Autograft versus allograft for benign lesions in children

Benign bone lesions in children are often so large in size that there is not an adequate amount of bone available for an autograft to fill the resultant cavity after surgical curettage. This study compared autografts and allografts with respect to the time required and the success of graft incorporation. Fifty-four patients with 61 lesions were studied. Lesions were classified as small volume (less than 60 cc) or large volume (more than 60 cc) and were separated into four groups: small-volume autograft, large-volume autograft, small-volume allograft, and large-volume allograft. Allografts appeared comparable to autografts when small-volume lesions were treated. The healing time was slightly longer for allografts with an average period of 21 months versus 27 months for autografts. Autografts were superior to allografts in rate and completeness of healing for solitary large lesions. This increased efficacy presumes a somewhat older child in which an adequate amount of bone is available for an autograft. A young child with multicentric or polyostotic lesions can still achieve successful incorporation with allografts. In this study, 38% healed completely and 29% healed partially. Allografts have a distinct place in the treatment of benign bone lesions in children.     

The syndromes of degenerative cervical disease.

Senescence of the cervical spinal motion segment is manifest by changes in each anatomic component. The pathoanatomical change that predominates varies from one person to the next. Sufficient compromise of local neural structures will precipitate the onset of symptoms. The pattern of symptoms and any associated physical signs will vary according to which structures are stimulated or compressed. Radicular and myelopathic syndromes are produced by nerve root and spinal cord compression, respectively. These patterns can occur individually or in combination. Other less clearly understood patterns of local and referred symptoms may be mediated by the sinu-vertebral nerves or the medial branches of the posterior ramus. Techniques for the precise diagnosis of these syndromes are needed. Separating patterns of symptomatic degenerative cervical disease from other causes of neck, shoulder, and arm symptoms rests on an awareness of the broad spectrum of subjective complaints, a thorough physical examination, and confirmatory diagnostic studies. Clear delineation of the etiology will increase the likelihood of successful treatment.     

Threaded cages for degenerative cervical disease.

Multiple techniques are used to accomplish anterior interbody fusion in the cervical spine. These various options reflect the lack of any one approach to obtain superior results. Extrapolating from the lumbar spine experience, a cervical cage was proposed as an alternative to the status quo. A device evaluation study was done to determine the safety and efficacy of the cage with a comparison with current allograft or autograft fusion techniques. The study resulted in two publications. One study is a multicenter trial whereas the other is a one-author study with long-term results. A review of the data from both studies follows. Comparable outcomes were seen with the allograft and autograft control group and the experimental group in the multicenter trial. However, that study reported significantly better fusion rates for the patients with cervical cages compared with the control group. Both studies reported a high percentage of donor site morbidity in the patients in the control group who had autograft fusion. A trend toward better outcomes for patients who received a cervical cage was seen in the long-term followup study. The data presented suggest interbody fusion cages are a safe and effective treatment of degenerative cervical disc disorders and avoid iliac crest donor site morbidity.     

同种异体椎间盘移植治疗颈椎间盘疾患的安全性及疗效

【摘要】 目的：探讨同种异体颈椎间盘移植的安全性与可行性,分析多中心同种异体椎间盘移植治疗颈椎间盘疾患的临床疗效。方法：前瞻性、非双盲观察同种异体颈椎间盘移植治疗颈椎间盘疾患的临床疗效。全组共27例,男22例,女5例;年龄37~58岁,平均45岁。所有病例均为颈椎退行性疾病患者,其中脊髓型颈椎病20例,颈椎间盘突出症7例。均经颈前入路手术行同种异体椎间盘移植,不使用任何内固定。术后常规行血常规等化验检查,定期复查颈椎X线片、CT及MRI,分别观察椎间盘愈合情况,测量移植椎间盘信号灰度值及钆喷酸葡胺对移植椎间盘的增强成像情况。临床功能分别采用疼痛VAS评分、颈椎功能障碍指数（NDI）及JOA评分系统评估,全身情况采用SF-36功能量表评估。结果：平均手术时间1.5h,平均失血量55ml。术后血常规等检查均正常,无感染、脱位等并发症。伤口均一期愈合。术后各随访时间点患者颈肩及上肢疼痛VAS评分、NDI、JOA评分、SF-36均较术前显著性改善（P<0.05）。随着随访时间延长,移植椎间盘高度有下降趋势,随访120个月的患者为4.08±1.75mm,是术后即刻高度的76%;屈伸活动度与术后即刻比较有增加趋势,随访120个月的患者为9.91°±4.65°;移植椎间盘MRI信号灰度值术后即刻为0.39±0.08,随访120个月的患者为0.15±0.07（P<0.05）。钆喷酸葡胺MRI增强扫描6h椎间盘灰度值达0.62±0.04,与增强前（0.28±0.06）比较有显著性差异（P<0.05）。移植椎间盘的旋转活动中心术后逐渐向椎间盘后下方移动,与术前比较在X、Y轴上均有显著性变化（P<0.05）。结论：同种异体椎间盘移植的临床应用是安全和可行的,远期虽有退变但仍能保持良好椎间高度与活动度,椎间盘营养通道得以重建,旋转活动中心趋向生理中心。是颈椎间盘退行性疾病外科治疗的一种新途径。     

Adhesions in a murine flexor tendon graft model: Autograft versus allograft reconstruction

Reconstruction of flexor tendons often results in adhesions that compromise joint flexion. Little is known about the factors involved in the formation of flexor tendon graft adhesions. In this study, we developed and characterized a novel mouse model of flexor digitorum longus (FDL) tendon reconstruction with live autografts or reconstituted freeze‐dried allografts. Grafted tendons were evaluated at multiple time points up to 84 days post‐reconstruction. To assess the flexion range of the metatarsophalangeal joint, we developed a quantitative outcome measure proportional to the resistance to tendon gliding due to adhesions, which we termed the Gliding Coefficient. At 14 days post‐grafting, the Gliding Coefficient was 29‐ and 26‐fold greater than normal FDL tendon for both autografts and allografts, respectively (p < 0.001), and subsequently doubled for 28‐day autografts. Interestingly, there were no significant differences in maximum tensile force or stiffness between live autograft and freeze‐dried allograft repairs over time. Histologically, autograft healing was characterized by extensive remodeling and exuberant scarring around both the ends and the body of the graft, whereas allograft scarring was abundant only near the graft–host junctions. Gene expression of GDF‐5 and VEGF were significantly increased in 28‐day autografts compared to allografts and to normal tendons. These results suggest that the biomechanical advantages for tendon reconstruction using live autografts over devitalized allografts are minimal. This mouse model can be useful in elucidating the molecular mechanisms in tendon repair and can aid in preliminary screening of molecular treatments of flexor tendon adhesions. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:824–833, 2008     

Autograft versus allograft with or without demineralized bone matrix in posterolateral lumbar fusion in rabbits. Laboratory investigation

OBJECT: Posterolateral spinal fusions are performed to treat different spinal disorders. Autograft continues to be the gold standard; it is, however, associated with donor site morbidity and limited sources. Allograft has been used, but has been reported to result in lower fusion rates. Demineralized bone matrix (DBM) has also been used and reportedly increases the fusion rate in a variety of critical defect models. Different forms of DBM are available, not all have been independently studied. To evaluate the effect of a xenogenic DBM added to allograft on the fusion rate of posterolateral lumbar spine arthrodesis the authors designed an experimental study comparing posterolateral fusion rate using autograft, allograft, and allograft plus a xenogenic DBM in a validated animal model. METHODS: A bilateral, 1-level (L4-5) intertransverse process fusion was performed in 45 male New Zealand rabbits. Iliac crest bone graft was harvested bilaterally from each rabbit. The rabbits were randomly assigned to 3 groups: Group I, Autograft, 15 rabbits; Group II, Allograft, 15 rabbits; and Group III, Allograft plus DBM in a paste form (Dynagraft). The animals were killed 8 weeks after surgery. Fusion was assessed radiographically and by manual palpation by 2 independent observers. The results were analyzed using the Fisher exact test and chi-square test. RESULTS: The fusion rate was 46.6% (7 of 15 rabbits) in the autograft group, 33.3% (5 of 15 rabbits) in the allograft group, and 33.3% (5 of 15 rabbits) in the allograft plus DBM group (p > 0.05). CONCLUSIONS: Autograft produced a higher fusion rate than allograft in this spinal fusion rabbit model, but the difference was not statistically significant. Allograft plus xenogenic DBM showed the same fusion rate as allograft alone.     

Correlative radiological, self-assessment and clinical analysis of evolution in instrumented dorsal and lateral fusion for degenerative lumbar spine disease. Autograft versus coralline hydroxyapatite

This prospective longitudinal randomized clinical and radiological study compared the evolution of instrumented posterolateral lumbar and lumbosacral fusion using either coralline hydroxyapatite (CH), or iliac bone graft (IBG) or both in three comparable groups, A, B and C, which included 19, 18 and 20 patients, respectively, who suffered from symptomatic degenerative lumbar spinal stenosis and underwent decompression and fusion. The patients were divided randomly according to the graft used and the side that it was applied. The spines of group A received autologous IBG bilaterally; group B, IBG on the left side and hydroxyapatite mixed with local bone and bone marrow on the right side; group C, hydroxyapatite mixed with local bone and bone marrow bilaterally. The age of the patients in the groups A, B and C was 61±11 years, 64±8 years and 58±8 years, respectively. The SF-36, Oswestry Disability Index (ODI), and Roland-Morris (R-M) surveys were used for subjective evaluation of the result of the surgery and the Visual Analogue Scale (VAS) for pain severity. Plain roentgenograms including anteroposterior, lateral and oblique views, and lateral plus frontal bending views of the instrumented spine and CT scan were used to evaluate the evolution of the posterolateral fusion in all groups and sides. Two independent senior orthopaedic radiologists were asked to evaluate first the evolution of the dorsolateral bony fusion 3–48 months postoperatively with the Christiansens radiologic method, and secondly the hydroxyapatite resorption course in the spines of groups B and C. The diagnosis of solid spinal fusion was definitively confirmed with the addition of the bending views, CT scans and self-assessment scores. The intraobserver and interobserver agreement (r) for radiological fusion was 0.71 and 0.69, respectively, and 0.83 and 0.76 for evaluation of CH resorption. T₁₂–S₁ lordosis and segmental angulation did not change postoperatively. There was no radiological evidence for non-union on the plain roentgenograms and CT scans. Radiological fusion was achieved 1 year postoperatively and was observed in all groups and vertebral segments. Six months postoperatively there was an obvious resorption of hydroxyapatite granules at the intertransverse intersegmental spaces in the right side of the spines of group B and both sides of group C. The resorption of hydroxyapatite was completed 1 year postoperatively. Bone bridging started in the third month postoperatively in all instrumented spines and all levels posteriorly as well as between the transverse processes in the spines of the group A and on the left side of the spines of group B where IBG was applied. SF-36, ODI, and R-M score improved postoperatively in a similar way in all groups. There was one pedicle screw breakage at the lowermost instrumented level in group A and two in group C without radiologically visible pseudarthrosis, which were considered as having non-union. Operative time and blood loss were less in the patients of group C, while donor site complaints were observed in the patients of the groups A and B only. This study showed that autologous IBG remains the gold standard for achieving solid posterior instrumented lumbar fusion, to which each new graft should be compared. The incorporation of coralline hydroxyapatite mixed with local bone and bone marrow needs adequate bleeding bone surface. Subsequently, hydroxyapatite was proven in this series to not be appropriate for intertransverse posterolateral fusion, because the host bone in this area is little. However, the use of hydroxyapatite over the decorticated laminae that represents a wide host area was followed by solid dorsal fusion within the expected time.     

颈椎Modic改变与颈椎退行性疾病的关系

目的探讨颈椎Modic改变与颈椎退行性疾病之间的关系。方法对78例Modic改变患者的颈椎退行性疾病进行统计,分析其与Modic改变之间的关系。结果 78例患者中30例(38.5%)诊断为轻度颈椎退行性疾病,26例(33.3%)诊断为中度颈椎退行性疾病,22例(28.2%)诊断为重度颈椎退行性疾病。结论颈椎Modic改变好发于老年患者,以Ⅱ型改变居多,多发生于C5~6、C6~7节段,与颈椎退行性疾病的程度无明显关系。     

颈椎带锁钢板治疗颈椎退变性疾病

目的 探讨前路减压，植骨，颈椎带锁钢板固定治疗颈椎退变性疾病的疗效。方法 23例脊髓型颈椎病和颈椎后纵韧带骨化患者行颈前路钢板固定融合。术前，术后，随访期间评估患者神经状况。平均随访时间11.3个月。结果 所有患者植骨融合，并发症包括伤口大血肿1例，声音嘶哑1例，患者神经功能均改善。结论 前路减压，植骨，颈椎带锁网板固定治疗颈椎退变性疾病疗效满意。     

A meta-analysis of autograft versus allograft in anterior cervical fusion

We performed a meta-analysis of one- and two-level anterior cervical interbody fusion (ACDF) on data derived from published, peer-reviewed journal articles to determine whether there is a difference in fusion rate, graft complications, or clinical outcome in patients undergoing ACDF according to whether autograft or allograft was used. ACDF is a common procedure for cervical spondylotic radiculopathy. Most published studies comparing autograft and allograft have not demonstrated any difference between grafts. The medical literature dating from 1955 was reviewed. Of 395 titles, only four studies comparing autograft with allograft in ACDF were appropriate for this analysis. The data from these studies – 310 patients and 379 intervertebral levels – were pooled and statistical methods were applied. For both one- and two-level ACDF, autograft demonstrated a higher rate of radiographic union and a lower incidence of graft collapse. It was not possible to ascertain whether autograft is clinically superior to allograft. Although autograft has a higher fusion rate than allograft, clinical results do not depend solely on radiographic results. The risk of graft site morbidity and patient preference should be considered when choosing the type of graft for this operation. Received: 29 November 1999/Revised: 29 February 2000/Accepted: 23 March 2000     

Anterior microsurgical approach for degenerative cervical disc disease

Summary One hundred-ninety-six patients with spinal cord or nerve root compression were operated on by anterior microsurgical discectomy without graft between 1978 and 1987. The patients presented either with spinal cord compression (33%) or radicular symptoms with a duration of 12 days to more than then years (66%). Investigations to confirm these clinical syndromes employed myelography, CT or MRI. Two-hundred-eighty-eight levels were explored; 124 one level, 54 two level, 17 three level and 2 four level operations were done. The follow-up (mean 6.7 years) showed 66% of the patients with excellent or good results after two years. The low risks of anterior discectomy were further diminished with skilful microsurgical technique without intercorporeal fusion.A comparison of our results at follow-up with published series, in which the anterior approach was used but with intervertebral autologous bone graft after disc removal, shows no significant differences. We therefore recommend the anterior microsurgical discectomy without fusion as the treatment of choice.     

对混合术式治疗颈椎退变性疾病的思考

颈前路减压融合术（anterior cervical discectomy and fusion, ACDF/anterior cervical corpectomy and fusion,ACCF）治疗颈椎退行性疾病经历了半个多世纪的应用,临床疗效肯定。然而融合术后融合节段活动度丧失、邻近节段退变等问题困扰着脊柱外科医师。颈椎人工椎间盘置换术（CADR）可实现病变节段的彻底减压,重建颈椎序列,保留置换节段生物力学环境,是对融合手术的重要补充。经过十几年的迅速发展,学者们对CADR的研究逐渐深入,其临床应用病例不断增多,但是适应证的选择、术后异位骨化（heterotopic ossification,HO）、假体下沉、是否可以有效降低邻近节段退变（adjacent segment degeneration,ASD）等问题已成为人们关注的焦点。我们在激烈争论的同时,应该冷静思考：既然二者各有优缺点,能否寻找一种新的术式,综合CADR与ACDF/ACCF的优点,尽可能减少二者的缺点,获得满意的临床疗效？而且随着社会的不断进步,人们对疾病治疗效果的认知更注重于生活质量的保证。对于脊柱外科医师来说,选择最佳的手术方式,解除疾病带来的痛苦,改善和提高患者生活质量是治疗疾病的终极目标。     

Imaging of degenerative disease of the cervical spine

The introduction of new techniques to the magnetic resonance imaging (MRI) armamentarium is beginning to provide an MRI examination that overcomes many of the disadvantages noted in earlier reports. An analysis of the various advantages and disadvantages of MRI, plain film myelography, and computed tomographic myelography points to a potential revision of the sequence of diagnostic studies and the workup of cervical degenerative disease. MRI might now be the appropriate first test for the evaluation of the cervical spine in a patient with symptoms referable to degenerative disease when therapeutic intervention is considered. An initial T1-weighted sagittal image with a 3-mm slice thickness will provide excellent contrast evaluation of the vertebral body marrow, disc space height, neural canal, and spinal cord. Disc herniation, canal stenosis, subluxation, and malalignment can be appreciated. Next, a fast, variable flip angle, gradient-echo sequence can be performed to increase the signal density of the cerebrospinal fluid relative to the extradural elements and cord. This provides an increased conspicuousness of extradural disease. Axial gradient-echo fast sequences, with low flip angles, will provide a second orthogonal plane with increased conspicuousness of extradural changes relative to the neural foramen and thecal sac. If necessary, additional oblique views through the neural foramen can be obtained. Finally, if intramedullary disease is considered in the differential, a gated, refocused, T2-weighted examination in the sagittal plane will provide the necessary soft-tissue contrast to detect pathology without unwanted artifact. Thus, unlike plain film or computed tomographic myelography, an examination of the entire cervical region including the osseous structures, extradural cerebrospinal fluid interface, and the spinal cord can be obtained with a single modality in an outpatient setting and in a noninvasive fashion. MRI can certainly replace plain film myelography for the overwhelming majority of situations. If surface-coil MRI fails to demonstrate an abnormality responsible for the patient's clinical symptoms, then a high-resolution computed tomographic scan with or without intrathecal contrast can be obtained. While the cost at first may seem prohibitive, the additional information that MRI is capable of providing in a noninvasive outpatient setting more than compensates for the expense.     

Differences between arthroplasty and anterior cervical fusion in two-level cervical degenerative disc disease

Purpose

Although arthroplasty is an accepted option for two-level disease, there is a paucity of data regarding outcomes of two-level cervical arthroplasty. The current study was designed to determine differences between two-level cervical arthroplasty and anterior fusion.

Methods

Seventy-seven consecutive patients who underwent two-level anterior cervical operations for degenerative disc disease were divided into the arthroplasty (37 patients) and fusion (40 patients) groups. Clinical outcomes were measured by Visual Analogue Scale (VAS) of neck and arm pain, Japanese Orthopedic Association (JOA) scores, and Neck Disability Index (NDI). Every patient was evaluated by radiography and computed tomography for fusion or detection of heterotopic ossification.

Results

Thirty-seven patients (with 74 levels of Bryan discs) were compared with 40 patients who had two-level anterior fusion (mean follow-up of 39.6 ± 6.7 months). There was no difference in sex, but the mean age of the arthroplasty group was significantly younger (52.1 ± 9.1 vs. 63.0 ± 10.6 years, p < 0.001). The mean estimated blood loss was similar (p = 0.135), but the mean operation time was longer in the arthroplasty group (315.5 ± 82.0 versus 224.9 ± 61.8 min, p < 0.001). At 24 months post-operation, the arthroplasty group had increased their range of motion than pre-operation (23.5° versus 20.1°, p = 0.018). There were significant improvements in neck or arm VAS, JOA scores, and NDI in both groups. However, there were no differences in clinical outcomes or adverse events between the two groups.

Conclusions

Clinical outcomes of two-level arthroplasty and anterior cervical fusion are similar 39.6 months after surgery. Cervical arthroplasty preserves mobility at the index levels without increased adverse effects.     

Autograft versus allograft reconstruction of acute tibial plateau fractures: a comparative study of complications and outcome

Background

There is no consensus regarding the use of filling agent in the re-elevation of depressed tibial plateau fracture (TPF). Although autograft is considered as the gold standard approach of such reconstructions, its limitation has led to a recent attraction toward allograft substitution. In this study, we compare the complications and outcome of autograft and allograft in TPF reconstruction, in order to address the existing controversy.

Materials and methods

A total of 81 patients with acute TPF were included in this study. Allograft and autograft were applied in 58 and 23 cases, respectively. The mean age of the patients was 40.26 years, and the mean follow-up period of patients was 19.1 months. Clinical and radiological assessment of the outcome was conducted, employing the modified Rasmussen clinical criteria.

Results

A total of three infections were observed in our patients, from which two infections occurred in allograft received patients. Articular surface collapse was seen in two cases, including one allograft and one autograft receiving patient. The mean clinical score was 18.65 and 18.55 in autograft and allograft received patients, respectively (p = 0.09). The mean radiological score was 15.65 and 15.68 in autograft and allograft received patients (p = 0.3).

Conclusion

With respect to the comparable complication rate, clinical and radiological outcome of allogenic versus autologous reconstruction of TPF, freeze-dried allograft could be recommended as an appropriate substitute of autograft in this treatment. Nevertheless, the longer follow-up period of the patients could further extend our understanding of the clinical outcome of each component.