.
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Affiliation(s)
- E Guerado
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Costa del Sol, Universidad de Málaga, Marbella, Málaga, España.
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Das Reamer-Irrigator-Aspirator (RIA)-System. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2011; 23:446-52. [DOI: 10.1007/s00064-011-0117-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Abstract
The evolution of contemporary intramedullary reaming systems has recently generated the Reamer Irrigator Aspirator system (RIA-Synthes®), which has progressively gained in popularity as well as in indications. The preliminary results of its use over the initial period of 18 months ata single tertiary referral centre were prospectively collected and are presented. The wide spectrum of RIA's indications have been exploited, including 7 patients with polytrauma that underwent acute femoral nailing, 8 with femoral intramedullary osteomyelitis, 9 with pathological lesions of the femoral shaft, as well as 18 patients where the RIA system has been used to harvest morselised autologous bone graft in the presence of recalcitrant atrophie non-unions and bone defects. Overall its use was proven safe and efficient, achieving aggressive medullary canal debridement, collection of adequate samples for further analysis in the infected and oncology cases, as well as impressive volumes of the osteoinductive and osteogenic reaming debris for grafting purposes. No pulmonary complications or evidence of the second hit sequelae were recorded in the polytrauma patient subgroup despite the presence of a high ISS Further controlled clinical studies should follow focused in all different applications of this reliable, user-friendly and impressively versatile system, to validate these preliminary results.
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Abstract
Surgical treatment of spinal fractures consists of postural reduction and segmental arthrodesis, together with an eventual performance of spinal canal decompression. Spinal arthrodesis consists of the combination of a hardware system for mechanical stabilisation together with a biological substance for enhancement of bone formation. To date, autologous graft is the only biological substance demonstrated to possess osteogenic properties. Cancellous bone graft has greater cellular activity than cortical graft, whereas cortical graft is stronger. Consequently, according to biological and biomechanical properties of autograft, spinal posterior arthrodesis is better enhanced by cancellous autograft, whereas anterior interbody tricortical bone is more suitable for anterior fusion. Allograft does not cause harvesting complications as autograft does, and also its amount is theoretically unlimited; nevertheless the rate of bone fusion facilitated by allograft is far from that enhanced by autograft given that allograft has no osteoprogenitor cells. There is little evidence on the efficacy of demineralised bone matrix for spinal fusion. Bone morphogenetic proteins (BMPs) are in use in spinal surgery, but their exact role with respect to type, dose, and carrier, together with their cost-effectiveness, need further clinical delineation. Calcium phosphate compounds appear to be good as carriers; however, they have no osteoinductive or osteogenic properties. Current clinical literature seem to indicate their usefulness for bony fusion in spinal surgery, when combined with bone marrow aspirate or used as an extender for autologous bone graft. Age, length of fusion, location, and concurrent diseases should be definitive for fusion outcome; papers on spinal arthrodesis should neatly stratify these variables. Unfortunately, since that is not the rule, conclusions drawn from current literature are very unreliable. Autograft remains the gold standard, and cancellous bone is advisable in posterolateral approaches, whereas tricortical iliac crest autograft appears appropriate for interbody support. In longer segments, its expansion with BMPs looks safe at least. Basic knowledge has been achieved from animal experiments, and clinical application of the findings to humans should be done very cautiously; in any case, both anterior and posterior arthrodesis must be protected with instrumentation used according to appropriate biomechanical principles. A combination of failure of the correct graft together with proper instrumentation will result in poorer outcome, even if the right graft is used.
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Kovar FM, Wozasek GE. Bone graft harvesting using the RIA (reaming irrigation aspirator) system - a quantitative assessment. Wien Klin Wochenschr 2011; 123:285-90. [PMID: 21487820 DOI: 10.1007/s00508-011-1565-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 03/11/2011] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Autologous bone graft is still considered to be the gold standard for treating non-unions in trauma and orthopedic surgery. Intramedullary bone graft harvest appears to be an alternative to other bone graft options such as iliac crest bone graft and synthetic bone substitutes. A one-step reamer-irrigator-aspirator (RIA) system has been developed to reduce the intramedullary pressure and, as a consequence, minimize the risk of fat embolization. The purpose of this study was to determine whether the quantity of harvested intramedullary bone graft is comparable to the quantity of graft that was harvested from the iliac crest in other studies. The aim of the present study was to quantify harvested bone marrow and to compare our results to already published data. METHODS Eight human cadavers (7 males, 1 female, and 16 limbs) with an average age of 68 years (range, 49-79 years) were obtained for this study. Intramedullary reaming was performed in the tibiae and femora of each cadaver. Two different sizes (12- and 14-mm diameter) of the RIA system were used. After a medial parapatellar incision was made at the knee, antegrade and retrograde reaming were performed in the tibiae and femur to harvest bone graft. RESULTS A significantly greater quantity of bone graft was harvested from the femora (27 ± 12 g) than the tibiae (17 ± 9 g) (p = 0.007). CONCLUSIONS On the basis of our present results, harvesting intramedullary bone graft with the RIA system appears to be an innovative technique for bone grafting in limb reconstruction. A significantly greater quantity of bone graft was harvested from the femora than the tibiae (p = 0.007). No significant differences among age, sex, body weight, bone length, or BMI were observed. Our results showed that a sufficient quantity in weight of autogenous bone graft could be obtained using the RIA system.
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Affiliation(s)
- Florian M Kovar
- Department of Traumatology, General Hospital Vienna, Medical University Vienna, Vienna, Austria
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20
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Abstract
A case of postoperative fracture in the donor femur after obtaining autologous bone graft with a reamer/irrigator/aspirator is presented. This procedure was successful in healing a difficult femoral nonunion, but the patient sustained a fracture of the contralateral (bone graft donor) femur 20 days after surgery. A mechanical analysis is conducted of this case and recommendations are made. Unrestricted weightbearing on a limb that has undergone reamer/irrigator/aspirator bone graft harvesting, particularly in a noncompliant patient, is probably inadvisable. If possible, one should obtain bone graft from the same limb as the fracture being treated because this will leave the patient with one unaltered limb for mobilization.
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Cuttica DJ, DeVries JG, Hyer CF. Autogenous bone graft harvest using reamer irrigator aspirator (RIA) technique for tibiotalocalcaneal arthrodesis. J Foot Ankle Surg 2010; 49:571-4. [PMID: 20851005 DOI: 10.1053/j.jfas.2010.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 07/30/2010] [Indexed: 02/03/2023]
Abstract
Tibiotalocalcaneal arthrodesis is a technically demanding procedure that can be associated with a high number of complications, including nonunion. Bone grafting is commonly used in arthrodesis procedures to decrease the risk of nonunion. In this article, we describe a technique that uses a reamer-irrigator-aspirator (RIA) method for procurement of autogenous bone graft for use in tibiotalocalcaneal arthrodesis fixated with a retrograde intramedullary nail. Using the RIA technique, autogenous bone graft can be readily obtained without the need for additional incisions and dissection, thereby minimizing the need for additional sources of bone graft.
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Abstract
Bone grafting is involved in virtually every procedure in reconstructive orthopaedic surgery. Although autologous bone grafts have excellent biologic and mechanical properties, considerable donor site morbidity and the limited volume available must be taken into consideration. Currently, there are no heterologous or synthetic bone substitutes available that have superior biologic or mechanical properties. This review article summarizes the biologic and mechanical properties of autologous bone grafts, differentiates various autologous bone graft types, and compares them with other bone substitutes.
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Sabetrasekh R, Tiainen H, Lyngstadaas SP, Reseland J, Haugen H. A Novel Ultra-porous Titanium Dioxide Ceramic with Excellent Biocompatibility. J Biomater Appl 2010; 25:559-80. [DOI: 10.1177/0885328209354925] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The current study compares biocompatibility, cell growth and morphology, pore diameter distribution, and interconnectivity of a novel titanium dioxide (TiO2) bone graft substitute granules with three different commercially available bone graft granules Natix®, Straumann® BoneCeramic, and Bio-Oss®. Human primary mesenchymal stem cells were cultured on the bone graft substitutes and cell viability and proliferation were evaluated after 1 and 3 days. The microstructural properties of the bone graft substitutes were evaluated by scanning electron microscopy, micro-computed tomography analysis, and mechanical testing. The cell viability and proliferation, porosity, interconnectivity, open pore size, and surface area-to-volume ratio of TiO2 granules were significantly higher than commercial bone granules (Bio-Oss® and Straumann ® BoneCeramic).
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Affiliation(s)
- Roya Sabetrasekh
- Department for Biomaterials, Faculty for Dentistry, University of Oslo NO-0317 Oslo, Norway
| | - Hanna Tiainen
- Department for Biomaterials, Faculty for Dentistry, University of Oslo NO-0317 Oslo, Norway
| | - S. Petter Lyngstadaas
- Department for Biomaterials, Faculty for Dentistry, University of Oslo NO-0317 Oslo, Norway
| | - Janne Reseland
- Department for Biomaterials, Faculty for Dentistry, University of Oslo NO-0317 Oslo, Norway
| | - Håvard Haugen
- Department for Biomaterials, Faculty for Dentistry, University of Oslo NO-0317 Oslo, Norway,
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Tarkin IS, Siska PA, Zelle BA. Soft tissue and biomechanical challenges encountered with the management of distal tibia nonunions. Orthop Clin North Am 2010; 41:119-26; table of contents. [PMID: 19931060 DOI: 10.1016/j.ocl.2009.07.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A thoughtful treatment algorithm is required to optimally treat distal tibia nonunion. A healthy respect for the tenuous soft tissue envelope, compromised vascularity, and challenging mechanical environment is advisable. Achieving osseous union and improved functionality requires an individualized plan of care based on the personality of the nonunion and host. Attention must be focused on providing mechanical stability at the site of nonunion and providing biologic supplementation.
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Affiliation(s)
- Ivan S Tarkin
- Department of Orthopedic Surgery, Division of Traumatology, University of Pittsburgh, 3471 Fifth Avenue, Suite 911, Pittsburgh, PA 15213, USA.
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Complications associated with negative pressure reaming for harvesting autologous bone graft: a case series. J Orthop Trauma 2010; 24:46-52. [PMID: 20035178 DOI: 10.1097/bot.0b013e31819c0ccb] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A technical benefit of the reamer-irrigator-aspirator (RIA) system (Synthes, Paoli, PA) is the ability to harvest large volumes (40-90 cm3) of autogenous bone graft. Early evaluations of this technique have reported few problems, all of which were attributed to technical error. This case series reviews 6 RIA-associated complications including 4 fractures and their contributing risk factors. Cases were collected from 4 independent orthopaedic centers, and all patients underwent RIA bone graft harvesting in a lower extremity long bone injuries. In this population, 2 patients experienced acute RIA-associated events, necessitating an additional procedure or altered postoperative rehabilitation, whereas 4 patients fractured through their donor site in the early postoperative period. This series suggests that surgeons should (1) preoperatively assess cortical diameters at long bone harvest sites, (2) carefully monitor intraoperative reaming, and (3) avoid RIA bone graft harvesting in patients with a history of osteoporosis or osteopenia unless postharvest intramedullary stabilization is considered.
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Technical tricks when using the reamer irrigator aspirator technique for autologous bone graft harvesting. J Orthop Trauma 2010; 24:42-5. [PMID: 20035177 DOI: 10.1097/bot.0b013e3181b2b4eb] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This report describes technical tricks for using the reamer irrigator aspirator to harvest autologous bone graft from the femur. This device is a focus of interest in orthopaedics because it can be used to harvest bone graft from the femoral canal and medial condyle in voluminous quantities. Moreover, according to some authors, the osteogenic potential of this graft is at least as effective as that of autogenous bone obtained from the iliac crest. The reamer irrigator aspirator device has substantially different design characteristics and technicalities compared with those of a standard reamer. First, a guidewire must be redirected into multiple areas, including the center of the distal femur and into both condyles, to harvest ample bone graft. This is accomplished by prebending the guidewire in a stronger fashion than required for regular reaming in the case of femoral nailing procedures. This bend can increase the risk for eccentric reaming as well as lodging of the suctioning device within the femoral canal. Second, the front and lateral drilling surfaces of this device are very sharp and further cleaned and maintained sharp by the irrigation process to permit the surgeon to obtain significant volumes of graft with a single passage of this device. At the same time, however, this sharp front-end cutting design can increase the risk of iatrogenic fracture if reaming is performed without caution. Third, a powerful suctioning device is connected to the reamer such that the blood loss that can occur during continuous reaming, irrigation, and aspiration must be considered with this technique. We hereby discuss these potential dangers and describe the correct use of this device with technical tricks to minimize the risk of unexpected intraoperative events.
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Huffman LK, Harris JG, Suk M. Using the bi-masquelet technique and reamer-irrigator-aspirator for post-traumatic foot reconstruction. Foot Ankle Int 2009; 30:895-9. [PMID: 19755076 DOI: 10.3113/fai.2009.0895] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Level of Evidence: V, Expert Opinion
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Belthur MV, Conway JD, Jindal G, Ranade A, Herzenberg JE. Bone graft harvest using a new intramedullary system. Clin Orthop Relat Res 2008; 466:2973-80. [PMID: 18841433 PMCID: PMC2628246 DOI: 10.1007/s11999-008-0538-3] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 09/10/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED Obtaining autogenous bone graft from the iliac crest can entail substantial morbidity. Alternatively, bone graft can be harvested from long bones using an intramedullary (IM) harvesting system. We measured bone graft volume obtained from the IM canals of the femur and tibia and documented the complications of the harvesting technique. Donor site pain and the union rate were compared between the IM and the traditional iliac crest bone graft (ICBG) harvest. Forty-one patients (23 male, 18 female) with an average age of 44.9 years (range, 15-78 years) had graft harvested from long bones using an IM harvest system (femoral donor site, 37 patients; tibial donor site, four patients). Forty patients (23 male, 17 female; average age, 46.4 years; range, 15-77 years) underwent anterior ICBG harvest. We administered patient surveys to both groups to determine pain intensity and frequency. IM group reported lower pain scores than the ICBG group during all postoperative periods. Mean graft volume for the IM harvest group was 40.3 mL (range, 25-75 mL) (graft volume was not obtained for the ICBG group). Using an intramedullary system to harvest autogenous bone graft from the long bones is safe provided a meticulous technique is used. LEVEL OF EVIDENCE Level III, retrospective comparative study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Janet D. Conway
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
| | - Gaurav Jindal
- Children’s Healthcare of Atlanta at Scottish Rite, Atlanta, GA USA
| | - Ashish Ranade
- Shriners Hospitals for Children, Philadelphia, PA USA
| | - John E. Herzenberg
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215 USA
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Pape HC, Tarkin IS. Reamer Irrigator Aspirator: A New Technique for Bone Graft Harvesting from the Intramedullary Canal. ACTA ACUST UNITED AC 2008. [DOI: 10.1053/j.oto.2008.08.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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30
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Tarkin IS, Sojka JM. Biomechanical Strategies for Managing Atrophic and Oligotrophic Nonunions. ACTA ACUST UNITED AC 2008. [DOI: 10.1053/j.oto.2008.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Watson JT. Nonunion with Extensive Bone Loss: Reconstruction with Ilizarov Techniques and Orthobiologics. ACTA ACUST UNITED AC 2008. [DOI: 10.1053/j.oto.2008.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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