骨盆髂嵴外固定架Schanz钉置钉区域的影像学研究

目的:对骨盆髂嵴外固定架Schanz钉置钉区域进行影像学研究以指导置钉.方法:将筛选出的9例成人正常骨盆的2.0 mm层厚轴向CT扫描结果导入MIMICS 10.0软件.通过后者将髂嵴外固定架Schanz钉置钉区域,即位于髂前上棘及臀中肌结节之间的、髋臼之上的髋臼前柱的高位部分,进行真正矢状面及冠状面重建.然后应用该软件的测量工具于重建面上进行测量,最后对测量结果进行分析.结果:位于髂前上棘前缘后方16.5 mm宽度为49.6 mm的髂嵴节段可用作定位髂嵴外固定架Schanz钉的进钉点.该节段髂嵴所覆盖骨质相对丰厚及纵深,可完全容纳直径为5.0 mm的Schanz钉,并可经髂嵴将该直径的螺钉最浅打入71.7 mm至髋臼顶及最深打入143.5 mm至髋臼后方相对致密的骨质.结论:本研究结果可用于指导髂嵴外固定Schanz钉的置入,于上述进钉点区域将Schanz钉朝向髋臼或其后方打入臼顶或臼后相对致密的骨质以获得较好的把持力从而增强固定效果.     

How can we optimize anterior iliac crest bone harvesting? An anatomical and radiological study

Purpose

Anterior iliac crest bone is a widely used donor site for bone harvesting. It provides an autologous bone graft consisting of cancellous bone that can be packed or cortical bone with greater structural support. Uses include spinal fusion and fracture non-union surgery. Although its use is common, dedicated anatomical and radiological studies analysing graft dimensions and optimal harvesting site in relation to local anatomical landmarks [anterior superior iliac spine (ASIS), anterior iliac tubercle (AIT) and lateral femoral cutaneous nerve (LFCN)] have not been described.

Methods

Twenty-eight female hemipelvises were dissected for this study. The LFCN, ASIS and AIT were identified. Calliper measurements and CT scan analysis were undertaken to determine the optimum positions in obtaining a 5-mm-thickness tricortical graft whilst remaining safe for the LFCN.

Results

According to our measurements, the optimal location for harvesting a 5-mm-thick tricortical graft with 35-mm height and 47-mm width is situated anterior to a line passing at the level of the thickest point of the AIT. This thickest point was situated at a mean 67 mm from the centre of the EIAS in our study.

Conclusion

This anatomical and radiographic study determined the anatomical iliac crest landmarks to avoid neurological injury when taking an optimal 5-mm-width tricortical bone graft.     

Relationships between bone structure in the iliac crest and bone structure and strength in the lumbar spine

The purpose of this study was to examine the relationship between histomorphometric variables of cancellous bone structure and ultimate compressive strength (UCS) in the second lumbar vertebra (L2) and to determine whether structural variables in the iliac crest are predictive of the same variables and of UCS in L2. At autopsy, 7.5 mm diameter cores were removed from the iliac crest and from L2 of 29 subjects who had died suddenly without bone disease. Cancellous bone volume (BV/TV, %) was significantly lower in L2 than in iliac crest due to lower trabecular number (Tb.N, per mm) and thickness (Tb.Th, µm). There were significant correlations between iliac crest and L2 for BV/TV, Tb.N and trabecular separation (Tb.Sp, µm), but not for Tb.Th. BV/TV was negatively correlated, and Tb.Sp was positively correlated with age at both sites. Tb.Th was not significantly correlated with age in the iliac crest, but a significant negative correlation was observed in L2. The UCS of vertebral cores was negatively correlated with age. BV/TV and Tb.Th in L2 were positively correlated with UCS in L2. Cortical width and BV/TV in iliac crest were positively correlated with UCS in L2. We conclude that: (1) cancellous bone volume in the iliac crest is higher than in the lumbar spine due to thicker, more closely spaced trabecular plates, (2) the changes in structural variables with age are generally similar in the iliac crest and lumbar vertebra, but trabecular thinning with age is more evident in the spine than in the ilium, and (3) the compressive strength of cancellous bone in the lumbar spine is correlated with histomorphometric variables of bone structure, as measured both in the lumbar spine and in the iliac crest.     

Understanding bone safety zones during bone marrow aspiration from the iliac crest: the sector rule

Purpose

Should the trocar suddenly lose contact with bone during bone marrow aspiration, it may result in visceral injury. The anatomy of the ilium and the structures adjacent to the iliac bone were studied to determine the danger of breach by a trocar introduced into the iliac crest.

Methods

The authors followed two series of patients, one series to do measurements of distance and angles of the structures at risk to the iliac bone and the other to evaluate the risk of a trocar being directed outside the iliac wing during bone marrow aspiration. The authors also examined 24 pelvices by computed tomography (CT) scans of mature adults (48 iliac crests). Lines dividing the iliac wing into six equal sectors were used to form sectors (e.g. sector 1 anterior, sector 6 posterior). Vascular or neurological structures were considered at risk if they were accessible to the tip of a 10-cm trocar introduced into the iliac crest with a possible deviation of 20° from the plane of the iliac wing on the three-dimensional reconstruction. The authors tracked bone marrow aspiration of six different surgeons and calculated among 120 patients (480 entry points) the number of times the needle lost contact with bone in each sector of aspiration.

Results

The sector system reliably predicted safe and unsafe areas for trocar placement. Among the 480 entry points in the 120 patients, 94 breaches were observed and higher risks were observed in the thinner sectors. The risk was also higher in obese patients and the risk decreased with more experienced surgeons. The trocar could reach the external iliac artery on pelvic CT scans in the four most anterior sectors with a higher frequency in women. Posterior sectors were at risk for sciatic nerve and gluteal vessel damage when the trocar was pushed deeper than 6 cm into the posterior iliac crest. In cadavers, the dissection demonstrated nine vascular or neurological lesions.

Conclusions

Using the sector system, trocars can be directed away from neural and vascular structures and toward zones that are likely to contain larger bone marrow stock.     

Anatomy of the ilium for bone marrow aspiration: map of sectors and implication for safe trocar placement

Purpose

The bony anatomy of the human ilium has been well described from a qualitative perspective; however, there are little quantitative data to help the surgeon to perform bone marrow aspiration from the iliac crest in the thickest part of the ilium. The minimum thickness of the spongiousus bone in an iliac wing (transverse thickness between the two tables) is an important factor in ensuring the safe placement of a trocar between the two tables of the iliac wing. For example, with an 8-gauge (3.26 mm) trocar, one can consider that if the transverse thickness of the spongiousus bone of the iliac wing is <3 mm, it will be difficult to insert the trocar safely between the two tables.

Methods

For this study, we measured spongiousus bone thickness on 48 iliac wings to map the ilium in six sectors, which were defined by drawing lines from equidistant points spaced along the rim of the iliac crest to the centre of the hip. These sectors can be transposed in the same manner to any patient. To evaluate the risks to reach vascular or neurologic structures, 410 trocars were introduced in the different sectors of 20 iliac bones of ten cadavers.

Results

A map was constructed indicating the thickness of the spongiousus bone in each sector. The thickness data was used to create a map that identifies the sites where bone marrow can be obtained with a trocar of 3-mm diameter according to the thickness of the spongiousus bone. Sectors 2, 3 and 6 appear to be more favourable for accommodating a 3-mm diameter trocar. Sectors 1, 4 and 5 comprise the areas with the thinnest parts of the iliac crest, with some areas being thinner than the trocar diameter. The sector system reliably predicted safe and unsafe areas for trocar placement. In cadavers, dissection demonstrated nine vascular or neurologic lesions created when trocars were introduced into sectors 1, 5 and 6.

Conclusion

Using the sector system, trocars can be directed away from neural and vascular structures and towards zones that are likely to contain larger bone marrow stock.     

Anatomically safe and minimally invasive transcrestal technique for procurement of autogenous cancellous bone graft from the mid-iliac crest

Background

Open iliac bone harvesting techniques can result in significant complications and residual morbidity. In reconstructive procedures where a small volume of autogenous cancellous bone graft is required, a minimally invasive technique for bone harvesting applied at the mid-iliac crest has been deemed satisfactory. We sought to assess the application of a well-established surgical technique to procure adequate volume of autogenous cancellous iliac bone graft with minimal trauma to adjacent structures.

Methods

We retrospectively reviewed the cases of patients who underwent a minimally invasive transcrestal mid-iliac bone graft procurement technique between May 2003 and December 2007. The technique was performed using a 3.5-mm Steinmann pin as a trocar and a 4.5-mm AO drill sleeve as a trephine. We administered a questionnaire, either in the clinic or by mail, to assess a number of parameters, including postoperative pain, dysthesia, parasthesia, status of the donor site wound and patient satisfaction.

Results

Of the 37 consecutive patients who underwent the procedure, data from 26 patients were available for assessment. Donor site pain resolved within a few days of the surgery, and none of the patients experienced symptoms of chronic pain. At the final review, none of the patients reported any unpleasant signs and symptoms related to the residual scar.

Conclusion

We recommend that the described minimally invasive trephine method be used when a small cancellous bone graft is needed. We found that patient morbidity was significantly lower with the trephine harvest technique than with open bone harvesting methods at the anterior iliac crest.     

Reconstruction of iliac crest with bovine cancellous allograft after bone graft harvest for symphysis pubis arthrodesis

Purpose

The aim of this study was to evaluate the safety and efficiency, as well as the incorporation characteristics of a specific type of xenograft used for iliac crest defects post-harvesting tri-cortical iliac crest bone graft.

Methods

Sixteen patients diagnosed with chronic anterior pelvic pain were operated for pubic symphysis fusion. The tri-cortical graft harvested from the iliac crest was inserted into the pubic symphysis and compressed with a reconstruction plate. The defect in the iliac crest was filled with a block of cancellous bovine substitute (Tutobone®). The length of iliac crest defect, time to fusion of pubic symphysis, time to incorporation of the graft and complications were recorded. The postoperative pain and patients’ satisfaction were evaluated.

Results

The median age of patients was 36.5 years (range 27–75). Fusion was obtained in 15 patients (94 %). The median time to fusion was four months (range three to seven). The length of the iliac crest bone defect ranged from 40 to 70 mm. Integration of the bovine substitute was achieved in 15 patients (94 %) over a median period of three months (range two to six). The postoperative median pain score was 2 (range 1–5). Twelve patients (75 %) reported good satisfaction. No major complications or allergic reactions were observed.

Conclusions

The xenograft used in this study provided a safe and effective method of reconstruction of iliac crest donor site defects. It has satisfactory incorporation, high biocompatibility and no signs of inflammatory reactions. This new technique is simple and easily reproducible in routine clinical practice.     

Trabecular architecture in women and men of similar bone mass with and without vertebral fracture: II. Three-dimensional histology

We recently developed a simple and inexpensive method that complements established bone histomorphometry procedures by enabling the two-dimensional imaging of cancellous bone to be viewed within its three-dimensional context with the marrow tissue in place and without detriment to the material for other histological purposes. The method, based on the preparation and superficial staining of slices 300 microm thick, enables "real" (i.e., unstained) trabecular termini to be separated from "artifactual" (i.e., stained) termini, providing a direct measure of cancellous connectivity in osteopenic bone. The technique was applied to osteopenic age-matched, white, postmenopausal women (31 with and 22 without vertebral compression fractures) with a similar bone status, as measured at the spine by absorptiometry and at the iliac crest by histology (see part I of this study). Despite the similarity in the mass of trabecular bone at either site, the results showed a significant difference (p < 0. 05) in the number of "real" trabecular termini between the groups, such that the fracture group had almost four times as many termini (mean +/- SE: 1.98 +/- 0.51/30 mm(2)) at the iliac crest as the nonfracture group (mean +/- SE: 0.53 +/- 0.31/30 mm(2)). Previous histomorphometry of the same material failed to detect a structural distinction between the two groups using established variables. It was concluded that a mass-independent trabecular discontinuity contributes to skeletal failure and that determination of the number of "real" disconnections (i.e., unstained termini) by the direct method proposed may provide a more sensitive discriminant of fracture than the present indirect procedures. A group of fracture and nonfracture men (see part I) suggested a similar distinction (fracture: 0.69 +/- 0.30/30 mm(2); nonfracture: 0.18 +/- 0.18/30 mm(2)), although the difference was not significant.     

Bone graft harvesting from the distal radius, olecranon, and iliac crest: a quantitative analysis

The purpose of this study was to quantify the volume and density of cancellous bone available from 3 commonly used bone graft sites in upper extremity surgery: the distal radius, olecranon process, and anterior iliac crest. Sixteen cadavers (age range, 59-98 years) with no prior history of bone harvest or metabolic conditions affecting bone were used. Cancellous graft was obtained using standardized techniques designed to simulate the clinical setting. Packed cancellous bone volume was determined as the volume occupied by the harvested bone after compression packing with a uniform load. Defect volume was determined by measuring the volume of the site from which bone was harvested. The distal radius and olecranon provided similar volumes of packed cancellous bone (2.7 and 2.8 cc, respectively). The anterior iliac crest provided approximately twice this amount (5.3 cc). The packed cancellous bone volume/defect volume ratio was not different between the 3 sites studied. Male gender was associated with a significantly greater amount of packed cancellous bone volume for all sites. We believe the olecranon to be an alternative to the distal radius as a source of bone graft for upper extremity procedures. We suggest using the anterior iliac crest when a large volume of cancellous bone is required.     

Solvent-preserved,bovine cancellous bone blocks used for reconstruction of thoracolumbar fractures in minimally invasive spinal surgery—first clinical results

We investigated the osseointegration of solvent-preserved, xenogenous cancellous bone blocks in the treatment of unstable fractures of the thoracolumbar junction. In 22 patients, the anterior repair procedure was performed by thoracoscopy or minimally invasive retroperitoneal surgery. Twenty-two patients had undergone monosegmental anterior fusion and were surveyed prospectively. Solvent-preserved, bovine cancellous bone blocks were used in 11 patients; iliac crest bone graft was used in the others. Follow-up after 12 months included CT scans, which revealed successful osseointegration in eight out of 11 patients who had received autogenous iliac crest bone grafts, while three patients showed a partial integration. There were no graft fragmentations. In patients who had received solvent-preserved, xenogenous cancellous bone blocks, complete osseointegration was achieved at the graft–bone interface in only two out of 11 cases, after 1 year. Partial integration was found in three patients. In view of these results, autogenous iliac crest bone grafts are still the unrivalled standard for defect repair in spinal surgery.     

Cancellous bone in human acetabulum: microradiographic and histomorphometric aspects

The acetabular cancellous bone of 18 subjects aged 57–88 years was characterized by low mass and a poorly ramified pattern according to microradiographic analysis. There was no correlation between the histomorphometric data of this region and those of the iliac crest. Microcalluses were visible in 13 acetabular samples, whereas they were absent from the iliac crest. As the acetabular trabeculae appeared decidedly longitudinal, age-related bone rarefaction is suggested to occur in two different ways: uniform thinning of the trabeculae and selective disappearance of transverse elements. The remaining longitudinal trabeculae are considered to be most useful for the weight-bearing function of the hip joint.In memoriam Professor Dr. J. Wagner, Head of the Department of Orthopaedic Surgery, Hôpital Universitaire Brugmann, Université Libre de Bruxelles     

Reconstruction of iliac crest with rib to prevent donor site complications: A prospective study of 26 cases

Background:

The tricortical bone graft from the iliac crest are used to reconstruct the post corpectomy spinal defects. The donor iliac area defect is large and may give rise to pain at donor site, instability of pelvis, fracture of ilium, donor site muscle herniation or abdominal content herniation. Rib removed during thoracotomy was used by us to reconstruct the iliac crest defect.

Materials and Methods:

Twenty-six patients who underwent thoracotomy for dorsal spine corpectomy or curettage for various spinal pathologies from June 2002 to May 2004 were included in the study. After adequate decompression the spine was reconstructed by tricortical bone graft from iliac crest and reconstruction of the iliac crest was done with the rib removed for exposure during thoracotomy.

Results:

The mean follow up was 15 months. All patients had good graft incorporation which was evaluated on the basis of local tenderness and radiographs. One patient had graft displacement.

Conclusion:

The reconstruction of iliac crest by rib is a simple and effective procedure to prevent donor site complications.     

Single-blinded prospective randomized study comparing open versus needle technique for obtaining autologous cancellous bone from the iliac crest

One of the most frequent complications of cervical anterior discectomy with fusion is pain at the donor site, usually the iliac crest. Despite the advent of new materials, autologous bone is still the gold standard for fusion procedures. A prospective, single blinded, randomized study was performed to evaluate the effect of a minimal invasive technique to obtain autologous bone from the iliac crest on pain. The minimal invasive technique uses a large needle to obtain cancellous bone. Consecutive patients scheduled for cervical anterior discectomy with a fusion using a cage were randomly assigned either to the classical open group or the needle group. Patients were unaware of the two possible options for obtaining autologous bone. They were asked to fill in visual analogue scores (VASs) at fixed moments during the first 6 weeks postoperatively. Three VASs were recorded: the score at the moment, the minimal score and the maximal score during the last 24 h. The wound at the iliac crest was measured 6 weeks postoperatively. Complications were registered. Fifty patients were enrolled. Twenty-five patients were assigned to each group . The pain scores from the needle group were significantly less than from the open group. At 2 weeks postoperatively, nearly all patients (88%) of the needle group were free of pain at the iliac crest, whereas ten patients (40%) of the open group still had some pain. Complications only occurred in the open group. Six patients complained of diminished sensibility. In two cases, it had resolved at 6 weeks postoperatively. In one case, a hemorrhage occurred. Surgical evacuation was not necessary. Obtaining autologous cancellous bone through a large needle for filling a cervical cage (even multiple cages) is safe and evidently less painful than through a classical open procedure. If pain exists it does not last very long. Generally, the pain is resolved within 2 weeks.The preliminary findings for the first 30 patients of this study were reported on the Cervical Spine Research Society (European Section) in Barcelona in 2003.     

Morbidity of graft harvesting versus bone marrow aspiration in cell regenerative therapy

Purpose

Using bone marrow mesenchymal stem cells (MSCs) with aspiration from the iliac crest is commonly used in reconstructive orthopaedic surgery. Because bone marrow aspiration is a percutaneous technique, the morbidity as compared with the classical bone graft should be decreased.

Method

Therefore in a retrospective review of 523 consecutive cases of bone marrow aspiration performed at the Henri Mondor Hospital from 1990 to 2006 for the treatment of fractures, minor and major complications were identified and compared to the number of complications observed during the same period with 435 classical iliac crest bone graft procedures performed for the same indications of treatment of fractures. Minor complications included superficial infections, superficial seromas, and minor haematomas. Major complications included herniation of abdominal contents through massive bone graft donor sites, vascular injuries, deep infections at the donor site, neurologic injuries, deep haematoma formation requiring surgical intervention or transfusion, and iliac wing fractures.

Result

Bone marrow aspiration decreased significantly the number of complications as compared with harvesting classical iliac crest bone graft that was associated with significant morbidity. Adverse events were significantly lower (p?Conclusion In our series the number of complications with bone marrow aspiration was ten times less than the complications observed with the classical technique of bone piece harvesting from the iliac crest, and the complications were clearly less severe.     

Evaluation of hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate as a bone graft substitute for posterolateral spinal fusion

Background:

Autologous cancellous bone is the most effective biological graft material. However, harvest of autologous bone is associated with significant morbidity. Since porous hydroxyapatite and beta-tricalcium phosphate are biodegradable materials and can be replaced by bone tissue, but it lacks osteogenic property. We conducted a study to assess their use as a scaffold and combine them with bone marrow aspirate for bone regeneration using its osteogenic property for posterolateral spinal fusion on one side and autologous bone graft on the other side and compare them radiologically in terms of graft incorporation and fusion.

Materials and Methods:

Thirty patients with unstable dorsal and lumbar spinal injuries who needed posterior stabilization and fusion were evaluated in this prospective study from October 2005 to March 2008. The posterior stabilization was done using pedicle screw and rod assembly, and fusion was done using hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate as a bone graft substitute over one side of spine and autologous bone graft obtained from iliac crest over other side of spine. The patients were followed up to a minimum of 12 months. Serial radiographs were done at an interval of 3, 6, and 12 months and CT scan was done at one year follow-up. Graft incorporation and fusion were assessed at each follow-up. The study was subjected to statistical analysis using chi-square and kappa test to assess graft incorporation and fusion.

Results:

At the end of the study, radiological graft incorporation and fusion was evident in all the patients on the bone graft substitute side and in 29 patients on the autologous bone graft side of the spine (P > 0.05). One patient showed lucency and breakage of distal pedicle screw in autologous bone graft side. The interobserver agreement (kappa) had an average of 0.72 for graft incorporation, 0.75 for fusion on radiographs, and 0.88 for the CT scan findings.

Conclusion:

Hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate seems to be a promising alternative to conventional autologous iliac bone graft for posterolateral spinal fusion.     

Pharyngocutaneous fistula after anterior cervical spine surgery

Pharyngocutaneous fistulae are rare complications of anterior spine surgery occurring in less than 0.1% of all anterior surgery cases. We report a case of a 19 year old female who sustained a C6 burst fracture with complete quadriplegia. She was treated urgently with a C6 corpectomy with anterior cage and plating followed by posterior cervical stabilization at another institution. Post operatively she developed a pharyngocutaneous fistula that failed to heal despite several attempts of closure and esophageal exclusion with a Jpeg tube. The patient was eventually successfully treated with a three-stage procedure consisting of firstly a posterior approach to reinforce the posterior stabilization of the cervical spine that was felt to be inadequate, secondly an anterior approach with removal of all the anterior instrumentation followed by iliac crest bone graft and thirdly a superior based sternocleidomastoid flap that was interposed between the esophagus and the anterior cervical spine. The patient's fistula healed successfully. However, yet asymptomatic, the anterior iliac crest bone graft resorbed almost completely at 16 months follow up. In light of this complication, we discuss the surgical options for the treatment of pharyngocutaneous fistulae and the closure of this fistula using a superiorly based sternocleidomastoid muscle flap.     

The anatomical variation of the lateral femoral cutaneous nerve in relation to the anterior superior iliac spine and the iliac crest

The location of lateral femoral cutaneous nerve (LFCN) in relation to the anterior superior iliac spine (ASIS) and the iliac crest was investigated in 96 embalmed cadaveric specimens. Fifty-six nerves (58.3%) passed medial to the ASIS. Twenty-two nerves (22.9%) passed at the ASIS. Eighteen nerves (18.8%) passed lateral to the ASIS. The LFCN is usually located at 2.1 ± 0.8 to 3.9 ± 1.0 cm below the crest in the range of 2–5 cm lateral to the ASIS, respectively. When the anterior iliac crest bone graft harvesting is planned, the anatomical variation in this area should be concerned to reduce the risk of LFCN injury.     

Fractal Analysis of Trabecular Bone in Knee Osteoarthritis (OA) is a More Sensitive Marker of Disease Status than Bone Mineral Density (BMD)

The purpose of this study was to determine whether fractal analysis (FSA) of macroradiographs or bone mineral density (BMD) is more sensitive in detecting disease-related cancellous bone alterations in knee osteoarthritis (OA). Differences in BMD between 11 OA (6 females) and 11 non-OA reference (7 females) tibiae were compared with differences in trabecular organization measured by computerized method of fractal signature analysis (FSA) of digitized macroradiographs (×3.5 to ×5). OA knees had anatomic and radiographic evidence of medial compartment disease. FSA measured cancellous bone organization at 4 regions of interest (ROI): medial and lateral subchondral (Sc) and subarticular (Sa) sites, dual X-ray absorptiometry (DXA) measured BMD at the same ROIs. Compared to non-OA, OA tibiae had significant increased (P < 0.05) in FSA of vertical trabeculae in the medial Sa region (trabecular size range: 0.42–0.54; 0.90–1.98 mm) and significant decrease (P < 0.05) in FSA for some horizontal trabeculae in the Sc region (trabecular size range: medial side 0.12–0.18 mm; lateral side 0.12–0.24 mm). Compared to non-OA, BMD of OA tibiae was not significantly different at any ROI. BMD was not sensitive to changes in trabecular organization detected by FSA. The increase in FSA of vertical trabeculae in the medial Sa region was consistent with trabecular fenestration and thinning, which may have been detected as decreased BMD in a larger sample. For studies involving small sample sizes, quantifying changes in trabecular organization is more sensitive than BMD for detecting bone alterations in knee OA.     

Results of triple muscle (sartorius,tensor fascia latae and part of gluteus medius) pedicle bone grafting in neglected femoral neck fracture in physiologically active patients

Background:

Femoral neck fractures are notorious for complications like avascular necrosis and nonunion. In developing countries, various factors such as illiteracy, low socioeconomic status, ignorance are responsible for the delay in surgery. Neglected fracture neck femur always poses a formidable challenge. The purpose of this study was to evaluate the results of triple muscle pedicle bone grafting using sartorius, tensor fasciae latae and part of gluteus medius in neglected femoral neck fracture.

Materials and Methods:

This is a retrospective study with medical record of 50 patients, who were operated by open reduction, internal fixation along with muscle pedicle bone grafting by the anterior approach. After open reduction, two to three cancellous screws (6.5 mm) were used for internal fixation in all cases. A bony chunk of the whole anterior superior iliac spine of 1 cm thickness, 1 cm width and 4.5 cm length, taken from the iliac crest comprised of muscle pedicle of sartorius, tensor fascia latae and part of gluteus medius. Then the graft with all three muscles mobilized and put in the trough made over the anterior or anterosuperior aspect of the femoral head. The graft was fixed with one or two 4.5 mm self-tapping cortical screw in anterior to posterior direction.

Results:

14 patients were lost to followup. The results were based on 36 patients. We observed that in our series, there was union in 34, out of 36 (94.4%) patients. All patients were within the age group of 15-51 years (average 38 years) with displaced neglected femoral neck fracture of ≥30 days. Mean time taken for full clinicoradiological union was 14 weeks (range-10-24 weeks).

Conclusion:

Triple muscle pedicle bone grafting gives satisfactory results for neglected femoral neck fracture in physiologically active patients.     

Changes in mean trabecular orientation in the medial condyle of the proximal tibia in osteoarthritis

In osteoarthritis of the knee, degenerative changes occur in the articular cartilage and underlying subchondral bone, particularly of the medial tibial condyle. Cancellous bone sclerosis that accompanies osteoarthritis is not only the result of an increase in bone volume fraction but also a change in trabecular structure. In a comparison with agematched controls (n=4), osteoarthritis (n=11) demonstrated a significant (P0.05) increase in bone volume fraction and trabecular thickness. Overal trabecular orientation in the osteoarthritic group was more vertical or perpendicular to the articular surface than the control group (P0.05) especially in the trabeculae of the cancellous bone layer closest to the articular surface. These alterations in trabecular bone structure could have significant consequences for the mechanical properties of osteoarthritic bone.