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Objective The primary goals for alveolar cleft grafting are to gain and maintain bone in the cleft area that provides continuity for the maxillary segments, allowing the stability of the maxilla and building the bony foundation for the erupting cleft teeth and closure of the oronasal communication. The current study compared the effectiveness of the double iliac corticocancellous bone blocks technique versus the particulate autogenous spongy bone graft from the anterior iliac crest in alveolar cleft grafting in the mixed dentition stage. Patients and methods The current randomized clinical study included 18 patients with unilateral alveolar clefts. They were divided into two equal groups according to the technique used for grafting; group (1) included nine patients in whom grafting with double iliac corticocancellous bone blocks with cancellous bone particulates in between was used (study group), and group (2) included nine patients in whom conventional cancellous particulate bone grafting from anterior iliac crest was used (Control group). Results Nine months postoperatively, the study group showed superior results regarding graft width, height, and volume compared to the control group in the current study. Conclusion Regarding the graft success factors represented by the maintained graft labio-palatal width, graft height, and total graft volume, the technique of double iliac corticocancellous bone blocks was markedly effective in reconstructing alveolar clefts when compared with the conventional grafting technique that utilized cancellous particulate bone alone from the anterior iliac crest. Clinical relevance. The double iliac corticocancellous bone blocks technique maintained the grafted bone volume, width, and height.

Purpose To perform a meta-analysis of RCTs evaluating donor site morbidity after bone–patellar tendon–bone (BTB), hamstring tendon (HT) and quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR). Methods PubMed, OVID/Medline and Cochrane databases were queried in July 2022. All level one articles reporting the frequency of specific donor-site morbidity were included. Frequentist model network meta-analyses with P -scores were conducted to compare the prevalence of donor-site morbidity, complications, all-cause reoperations and revision ACLR among the three treatment groups. Results Twenty-one RCTs comprising the outcomes of 1726 patients were included. The overall pooled rate of donor-site morbidity (defined as anterior knee pain, difficulty/impossibility kneeling, or combination) was 47.3% (range, 3.8–86.7%). A 69% (95% confidence interval [95% CI]: 0.18–0.56) and 88% (95% CI: 0.04–0.33) lower odds of incurring donor-site morbidity was observed with HT and QT autografts, respectively ( p  < 0.0001, both), when compared to BTB autograft . QT autograft was associated with a non-statistically significant reduction in donor-site morbidity compared with HT autograft (OR: 0.37, 95% CI: 0.14–1.03, n.s.). Treatment rankings (ordered from best-to-worst autograft choice with respect to donor-site morbidity) were as follows: (1) QT ( P -score = 0.99), (2) HT ( P -score = 0.51) and (3) BTB ( P -score = 0.00). No statistically significant associations were observed between autograft and complications (n.s.), reoperations (n.s.) or revision ACLR (n.s.). Conclusion ACLR using HT and QT autograft tissue was associated with a significant reduction in donor-site morbidity compared to BTB autograft. Autograft selection was not associated with complications, all-cause reoperations, or revision ACLR. Based on the current data, there is sufficient evidence to recommend that autograft selection should be personalized through considering differential rates of donor-site morbidity in the context of patient expectations and activity level without concern for a clinically important change in the rate of adverse events. Level of evidence Level I.

A variety of graft sources have been used for ACL reconstruction to improve functions and kinematics in ACL deficient knees. The two most commonly used autogenous grafts are the central third of the patellar tendon and the hamstring tendon constructs. The choice of different grafts and different construct influence the final clinical outcome of ACL reconstruction. The 3 groups, of 25 patients each, were generated by choosing the technique (PT tendon, 4 strand hamstring, and single hamstring plus extraarticular plasty) to utilize and followed for 5 years, with an alternate systematic sampling. Our comparison has shown significant kneeling pain in the patellar tendon with respect to the groups with hamstrings techniques. Single hamstring plus extraarticular plasty achieved subjective score significantly higher with respect to the other two groups as well as for the time to resume sport. The study confirms that patellar tendon and hamstring can be equivalent options for ACL reconstruction. This study demonstrated that a superior outcome as far as subjective clinical findings were concerned, was obtained in group III. Patients in the latter group were also able to return to sports sooner than those in the bone‐patellar tendon graft group and the four‐strand hamstring group.

Purpose This study aimed to retrospectively compare the enlargement and migration of the femoral tunnel aperture after anatomic rectangular tunnel anterior cruciate ligament (ACL) reconstruction with a bone–patella tendon–bone (BTB) or hamstring tendon (HT) graft using three-dimensional (3-D) computer models. Methods Thirty-two patients who underwent ACL reconstruction and postoperative computed tomography (CT) at 3 weeks and 6 months were included in this study. Of these, 20 patients underwent ACL reconstruction with a BTB graft (BTBR group), and the remaining 12 with an HT graft (HTR group). The area of the femoral tunnel aperture was extracted and measured using a 3-D computer model generated from CT images. Changes in the area and migration direction of the femoral tunnel aperture during this period were compared between the two groups. Results In the HTR group, the area of the femoral tunnel aperture was significantly increased at 6 months compared to 3 weeks postoperatively ( P  < 0.05). The average area of the femoral tunnel aperture at 6 months postoperatively was larger by 16.0 ± 12.4% in the BTBR group and 41.9 ± 22.2% in the HTR group, relative to that measured at 3 weeks postoperatively ( P  < 0.05). The femoral tunnel aperture migrated in the anteroinferior direction in the HTR group, and only in the inferior direction in the BTBR group. Conclusions The femoral tunnel aperture in the HTR group was significantly more enlarged and more anteriorly located at 6 months after ACL reconstruction, compared to the BTBR group. Level of evidence IV.

Sixty-eight patients were clinically evaluated preoperatively, 3, 5, 7, 9 months, 1 and 2 years after ACL reconstruction, 34 with patellar tendon graft, 34 with hamstring graft. Outcome regarding graft choice and anterior knee laxity ( P  = 0.04) was in favour of patellar tendon graft. Hamstring graft led to a larger laxity, 2.4 mm compared with patellar tendon graft, 1.3 mm at 1 year and 2.5 mm and 1.5 mm, respectively, at 2 years ( P  = 0.05). There was a significant difference in rotational knee stability in favour of the patellar tendon graft at all test occasions but 9 months. A general effect regarding graft choice and muscle torque was found at 90°/s for quadriceps ( P  = 0.03) and hamstrings ( P  ≤ 0.0001) and at 230°/s for hamstrings ( P  ≤ 0.0001). No treatment effect regarding graft choice and one-leg hop test, postural sway or knee function was found. No group differences in anterior knee pain were found at any of the test occasions but 2 years in favour of hamstring graft compared to patellar tendon graft ( P  = 0.04). Patellar tendon graft resulted in higher activity level than hamstring graft at all test occasions but 1 year ( P  = 0.01). Patellar tendon ACL reconstruction led to more stable knees with less anterior knee laxity and less rotational instability than hamstring ACL reconstruction. Hamstring graft patients had not reached preoperative level in hamstring torque even 2 years after ACL reconstruction. Athletes with patellar tendon graft returned to sports earlier and at a higher level than those with hamstring graft.

Background Following curettage of giant cell tumor of bone (GCTB), it is common to fill the cavity with polymethylmethacrylate (PMMA) bone cement, bone allograft, or artificial bone to maintain bone strength; however, there is a 2–14% risk of postoperative fractures. We conducted this retrospective study to clarify the risk factors for fractures after curettage for GCTB of the extremities. Methods This study included 284 patients with GCTBs of the extremities who underwent curettage at our institutions between 1980 and 2018 after excluding patients whose cavities were not filled with anything or who had additional plate fixation. The tumor cavity was filled with PMMA bone cement alone ( n =  124), PMMA bone cement and bone allograft ( n =  81), bone allograft alone ( n =  63), or hydroxyapatite graft alone ( n =  16). Results Fractures after curettage occurred in 10 (3.5%) patients, and the median time from the curettage to fracture was 3.5 months (interquartile range [IQR], 1.8–8.3 months). The median postoperative follow-up period was 86.5 months (IQR, 50.3–118.8 months). On univariate analysis, patients who had GCTB of the proximal or distal femur (1-year fracture-free survival, 92.5%; 95% confidence interval [CI]: 85.8–96.2) presented a higher risk for postoperative fracture than those who had GCTB at another site (100%; p  = 0.0005). Patients with a pathological fracture at presentation (1-year fracture-free survival, 88.2%; 95% CI: 63.2–97.0) presented a higher risk for postoperative fracture than those without a pathological fracture at presentation (97.8%; 95% CI: 95.1–99.0; p  = 0.048). Patients who received bone grafting (1-year fracture-free survival, 99.4%; 95% CI: 95.7–99.9) had a lower risk of postoperative fracture than those who did not receive bone grafting (94.4%; 95% CI: 88.7–97.3; p  = 0.003). Conclusions For GCTBs of the femur, especially those with pathological fracture at presentation, bone grafting after curettage is recommended to reduce the risk of postoperative fracture. Additional plate fixation should be considered when curettage and cement filling without bone grafting are performed in patients with GCTB of the femur. This should be specially performed for those patients with a pathological fracture at presentation.

Purpose Bone-patellar tendon–bone technique (BPTB) for anterior cruciate ligament injuries is associated with a higher risk of donor-site morbidity. To evaluate whether platelet-rich plasma (PRP), due to its anti-inflammatory properties and capacity to stimulate tissue regeneration, was able to reduce the anterior knee pain, the kneeling pain, and donor-site morbidity, as evidenced by evaluation of VISA and VAS scoring scales and MRI analysis of the tendon and bone defect, we performed a clinical randomized controlled study where PRP gel was applied to donor site after ACL reconstruction with BPTB. Methods Forty young athletes with the indication of ACL reconstruction with patellar tendon grafts were randomly assigned to group A ( n  = 20 patients, control group) or group B ( n  = 20 patients, PRP group). The autologous PRP gel was applied to both the patellar and tendon bone plug harvest site and stabilized by the peritenon suture. At 12-month follow-up, all patients underwent clinical examination and VAS and VISA questionnaires, respectively, evaluating the average daily pain of the knee and the pain during particular activities involving the knee, were filled. MRI at the same time point was also performed. Results VISA scores were significantly higher in the patients treated with PRP (84.5 ± 11.8 and 97.8 ± 2.5 for group A and for group B; P  = 0.041), whereas no significant difference in postoperative VAS scores between the two groups was observed (1 ± 1.4 and 0.6 ± 0.9 for group A and group B, n.s.). In 85% of PRP group patients, the tibial and patellar bone defect was satisfactorily filled by new bony tissue (>70% of bone gap filled), whereas this percentage was just of 60% in control group patients, but this difference was not statistically significant. Conclusions The study shows the usefulness of PRP in reducing subjective pain at the donor-site level after ACL reconstruction with BPTB. However, this approach deserves further investigations to confirm PRP efficacy and to elucidate its mechanism of action. Level of evidence Prospective randomized controlled study, Level I.

Purpose The aim of this study was to compare the clinical outcomes of arthroscopic single-bundle anterior cruciate ligament (ACL) reconstruction with six-strand hamstring tendon (HT) allograft versus bone-patellar tendon-bone (BPTB) allograft. Methods The prospective randomized controlled trial was included 129 patients. Sixty-nine patients received reconstruction with six-strand HT allografts (HT group), whereas 60 patients with BPTB allografts (BPTB group). Outcome assessment included re-rupture findings, International Knee Documentation Committee (IKDC) scores, Lysholm scores, KT-1000 arthrometer, Lachman test, pivot-shift test, range of motion (ROM) and single-leg hop test. Results At a mean follow-up of 52 months, 113 patients (HT group, 61 patients; BPTB group, 52 patients) completed a minimum 4-year follow-up. Four patients in HT group and six in BPTB group experienced ACL re-rupture (6.2 vs. 10.3 %) and received revision surgery. Significant between-group differences were observed in KT-1000 outcomes and pivot-shift test 1 (1.2 ± 1.5 vs. 1.8 ± 1.3, p  = 0.025; positive rate 6.5 vs. 18.9 %, p  = 0.036), 2 (1.1 ± 1.4 vs. 1.6 ± 1.2, p  = 0.044; 8.1 vs. 20.7 %, p  = 0.039), 4 (1.1 ± 1.5 vs. 1.7 ± 1.4, p  = 0.031; 9.7 vs. 25 %, p  = 0.012) years postoperatively. The outcomes between the two groups were comparable in terms of IKDC scores, Lysholm scores, Lachman test, ROM and single-leg hop test. Conclusions Six-strand HT allograft achieved superior anteroposterior and rotational stability after single-bundle ACL reconstruction. It is a reasonable graft substitute for ACL reconstruction. Level of evidence II.

Background Reconstruction of large bone defects after tumor resection remains a major challenge in orthopedic surgery. Although autologous bone grafts have excellent osteogenic potential, their application is limited by the small volume available for harvest. Conversely, artificial bone substitutes, such as β-tricalcium phosphate (β-TCP), can be produced in large quantities but possess limited osteoinductive capacity. We present a case in which hybrid grafting using irradiated bone and β-TCP–derived regenerated fibula was performed to reconstruct a large segmental defect following resection of a recurrent bone tumor, achieving successful bone union. Case presentation A 10-year-old boy with fibrous dysplasia of the proximal femur initially underwent curettage, fibular strut grafting, and β-TCP implantation, including cylindrical β-TCP placement at the fibular donor site. At age 28, local recurrence was suspected, and the possibility of an intermediate malignant bone tumor could not be excluded. Therefore, a wide resection was selected after careful clinical consideration. The resulting segmental defect was reconstructed using an intercalary extracorporeally irradiated autograft, augmented with the regenerated fibula derived from the previous β-TCP implantation. At 1 year postoperatively, radiographic findings demonstrated bone union not only at the femoral osteotomy sites but also between the regenerated fibula and irradiated bone. Objective imaging analyses were performed to evaluate bone regeneration around the reconstructed segment using postoperative radiographs and CT as part of postoperative follow-up. Grayscale values at the osteotomy gaps reached levels comparable to cortical bone on radiographs. Computed tomography further revealed a significant increase in Hounsfield unit values at the bridging region between the regenerated fibula and irradiated bone. Conclusion Hybrid grafting using a β-TCP–derived regenerated fibula and irradiated bone successfully reconstructed a large femoral defect, highlighting the biological potential of regenerated bone. This reconstruction was based on the in vivo bioreactor concept, and objective imaging analysis proved useful for evaluating bone regeneration adjacent to the recycled bone.

Purpose Donor site pain affects 32–43 % of patients after anterior cruciate ligament surgery when the autograft is freshly harvested bone-patellar tendon-bone tissue. Our aim was to compare functional and morphological differences between donor sites with and without serum albumin-coated bone allograft filling. Methods After harvesting and implanting the graft, the tibia site was filled with either fresh autologous cancellous bone enhanced with albumin-coated allograft or autologous bone alone. The patella site was filled either with albumin-coated allograft or with blood clot. Knee function was evaluated by the VISA, Lysholm and IKDC scores and a visual analog scale of pain during standing, kneeling and crouching after six weeks and six months. Computed tomography was performed at six months for morphological evaluation. Results At six weeks, both groups were still recovering from surgery and the overall knee function was still impaired but the functional scores were significantly higher in the Bone-Albumin group. The pain with crouching and kneeling was also lower as compared to controls. At six months, the knee function scores were close to normal, with a slight decrease in the controls. Pain at kneeling was still prominent in the controls, but significantly lower in the Bone-Albumin group. Computed tomography showed significantly smaller bone defects and higher bone density in the Bone-Albumin group. Conclusions Results from the present study indicate that donor site pain, a disturbing long-term side effect of bone-patellar tendon-bone surgery, is significantly reduced if bone buildup in the patella and the tibia is augmented by serum albumin-coated bone allografts.