BACKGROUND: Reconstruction of mandibular defects caused by combat injuries is challenging for clinicians due to soft tissue defects and high complication risk. This study evaluated the outcomes of mandibular continuous defects reconstruction with non-vascularized iliac crest graft (NVICG) in patients with combat injuries.
METHODS: Patients with continuous mandibular defects acquired by high-velocity agents, who received NVICG reconstruction with or without microvascular-free soft tissue or regional flaps, were included in the study. The outcome variable was graft loss due to postoperative complications or full (more than 90 %) resorption. The primary predictor variable was soft tissue defect in the recipient area. The secondary predictor variable was the length of the defect. Variables related to patients, defect site, surgery, and other complications were also evaluated. Statistical analysis was performed with the usage of independent sample t-test, Pearson\'s chi-squared and Fisher\'s exact tests with a significance level of P < 0.05 RESULTS: The study included 24 patients with 27 mandibular defects. Overall, the general success rate of reconstructions was 59.3 %. Soft tissue defects were significantly associated with graft failure and other complications (p < 0.05), which were mostly related to soft tissue defects. The graft success rate was only 14.3 % even in minor soft tissue defects. In turn, in reconstructions with sufficient soft tissue coverage, the graft survived in 75.0 % of the cases. In addition, patients with more delayed reconstruction had significantly fewer graft failures than those with earlier surgery (p < 0.05). No associations were found between defect size and complications.
CONCLUSIONS: The sufficient soft tissue coverage is essential in the reconstruction of mandibular defects caused by combat injuries. Also, minor soft tissue defects should be covered with soft tissue flaps to avoid complications and graft loss in these specific injuries. Even large defects can be reconstructed with NIVICG if the soft tissue coverage is sufficient.

In this case report, we want to show how a patient who underwent surgery for a distal humerus fracture developed postoperative ulnar neuropathy symptoms, how nonunion persisted even at the ninth month of follow-up, and whether the nonunion was connected to the ulnar neuropathy that developed. Due to this, we used this case to explore ulnar nerve care and whether ulnar nerve transposition, manipulation, or decompression should be carried out during surgery on patients with distal humerus fractures. A 52-year-old man with a bi-columnar distal humerus fracture from a fall on his right elbow underwent open reduction and internal fixation at an external center one year before. Elbow restriction, discomfort, numbness, and weakness in the fourth and fifth digits of the right hand were all symptoms the patient experienced eight months following the surgery. We discovered the distal right humerus\' nonunion during the radiological exams. It became apparent that the patient had no signs of ulnar neuropathy before the injury. In the eighth month following the injury, the patient had implant removal, open reduction internal fixation with autograft, and ulnar nerve transposition. We discovered during follow-up that the patient\'s ulnar neuropathy symptoms had subsided. The surgeon\'s familiarity with the procedure and command of the anatomy of the elbow has a role in managing the ulnar nerve in distal humerus fractures. We concluded that more study is required to determine the connection between the onset of ulnar neuropathy and nonunion while treating distal humerus fractures.

BACKGROUND: Kienböck\'s disease is idiopathic lunate avascular necrosis, which may lead to lunate collapse, abnormal carpal motion and wrist arthritis. The current study aimed to assess the outcomes of treating stage IIIA Kienböck\'s disease by a novel technique of limited carpal fusion via partial lunate excision with preservation of the proximal lunate surface and scapho-luno-capitate (SLC) fusion.
METHODS: We conducted a prospective study of patients with grade IIIA Kienböck\'s disease managed with a novel technique of limited carpal fusion comprising SLC fusion with preservation of the proximal lunate articular cartilage. Autologous iliac crest bone grafting and K-wires fixation were used to enhance the osteosynthesis of the SLC fusion. The minimum follow-up period was 1 year. A visual analog scale (VAS) and the Mayo Wrist Score were utilized for the evaluation of patient residual pain and functional assessment, respectively. A digital Smedley dynamometer was used to measure the grip strength. The modified carpal height ratio (MCHR) was used for monitoring carpal collapse. The radioscaphoid angle, scapholunate angle, and the modified carpal-ulnar distance ratio were used for the assessment of carpal bones alignment and ulnar translocation of carpal bones.
RESULTS: This study included 20 patients with a mean age of 27.9 ± 5.5 years. At the last follow-up, the mean range of flexion/extension range of motion (% of normal side) improved from 52.8 ± 5.4% to 65.7 ± 11.1%, P = 0.002, the mean grip strength (% of normal side) improved from 54.6 ± 11.8% to 88.3 ± 12.4%, P = 0.001, the mean Mayo Wrist Score improved from 41.5 ± 8.2 to 81 ± 9.2, P = 0.002, and the mean VAS score reduced from 6.1 ± 1.6 to 0.6 ± 0.4, P = 0.004. The mean follow-up MCHR improved from 1.46 ± 0.11 to 1.59 ± 0.34, P = 0.112. The mean radioscaphoid angle improved from 63 ± 10º to 49 ± 6º, P = 0.011. The mean scapholunate angle increased from 32 ± 6º to 47 ± 8º, P = 0.004. The mean modified carpal-ulnar distance ratio was preserved and none of the patients developed ulnar translocation of the carpal bones. Radiological union was achieved in all patients.
CONCLUSIONS: Scapho-luno-capitate fusion with partial lunate excision and preservation of the proximal lunate surface is a valuable option for treating stage IIIA Kienböck\'s disease, with satisfactory outcomes. Level of evidence Level IV. Trial registration Not applicable.

Fracture of the anterior maxilla usually causes a scooped-out defect in this region which leads to loss of lip support and a sub-optimal condition for placement of implants. The iliac crest is a frequently used donor location in oral and maxillofacial procedures for bone augmentation in order to restore jaw deformities brought on by trauma or pathological diseases prior to the placement of dental implants. Here we present the case of a patient who had undergone reconstruction of the maxillary osseous defect caused due to trauma by iliac crest grafting, followed by placement of dental implants after six months.

UNASSIGNED: Achieving predictable aesthetic results of large craniofacial defects has always been difficult, and it requires a multidisciplinary approach.
UNASSIGNED: The chief concern of the patient was poor aesthetics due to a congenital craniofacial defect.
UNASSIGNED: The patient was a known case of plexiform neurofibromatosis and had a congenital temporo-orbital bone defect of unknown origin.
UNASSIGNED: The reconstruction of the defect was done using rapid prototyping (RPT) and iliac crest graft. Three-dimensional computed tomography imaging and RPT were used to obtain a customized titanium prosthesis to rehabilitate the temporal defect and the defect lateral to the orbit was reconstructed using an iliac crest graft.
UNASSIGNED: Postoperative results were satisfactory and predictable. The positive change in appearance has improved the psychological well-being of the patient.
UNASSIGNED: A multidisciplinary approach, use of advanced and improved technology helps in better treatment planning and achieving desired aesthetic results.

UNASSIGNED: Vertical discrepancy between the fibula flap and the native mandible results in difficult prosthetic rehabilitation. The aim of this study was to evaluate the outcomes of 3D reconstruction of the mandible in oncologic patients using three different techniques through virtual surgical planning (VSP), cutting guides, customized titanium mesh and plates with CAD/CAM technology, STL models and intraoperative dynamic navigation for implant placement. Material and methods.
UNASSIGNED: Three different techniques for mandibular reconstruction and implant rehabilitation were performed in 14 oncologic patients. Five patients (36%) underwent VSP, cutting guides, STL models and a customized double-barrel titanium plate with a double-barrel flap and immediate implants. In six patients (43%), VSP, STL models and a custom-made titanium mesh (CAD/CAM) for 3D reconstruction with iliac crest graft over a fibula flap with deferred dental implants were performed. Three patients (21%) underwent VSP with cutting guides and customized titanium plates for mandibular reconstruction and implant rehabilitation using intraoperative dynamic navigation was accomplished. Vertical bone reconstruction, peri-implant bone resorption, implant success rate, effects of radiotherapy in vertical reconstruction, bone resorption and implant failure, mastication, aesthetic result and dysphagia were evaluated.
UNASSIGNED: Significant differences in bone growth between the double-barrel technique and iliac crest graft with titanium mesh technique were found (p<0.002). Regarding bone resorption, there were no significant differences between the techniques (p=0.11). 60 implants were placed with an osseointegration rate of 91.49%. Five implants were lost during the osseointegration period (8%). Peri-implant bone resorption was measured with a mean of 1.27 mm. There was no significant difference between the vertical gain technique used and implant survival (p>0.385). Implant survival rates were higher in non-irradiated patients (p<0.017). All patients were rehabilitated with a fixed implant-supported prosthesis reporting a regular diet (80%), normal swallowing (85.7%) and excellent aesthetic results.
UNASSIGNED: Multi-stage implementation of VSP, STL models and cutting guides, CAD/CAM technology, customized plates and in-house dynamic implant navigation for mandibular defects increases bone-to-bone contact, resolves vertical discrepancy and improves operative efficiency with reduced complication rates and minimal bone resorption. It provides accurate reconstruction that optimizes implant placement, thereby improving facial symmetry, aesthetics and function.

BACKGROUND: Harvesting vascularized bone grafts with computer-assisted surgery represents the gold standard for mandibular reconstruction. However, current augmented reality (AR) approaches are limited to invasive marker fixation. This trial compared a markerless AR-guided real-time navigation with virtually planned and 3D printed cutting guides for harvesting iliac crest grafts.
METHODS: Two commonly used iliac crest transplant configurations were virtually planned on 10 cadaver hips. Transplant harvest was performed with AR guidance and cutting guide technology. The harvested transplants were digitalized using cone beam CT. Deviations of angulation, distance and volume between the executed and planned osteotomies were measured.
RESULTS: Both AR and cutting guides accurately rendered the virtually planned transplant volume. However, the cumulative osteotomy plane angulation differed significantly (p = 0.018) between AR (14.99 ± 11.69°) and the cutting guides (8.49 ± 5.42°). The cumulative osteotomy plane distance showed that AR-guided navigation had lower accuracy (2.65 ± 3.32 mm) than the cutting guides (1.47 ± 1.36 mm), although without significant difference.
CONCLUSIONS: This study demonstrated the clinical usability of markerless AR-guided navigation for harvesting iliac crest grafts. Further improvement of accuracy rates might bring clinical implementation closer to reality.

BACKGROUND: Defects of the facial skeleton often require complex reconstruction with vascularized grafts. This trial elucidated the usability, visual perception and accuracy of a markerless augmented reality (AR)-guided navigation for harvesting iliac crest transplants.
METHODS: Random CT scans were used to virtually plan two common transplant configurations on 10 iliac crest models, each printed four times. The transplants were harvested using projected AR and cutting guides. The duration and accuracies of the angulation, distance and volume between the planned and executed osteotomies were measured.
RESULTS: AR was characterized by the efficient use of time and accurate rendition of preoperatively planned geometries. However, vertical osteotomies and complex anatomical settings displayed significant inferiority of AR guidance compared to cutting guides.
CONCLUSIONS: This study demonstrated the usability of a markerless AR setup for harvesting iliac crest transplants. The visual perception and accuracy of the AR-guided osteotomies constituted remaining weaknesses against cutting guide technology.

BACKGROUND: Comminuted fractures of the posterior acetabular wall, pose a significant challenge in the reduction and fixation of the fracture fragments and usually result in dubious functional outcomes. Primary reconstruction of the severely comminuted posterior wall using the autologous tricortical iliac crest graft has shown promising results, especially in fractures not amenable for anatomical reduction and fixation. Thus, the present study analyses the functional and radiological outcomes of severely comminuted posterior wall acetabular fractures, primarily reconstructed with an autologous tricortical iliac crest graft.
METHODS: This is a retrospective study, where all cases of comminuted posterior wall acetabulum fractures treated primarily with reconstruction using ipsilateral autologous tricortical iliac crest graft between January 2011 and November 2018 were included. The data of patients were retrieved from the hospital records and all the patients were assessed clinically and radiologically at the final follow-up.
RESULTS: Fourteen patients (ten males and four females) were operated on with a mean operative time of 160 min (range 125 to 190 min) and a mean blood loss of 410 ml (range 320 ml to 830 ml). At 2 years of follow-up, 11 patients (78.57%) had good to excellent functional outcomes based on the modified Merle d\'Aubigne and Postel scoring system. The radiological assessment using Matta\'s criteria indicated excellent outcomes in two patients (14.48%), good in six patients (42.85%), fair in six patients (42.85%).
CONCLUSIONS: Primary reconstruction of the comminuted posterior wall acetabulum fractures is a potential alternative and salvageable option with favourable outcomes. However, it ought to be considered in severely comminuted fractures where anatomical reduction and internal fixation is not feasible.

Mandibular reconstruction with fibula flap shows a 3D discrepancy between the fibula and the remnant mandible. Eight patients underwent three-dimensional reconstruction of the fibula flap with iliac crest graft and dental implants through virtual surgical planning (VSP), stereolitographic models (STL) and CAD/CAM titanium mesh. Vertical ridge augmentation and horizontal dimensions of the fibula, peri-implant bone resorption of the iliac crest graft, implant success rate and functional and aesthetic results were evaluated. Vertical reconstruction ranged from 13.4 mm to 10.1 mm, with an average of 12.22 mm. Iliac crest graft and titanium mesh were able to preserve the width of the fibula, which ranged from 8.9 mm to 11.7 mm, with an average of 10.1 mm. A total of 38 implants were placed in the new mandible, with an average of 4.75 ± 0.4 implants per patient and an osseointegration success rate of 94.7%. Two implants were lost during the osseointegration period (5.3%). Bone resorption was measured as peri-implant bone resorption at the mesial and distal level of each implant, with a variation between 0.5 mm and 2.4 mm, and with a mean of 1.43 mm. All patients were rehabilitated with a fixed implant prosthesis with good aesthetic and functional results.