Search Results (209)

Reconstruction of craniomaxillofacial (CMF) bony defects requires individualized strategies based on defect characteristics and graft bed biology, with traditional approaches relying on autogenous non-vascularized bone grafts or vascularized free flaps that, while reliable, are associated with donor-site morbidity and operative complexity. Biologically driven reconstructive strategies, including tissue engineering, cellular bone matrix allografts (CBMs), and growth factor adjuncts, have emerged as alternatives or complements to autograft-based reconstruction. This review introduces and details these new innovations with emphasis on the current literature, thus empowering surgeons to enhance their clinical armamentarium. Full article

Large bone defects resulting from trauma, tumor resection, infection, or degenerative diseases pose a major clinical challenge in orthopedic surgery and regenerative medicine. Despite advances in biomaterials and surgical techniques, successful outcomes are often compromised by poor vascularization, limited osteoinduction, and donor-site morbidity associated with autografts or allografts. However, conventional delivery systems suffer from burst release, rapid clearance, off-target effects, and supraphysiologic dosing, which can lead to undesirable complications such as ectopic ossification and inflammation, with some reports raising concerns about the long-term tumorigenic risk. Heparin, a naturally highly sulfated glycosaminoglycan structurally related to heparan sulfate, has emerged as a particularly attractive candidate for affinity-based biomaterial systems. It naturally binds over 300 growth factors, including bone morphogenetic proteins. By protecting these proteins from enzymatic degradation, enhancing their bioavailability, and mediating receptor clustering, heparin provides both biochemical stability and biofunctional modulation. This review provides a comprehensive overview of heparin-based delivery strategies in bone tissue engineering. We begin by describing the biological functions of heparin in modulating growth factor activity. We then discuss in detail the different heparin-based biomaterials designed to sustain the release of growth factors for bone tissue engineering, including the heparin–polycation coacervate system; heparin-based supramolecules; and heparin-based hydrogels, nanoparticles, and microspheres for sustained release of bone morphogenic proteins and other growth factors for bone tissue engineering. Finally, we assess the clinical and translational relevance of heparin-based systems, identify key challenges, and outline future perspectives, highlighting the potential of these biomaterials for providing safer and more effective therapies for bone regeneration. Full article

Background: The management of bone defects in pediatric oncology represents a major challenge in orthopedics, as it requires preserving both joint function and skeletal growth. Traditional reconstructive approaches, such as autografts and allografts, are limited by availability, complications, and incomplete biological integration. In this context, xeno-hybrid bone substitutes have emerged as a promising alternative. The aim of this study was to evaluate the safety and effectiveness of SmartBone^® ORTHO in the reconstruction of post-oncological bone defects in children. Methods: Twelve pediatric patients treated at the Centro Traumatologico Ortopedico (CTO) and OIRM Hospital, AOU Città della Salute e della Scienza of Turin (Italy), between 2016 and 2019 were retrospectively analyzed. Lesions included simple and aneurysmal bone cysts, non-ossifying fibroma, chondroblastoma, and other benign conditions. All patients underwent curettage followed by defect filling with SmartBone^® ORTHO. Results: At clinical and radiological follow-up, nine patients (75%) showed stable graft integration and complete functional recovery. Three patients (25%) developed local recurrence, which was managed with revision surgery and re-implantation of SmartBone^®, with all achieving stable outcomes. Radiographs demonstrated progressive increases in bone density and trabecular thickness, reaching values comparable to those of native bone within 6–12 months. Conclusions: SmartBone^® ORTHO proved to be a safe and effective biomaterial for pediatric post-oncological bone reconstruction, promoting rapid osteointegration and physiological bone remodeling without infection or intolerance. Full article

Background/Objectives: Nonunion after tibiotalocalcaneal (TTC) arthrodesis remains challenging, especially in revision settings where union rates are substantially lower than in primary procedures. Biological adjuncts are commonly used to enhance healing, yet most described methods employ fibular onlay struts and cancellous autograft. To our knowledge, intramedullary placement of a fibular autograft for ankle fusion has not previously been reported. This study presents a revision of TTC arthrodesis nonunion treated with this technique and summarizes existing evidence on revision ankle arthrodesis, fibular grafting, and bone marrow aspirate concentrate (BMAC). Methods: We report a revision TTC arthrodesis nonunion managed with a decorticated intramedullary fibular autograft spanning the tibiotalar canal, supplemented with cancellous iliac crest autograft and BMAC. A review of PubMed, Scopus, and Google Scholar (search date: 1 September 2025) was performed to identify studies addressing revision ankle fusion, fibular grafting techniques, and BMAC use in foot and ankle arthrodesis. Primary outcomes included union and complications, with CT-based assessment prioritized when available. Results: At 3 months, radiographs and CT demonstrated progressive osseous bridging consistent with fusion; the patient achieved pain-free weight-bearing without complications. Conclusions: Intramedullary fibular autograft in revision TTC arthrodesis is a novel biological-mechanical strategy that leverages endosteal contact and axial stability while augmenting osteogenesis with cancellous autograft and BMAC. The review supports the biological plausibility and safety of this approach and underscores the importance of CT-based assessment. Full article

Synthetic biomaterials used as bone graft extenders (BGE) in spinal fusion surgery can supplement but do not replace autologous bone. This pilot study evaluated a calcium sulfate/hydroxyapatite (CaS/HA) material as an antibiotic-eluting BGE and a carrier for bone morphogenetic protein-2 (BMP-2) in a rabbit posterolateral lumbar (L4–L5) spinal fusion model (PLF). Pre-set CaS/HA beads were loaded with tobramycin (TOB) and tested for in vitro antibiotic release and antibacterial activity against Staphylococcus aureus. For the in vivo PLF study, CaS/HA beads were used in two treatment strategies: (1) CaS/HA + TOB + autograft (left side) and (2) CaS/HA + BMP-2 (right side). Serum levels of TOB were quantified and spinal fusion was evaluated after 12 weeks. TOB exhibited a rapid initial release, followed by a decline below detectable levels after 6 h in vitro and 48 h in vivo. TOB-loaded CaS/HA beads demonstrated in vitro antibacterial activity for 19 days. In the PLF study, 5/6 and 6/6 specimens were fused radiologically in the TOB and BMP groups, respectively, and 100% using mechanical testing. Micro-CT analysis showed no significant difference in bone volume between the TOB and BMP-2 groups (364 ± 84 vs. 479 ± 95 mm³). Histology verified continuous bone bridging in both groups. Our in vitro findings indicate that locally added TOB could protect the CaS/HA material from bacterial colonization and did not adversely impact the CaS/HA material negatively to act as BGE. The addition of low-dose BMP-2 to the CaS/HA material proved effective in building bone without the need to harvest autologous bone. In summary, this pilot PLF study demonstrates that the tested CaS/HA material combined with BMP-2 could replace autologous bone harvesting in spinal fusion surgery. Addition of TOB could potentially protect the material from bacterial colonization during the early post-operative period but further studies in infection models are warranted. Full article

Campanacci grade III giant cell tumors of the distal radius frequently require en bloc resection to achieve adequate oncologic control. Reconstruction of the resulting defect remains challenging, particularly with respect to preservation of distal radioulnar joint stability and forearm rotation. Although proximal fibular autograft reconstruction is well established, ligamentous stabilization of the distal radioulnar joint is rarely incorporated in oncologic settings. This technical note describes an integrated reconstructive strategy combining proximal fibular autograft with distal oblique bundle reconstruction, illustrated by a representative clinical case. The technique involves segmental en bloc resection of the distal radius followed by reconstruction using an ipsilateral, nonvascularized proximal fibular autograft including the fibular head. Distal radioulnar joint stability is addressed through reconstruction of the distal oblique bundle using an autologous palmaris longus tendon graft. Surgical indications, operative steps, donor site stabilization, and perioperative management are detailed. Functional evolution was assessed using the Musculoskeletal Tumor Society scoring system and range-of-motion measurements. Histopathological examination confirmed negative oncologic margins. Early postoperative events included donor-site common peroneal nerve dysfunction and radiocarpal instability requiring temporary Kirschner wire stabilization. At nine months, the Musculoskeletal Tumor Society score reached 80%, with forearm rotation preserved at 68.8% pronation and 81.3% supination of normal values. Combined osseous and ligamentous reconstruction following distal radius resection is technically feasible and may allow preservation of distal forearm mechanics while maintaining oncologic principles. Broader validation will require application in larger clinical series and longer follow-up. Full article

Lumbar interbody fusion is widely performed for degenerative, deformity-related, and instability-associated spinal conditions. Yet, reported outcomes remain variable across grafting strategies and surgical techniques. While advances in instrumentation and cage design improve immediate construct stability, successful arthrodesis depends on early graft behavior within the interbody environment. This includes positional stability, interface contact, and load transfer prior to mature bone formation. Synthetic bone graft substitutes are commonly used to supplement or replace autograft. However, the clinical literature describing these materials is heterogeneous with respect to composition, structural presentation, surgical context, and outcome reporting. This narrative review synthesizes clinical, translational, and biomechanical studies published between 2019 and 2025 that evaluate synthetic bone graft substitutes used in adult lumbar interbody fusion. Rather than comparing individual products or reported fusion rates, grafts are organized by material class and examined through early mechanical events such as graft migration, loss of graft–endplate contact, and cage subsidence. Across recent studies, variability in fusion definitions, imaging modalities, postoperative timepoints, and documentation of early mechanical events limits direct comparison and quantitative synthesis. These findings highlight the need for improved reporting consistency and greater emphasis on engineering-relevant variables in future investigations. Full article

Background: Autologous bone graft is widely used for lumbar interbody fusion but may increase operative time and donor-site morbidity. Gene-activated grafts combining an osteoconductive scaffold with pro-angiogenic signaling may provide comparable fusion without graft harvesting. The aim of this paper is to compare radiographic fusion and health-related quality of life after single-level transforaminal lumbar interbody fusion (TLIF) using a gene-activated octacalcium phosphate graft containing plasmid DNA encoding vascular endothelial growth factor (OCP/VEGF) versus an autologous bone graft. Methods: 200 adults undergoing first-time single-level TLIF for degenerative lumbar stenosis were allocated 1:1 to OCP/VEGF (n = 100) or autograft (n = 100), prospectively. CT-based fusion assessment and SF-36 outcomes were evaluated at 6 and 12 months follow-up. Results: At 12 months after surgery, mean fusion-zone density was 617.6 ± 180.9 HU in the OCP/VEGF group versus 599.8 ± 181.9 HU in the autograft group (mean difference 17.8 HU; p = 0.484). Complete fusion on qualitative CT grading occurred in 77% versus 73%, respectively (risk difference 4%; p = 0.583). SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) improved significantly from baseline in both groups (p < 0.001), without clinically meaningful between-group differences at follow-up. Revision surgery occurred in 3% versus 5%. Conclusions: In single-level TLIF for degenerative lumbar stenosis, OCP/VEGF produced radiographic fusion and patient-reported outcomes comparable to autograft at 12 months, supporting its use as an autograft-sparing alternative. Full article

Knee biomechanical demands vary across different sports due to sport- and position-specific patterns of muscle recruitment. To return to performance, athletes must adequately restore knee kinematics to regain control over the same sport mechanics that led to the initial anterior cruciate ligament (ACL) injury. ACL graft selection should therefore minimize donor site morbidity and support sport-specific demands. This study aims to address the available evidence and guide surgical graft choice in athletes. A literature search of PubMed, MEDLINE, Scopus, and Web of Science (up to September 2025) assessed BPTB, hamstring, and quadriceps tendon autografts. Outcomes included revision, graft survival, return to sport, time to return, PROMs, anterior knee pain, donor site morbidity, and prognostic factors (age, sex). Sports were classified as pivoting, contact/collision, or endurance/non-pivoting. The results were synthesized narratively. In pivoting and cutting sports, bone–patellar tendon–bone (BPTB) autografts offer high survival rates but are associated with a high incidence of anterior knee pain, which is a substantial drawback in kneeling or flexion-intensive sports. Hamstring tendon (HT) grafts carry higher revision rates in female and younger patients, though they have low donor site morbidity that does not appear to affect long-term athletic performance. Quadriceps tendon (QT) grafts are emerging as a promising option for pivoting athletes. However, conflicting results indicate that the revision risk is comparable to that of HT grafts and possible long-standing extensor mechanism weakness. Contact and collision sports demonstrate similar trends, but kneeling and contact injuries are more common in this group. Thus, while prioritizing powerful hamstring strength, anterior knee pain symptoms should still be carefully considered. The diameter of the HT autograft should exceed 7.5 mm to ensure comparable revision outcomes with BPTB. QT grafts remain a limited-evidence attractive option. Endurance and non-pivoting athletes require fewer pivoting mechanics but rely heavily on muscle symmetry and repetitive motion. BPTB grafts are less suitable in this category due to alterations in sprint mechanics, muscle asymmetry, and repetitive patellofemoral joint loading. HT grafts provide favorable rates of return to sport, whereas evidence regarding QT graft use in non-pivoting athletes remains limited. Full article

Background: Anterior Cruciate Ligament (ACL) tears are increasingly frequent among adolescents and are often accompanied by meniscal and chondral injuries that may compromise long-term outcomes. While risk factors are well documented in adults, they remain less well defined in younger patients, who present unique anatomical and activity-related characteristics. Understanding these associations is essential for optimizing surgical timing and outcomes in this age group. The purpose of this study was to determine the rate of concomitant intra-articular injuries in adolescents undergoing ACL reconstruction and to identify associated risk factors. Methods: We retrospectively reviewed 186 adolescents (12–18 years) who underwent primary ACL reconstruction using a bone–patellar tendon–bone (BPTB) autograft between 1999 and 2020. Demographic, anthropometric, and intraoperative findings on meniscal and chondral lesions were collected. Multivariable logistic regression models were used to identify factors associated with concomitant injuries. Results: Concomitant intra-articular lesions were found in 108 of 186 patients (58.1%). Meniscal tears were the most common finding, involving the lateral meniscus in 27.4%, the medial meniscus in 18.8%, and both menisci in 11.9%. The posterior horn was the most common tear location, and longitudinal and bucket handle patterns predominated. Older age was associated with any concomitant lesion (p = 0.028), and surgical delay (p = 0.021) was associated with a higher likelihood of medial meniscal tears. Sex and BMI were not significantly associated. Conclusions: Concomitant injuries are common in adolescents undergoing ACL reconstruction. Older age and delayed surgery were associated with a higher likelihood of meniscal damage, emphasizing the need for early diagnosis and timely surgical management as potentially relevant to limiting long-term degenerative changes in young athletes. Level of evidence: Level III, retrospective study. Full article

Background: Post-extraction alveolar ridge is an important factor affecting dental implant restoration. Among myriads of bone grafting materials, dentinal grafts are gaining faster popularity among clinicians. Unlike conventional xenografts derived from animal sources, these autogenous materials may offer advantages in terms of biocompatibility and cost. Objective: This article aims to compare their performance with other commonly used materials, like xenografts, or natural blood clots and to examine whether they could maintain bone quality and quantity during socket healing with better properties than the rest of the graft materials in terms of implants success rate. Methods: This search was conducted in multiple medical databases (PubMed/MEDLINE, Scopus, Cochrane Library, Embase, and Google Scholar) for studies published between 2015 and 2025. This search focused exclusively on randomized controlled trials. The study quality was assigned by using the Cochrane Risk of Bias 2 tool, performing statistical pooling of results using random-effects meta-analysis when appropriate. Results: Eight randomized controlled trials involving 249 patients and 281 bone graft sites were selected according to inclusion and exclusion criteria. Dentinal grafts produced significant increase in formation of new bone compared to xenografts (12.4% greater, 95% CI: 6.8–18.0%, p < 0.001). The grafts also resorbed more completely, leaving less foreign material behind (8.6% less residual material, p < 0.001). Importantly, implants placed in bone preserved with dentinal grafts showed comparable stability and success rates to those in bone treated with xenografts. When compared to allowing sockets to heal naturally, dentinal grafts dramatically reduced bone loss by 60–70% horizontally and 65–75% vertically. Remarkably only minor complications were observed (2.2%), with no serious adverse events across all studies. Conclusions: Our analysis indicates that dentinal grafts represent a viable and potentially superior alternative to conventional xenografts for not only preserving alveolar bone after tooth extraction but also in any existing bone defects. The evidence particularly supports using partially demineralized preparations. These materials demonstrate excellent biocompatibility, produce good bone quality, and offer cost advantages. Full article

Background/Objectives: Persistent strength deficits and psychological impairments may compromise return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR). We investigate the relationship between thigh muscle isokinetic strength recovery at six months after ACLR and long-term psychological outcomes related to RTS in competitive male soccer players. Methods: Sixty male soccer players who underwent primary ACLR with bone–patellar tendon–bone autograft were retrospectively analyzed. Isokinetic testing of quadriceps and hamstrings was performed one week before surgery and six months post-surgery at 90°/s and 180°/s. Limb symmetry index (LSI) was calculated both pre- and post-operatively. At long-term follow-up (mean ≈ 4 years after RTS), athletes completed questionnaires assessing RTS status, ACL re-injuries, sport-related perceptions, and kinesiophobia using the Tampa Scale for Kinesiophobia (TSK). Statistical analyses were conducted to explore associations between post-operative LSI and TSK scores and to compare psychological and neuromuscular outcomes between athletes with and without ACL re-injury. Results: Absolute quadriceps and hamstring peak torque values significantly increased from pre- to post-surgery, with quadriceps strength deficits persisting only in the operated limb. However, quadriceps LSI significantly decreased post-operatively, while hamstring LSI remained stable. Pearson correlation analysis revealed a weak positive association between post-operative quadriceps LSI at 90°/s and TSK scores (r = 0.34). Overall, RTS rate was 91.7%, but a second ACL injury occurred in 18.2% of athletes. No significant differences were observed between re-injured and non-re-injured athletes in TSK scores or post-operative LSI values at either angular velocity (all p > 0.29). High kinesiophobia (TSK ≥ 37) was present in 56.7% of the cohort at long-term follow-up. Conclusions: Despite significant strength gains, quadriceps limb symmetry worsened six months after ACLR, with deficits confined to the operated limb, suggesting persistent neuromuscular inhibition. These physical deficits coexist with long-term kinesiophobia despite high RTS rates. The weak associations between strength symmetry and psychological outcomes highlight the multifactorial nature of RTS and support the need for an integrated physical, psychological, and neuro-cognitive approach to rehabilitation and RTS decision-making. Full article

Peripheral nerve injuries, especially neurotmesis, require precise repair strategies due to their severity and limited capacity for spontaneous regeneration. Nerve guidance conduits (NGCs) offer a promising alternative to autografts; however, consistent surgical techniques and anatomical references in rodent models could be enhanced. This ex vivo study focuses on describing and establishing a standardized, reproducible anatomical and technical protocol for implanting an NGC in the sciatic nerve of Wistar rats, identifying a 7 mm segment free of collateral branches as a safe site for neurotmesis. Thirty cadaveric hind limbs were positioned in lateral decubitus, and anatomical landmarks such as the greater trochanter, ischial bone, and femoral condyle guided the incision. A 1 cm scaffold was inserted and secured with 8-0 absorbable sutures, while muscle and skin were closed with 5-0 and non-absorbable sutures. The technique enabled safe access to the nerve, minimized risk to adjacent structures, and ensured proper scaffold positioning without tension. This standardized approach improves surgical reproducibility and supports anatomical integrity; however, because the study used ex vivo cadaveric samples, its capacity to facilitate functional nerve regeneration remains theoretical. While the protocol emphasizes the importance of surgical planning and suture patterns, it cannot account for active biological processes such as angiogenesis, inflammatory response, or axonal growth, which are critical for successful repair. Ultimately, this study provides a reliable anatomical platform for NGC evaluation under controlled experimental conditions, serving as a necessary precursor to in vivo validation of safety and functional outcomes. Full article

Bone tissue engineering offers a promising alternative to autografts and allografts for treating critical bone defects. Hydrogels, three-dimensional hydrophilic polymer networks, have emerged as leading scaffold materials due to their ability to mimic native extracellular matrix properties while providing tunable biocompatibility, biodegradability, mechanical characteristics, and high water content, enabling nutrient transport and cell viability. These scaffolds can be loaded with bioactive cues, including growth factors, peptides, and nanoparticles, and can deliver stem cells, supporting localised and sustained bone regeneration. Recent advances in hydrogel design have improved osteoinductivity and osteoconductivity through controlled physical, chemical, and mechanical properties, and sophisticated fabrication strategies such as 3D bioprinting and nanostructuring. This review provides a comprehensive overview of hydrogel-based scaffolds for bone tissue engineering, discussing material types, bioactive factor delivery, host tissue interactions, including immune modulation and osteogenic differentiation, and the latest preclinical and clinical applications. Finally, we highlight the remaining challenges and critical design requirements for developing next-generation hydrogels that integrate structural integrity with biological functionality. Full article

Background/Objectives: Osteosarcoma and Ewing sarcoma are the predominant malignant bone tumors of the lower limbs in children. With 5-year survival rates of 70–77% for localized disease, limb salvage with growth-compatible reconstruction has replaced amputation as the standard. This review aimed to synthesize current reconstruction strategies, propose an age-and defect-based decision algorithm, and highlight growth-preserving innovations for skeletally immature patients. Methods: This narrative review of surgical techniques—including rotationplasty, biological reconstruction (vascularized/non-vascularized fibula, allograft, recycled autograft, “hot dog” composite), bone transport, and endoprosthetic replacement (modular, extendable, 3D-printed)—was conducted, with a literature search covering January 1990 to October 2025 and emphasized pediatric studies published after 2020, emphasizing pediatric outcomes, complication profiles, and functional scores. Results: Across pediatric and mixed-age cohorts (typically n ≈ 10–30 per technique; median follow-up 3–10 years), rotationplasty demonstrated high durability with Musculoskeletal Tumor Society (MSTS) scores of 21–28/30, especially in children < 6 years. Biological reconstruction achieved >80% union in defects < 6 cm, while vascularized fibula grafts yielded 82–95% union for 6–15 cm defects. Bone transport produced reliable union for 3–15 cm defects but required prolonged fixation (40–60 days/cm) and had high pin-tract infection rates (50–60%). Extendable endoprostheses demonstrated 5-year prosthesis survival of 54–87%, while early joint-preserving 3D-printed implants improved MSTS scores from 17 to 28 points in a pediatric series (n = 7, mean follow-up 30 months). Conclusions: Personalized reconstruction guided by a child-centered algorithm optimizes oncologic control, skeletal growth, and long-term function. Emerging 3D-printed joint-preserving implants and noninvasive lengthening technologies promise further reduction in revisions and complications in pediatric limb salvage. Full article