Traumatic spondyloptosis: a series of 20 patients

OBJECT Spondyloptosis represents the most severe form of spondylolisthesis, which usually follows high-energy trauma. Few reports exist on this specific condition, and the largest series published to date consists of only 5 patients. In the present study the authors report the clinical observations and outcomes in a cohort of 20 patients admitted to a regional trauma center for severe injuries including spondyloptosis. METHODS The authors performed a retrospective chart review of patients admitted with spondyloptosis at their department over a 5-year period (March 2008–March 2013). Clinical, radiological, and operative details were reviewed for all patients. RESULTS In total, 20 patients with spondyloptosis were treated during the period reviewed. The mean age of the patients was 27 years (range 12–45 years), and 17 patients were male (2 boys and 15 men) and 3 were women. Fall from height (45%) and road traffic accidents (35%) were the most common causes of the spinal injuries. The grading of the American Spinal Injury Association (ASIA) was used to assess the severity of spinal cord injury, which for all patients was ASIA Grade A at the time of admission. In 11 patients (55%), the thoracolumbar junction (T10–L2) was involved in the injury, followed by the dorsal region (T1–9) in 7 patients (35%); 1 patient (5%) had lumbar and 1 patient (5%) sacral spondyloptosis. In 19 patients (95%), spondyloptosis was treated surgically, involving the posterior route in all cases. In 7 patients (37%), corpectomy was performed. None of the patients showed improvement in neurological deficits. The mean follow-up length was 37.5 months (range 3–60 months), and 5 patients died in the follow-up period from complications due to formation of bedsores (decubitus ulcers). CONCLUSIONS To the authors' best knowledge, this study was the largest of its kind on traumatic spondyloptosis. Its results illustrate the challenges of treating patients with this condition. Despite deformity correction of the spine and early mobilization of patients, traumatic spondyloptosis led to high morbidity and mortality rates because the patients lacked access to rehabilitation facilities postoperatively.

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Thoracic and lumbar tuberculous spondylitis treated by posterior debridement, graft placement, and instrumentation: a retrospective analysis in 19 cases

Journal of Neurosurgery Spine ◽

10.3171/spi.2005.3.6.0450 ◽

2005 ◽

Vol 3 (6) ◽

pp. 450-458 ◽

Cited By ~ 55

Author(s):

Feyza Karagöz Güzey ◽

Erhan Emel ◽

N. Serdar Bas ◽

Selim Hacisalihoglu ◽

Hakan Seyithanoglu ◽

...

Keyword(s):

Spinal Injury ◽

Posterior Instrumentation ◽

Neurological Deficits ◽

Easy Access ◽

Tuberculous Spondylitis ◽

Content Type ◽

The Mean ◽

Posterior Debridement ◽

Fine Print

Object. Surgical treatment of thoracic and lumbar tuberculous spondylitis is controversial. An anterior approach is usually recommended. The aim of the present study was to assess the efficacy of posterior debridement and the placement of posterior instrumentation for the treatment of patients with thoracic and lumbar tuberculous spondylitis. Methods. Nineteen patients with thoracic and lumbar tuberculous spondylitis underwent single-stage posterior decompression and debridement as well as the placement of posterior interbody grafts if necessary, instrumentation and posterior or posterolateral grafts. No postoperative neurological deterioration was noted. One patient died of myocardial infarction on Day 10. The mean follow-up duration, excluding the one death, was 52.7 months (range 16–125 months). In a 70-year-old patient, a single pedicle screw broke after 3 months. All patients were in better neurological condition after surgery and at the last follow-up examination. Neurological deficits were present in only two patients at the last follow up (one American Spinal Injury Association Grade B and one Grade C deficit preoperatively). Three other patients suffered intermittent back or low-back pain. The mean angulation measured in 13 patients with kyphotic deformity was 18.2° (range 5–42°) preoperatively; this was reduced to 17.3° (range 0–42°) after surgery. There was a 2.8° loss of correction (range 2–5°) after 44.3 months (16–64 months). Kyphosis did not progress beyond 15 months in any patient. Conclusions A posterior approach in combination with internal fixation and posterior or posterolateral fusion (with or without placement of posterior interbody grafts) may be sufficient for the debridement of the infection and to allow spinal stabilization in patients with thoracic and lumbar tuberculous spondylitis. This procedure is associated with easy access to the spinal canal for neural decompression, prevention of loss of corrected vertebral alignment in the long term, and facilitation of early mobilization.

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Pediatric isolated thoracic and/or lumbar transverse and spinous process fractures

Journal of Neurosurgery Pediatrics ◽

10.3171/2015.10.peds15377 ◽

2016 ◽

Vol 17 (6) ◽

pp. 639-644 ◽

Cited By ~ 8

Author(s):

Babatunde J. Akinpelu ◽

Scott L. Zuckerman ◽

Stephen R. Gannon ◽

Ashly Westrick ◽

Chevis Shannon ◽

...

Keyword(s):

Pediatric Patients ◽

Pediatric Population ◽

Spinous Process ◽

High Energy ◽

Neurological Deficits ◽

Lumbar Region ◽

Presenting Symptoms ◽

The Mean

OBJECTIVE Isolated transverse and spinous process fractures (TPFx and SPFx) in the thoracic and/or lumbar region have been deemed clinically insignificant in the adult population. This same rule is often applied to the pediatric population; however, little evidence exists in this younger group. The goal of this study was to describe the clinical, radiographic, and long-term data on isolated TPFx and SPFx in an exclusively pediatric population. METHODS A retrospective chart review at Monroe Carell Jr. Children's Hospital at Vanderbilt University identified 82 pediatric patients with isolated TPFx and/or SPFx following a traumatic event between January 2000 and December 2013. Patient demographic information, presenting symptoms, radiographic characteristics, and follow-up data were collected. Follow-up was used to determine the outcome (presence of neurological deficits) of such injuries via complete physical examination and, when available, radiographic evidence. RESULTS In the 82 identified patients, the mean age was 15.5 ± 3.1 years (mean is expressed ± SD throughout), with 72 injuries (87.8%) resulting from a motor vehicle, motorcycle, or all-terrain vehicle accident. There was a mean of 1.7 ± 1.0 fractured vertebral levels involved and a mean of 1.8 ± 1.1 fractures was identified per patient. Seventy-one patients (86.6%) needed bedside pain control, 7 (8.5%) were prescribed a brace, and 4 patients (4.9%) received a collar. Physical therapy was recommended for 12 patients (14.6%). A total of 84.1% had follow-up, and the mean length of follow-up was 19 ± 37 months. No patients had true neurological deficits at presentation or follow-up as a result of their isolated fractures, whereas 95.1% had other associated system injuries. CONCLUSIONS These data shows that there is no appreciable long-term complication associated with isolated thoracic and/or lumbar TPFx and/or SPFx in an exclusively pediatric population. Because these fractures are, however, associated with high-energy blunt trauma, they often result in associated soft-tissue or other skeletal injury. All pediatric patients in the cohort benefited from conservative management and aggressive treatment of their comorbidities.

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Spinal Injuries in a Tertiary Care Referral Center of Western Nepal

Nepal Journal of Medical Sciences ◽

10.3126/njms.v2i2.8967 ◽

2013 ◽

Vol 2 (2) ◽

pp. 156-159

Author(s):

P Devkota ◽

HK Manandhar ◽

PB Khadka

Keyword(s):

Traffic Accidents ◽

Road Traffic ◽

Spinal Injury ◽

Financial Burden ◽

Tertiary Care ◽

Spinal Injuries ◽

Neurological Deficits ◽

Medical Sciences ◽

Male Patients ◽

The Mean

Background: Spinal injury is a devastating condition often affecting young and healthy individuals around the world. This devastating injury not only creates enormous physical and emotional cost to individuals but also gives tremendous financial burden to the society. We evaluate the demography, types and causes of the spinal injuries and their management in patients admitted in a hospital. Methods: Medical records of 45 patients who were presented with spinal injuries in a year were analyzed. The age, sex, mode of injury, sites, types and level of injury, hospital stay, and treatment given were analyzed. Frankel grading was used for the evaluation of the neurological deficits. Results: The mean age of the patient was 47.5 years (range 19 - 78). Male patients were 60% (n=27) and female 40% (n=18). There were 42.2% (n=19) patients with E grade, 24.4% (n=11) patients with C grade, 20% (n=9) patients with D, three 6.6% (n=3) patients with A and B grades each of patients according to Frankel grade. Lumbar spine was the commonest site of injury. The most common cause of injury was fall, followed by road traffic accidents (RTA) and others. Nineteen patients were treated conservatively, 16 were operated, five patients were referred to other centers due to various reasons and the other five patients were discharged on their request. Conclusions: Spinal injuries are one of the rapidly growing injuries in our society and the commonest mode of injury was fall. The majority of patients were from the hilly areas. Nepal Journal of Medical Sciences | Volume 02 | Number 02 | July-December 2013 | Page 156-159 DOI: http://dx.doi.org/10.3126/njms.v2i2.8967

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Natural history and treatment options of radiation-induced brain cavernomas: a systematic review

Neurosurgical Review ◽

10.1007/s10143-021-01598-y ◽

2021 ◽

Author(s):

Gildas Patet ◽

Andrea Bartoli ◽

Torstein R. Meling

Keyword(s):

Systematic Review ◽

Natural History ◽

Radiation Treatment ◽

Neurological Deficits ◽

Cochrane Library ◽

Average Dose ◽

Cavernous Malformations ◽

Radiation Induced ◽

The Mean

AbstractRadiation-induced cavernous malformations (RICMs) are delayed complications of brain irradiation during childhood. Its natural history is largely unknown and its incidence may be underestimated as RCIMS tend to develop several years following radiation. No clear consensus exists regarding the long-term follow-up or treatment. A systematic review of Embase, Cochrane Library, PubMed, Google Scholar, and Web of Science databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was performed. Based on our inclusion/exclusion criteria, 12 articles were included, totaling 113 children with RICMs, 86 were treated conservatively, and 27 with microsurgery. We were unable to precisely define the incidence and natural history from this data. The mean age at radiation treatment was 7.3 years, with a slight male predominance (54%) and an average dose of 50.0 Gy. The mean time to detection of RICM was 9.2 years after radiation. RICM often developed at distance from the primary lesion, more specifically frontal (35%) and temporal lobe (34%). On average, 2.6 RICMs were discovered per child. Sixty-seven percent were asymptomatic. Twenty-one percent presented signs of hemorrhage. Clinical outcome was favorable in all children except in 2. Follow-up data were lacking in most of the studies. RICM is most often asymptomatic but probably an underestimated complication of cerebral irradiation in the pediatric population. Based on the radiological development of RICMs, many authors suggest a follow-up of at least 15 years. Studies suggest observation for asymptomatic lesions, while surgery is reserved for symptomatic growth, hemorrhage, or focal neurological deficits.

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Rehabilitation of the canine patient following spinal cord injury: a practical guide

Companion Animal ◽

10.12968/coan.2020.0060 ◽

2021 ◽

Vol 26 (1) ◽

pp. 1-6

Author(s):

Cheryl Corral

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Spinal Injury ◽

Neurological Deficits ◽

Practical Guide ◽

Cord Injury ◽

Physical Therapies

This article forms part of a series exploring the rehabilitation of the canine shoulder, elbow, back, hip and stifle following injury or disease. Discussed here are different rehabilitation techniques used to address neurological deficits, pain and weakness following spinal injury, including physical therapies, electrotherapies and acupuncture.

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Importance of a Follow-Up Ultrasound Protocol in Monitoring Posttraumatic Spleen Complications in Children Treated with a Non-Operative Management

Medicina ◽

10.3390/medicina57080734 ◽

2021 ◽

Vol 57 (8) ◽

pp. 734

Author(s):

Ivona Djordjevic ◽

Dragoljub Zivanovic ◽

Ivana Budic ◽

Ana Kostic ◽

Danijela Djeric

Keyword(s):

Splenic Abscess ◽

Operative Management ◽

High Energy ◽

Significant Difference ◽

Injury Grade ◽

Grade Ii ◽

The Mean ◽

Non Operative Management ◽

Grade Iii

Background and objectives: For the last three decades, non-operative management (NOM) has been the standard in the treatment of clinically stable patients with blunt spleen injury, with a success rate of up to 95%. However, there are no prospective issues in the literature dealing with the incidence and type of splenic complications after NOM. Materials and methods: This study analyzed 76 pediatric patients, up to the age of 18, with blunt splenic injury who were treated non-operatively. All patients were included in a posttraumatic follow-up protocol with ultrasound examinations 4 and 12 weeks after injury. Results: The mean age of the children was 9.58 ± 3.97 years (range 1.98 to 17.75 years), with no statistically significant difference between the genders. The severity of the injury was determined according to the American Association for Surgery of Trauma (AAST) classification: 7 patients had grade I injuries (89.21%), 21 patients had grade II injuries (27.63%), 33 patients had grade III injuries (43.42%), and 15 patients had grade IV injuries (19.73%). The majority of the injuries were so-called high-energy ones, which were recorded in 45 patients (59.21%). According to a previously created posttraumatic follow-up protocol, complications were detected in 16 patients (21.05%). Hematomas had the highest incidence and were detected in 11 patients (14.47%), while pseudocysts were detected in 3 (3.94%), and a splenic abscess and pseudoaneurysm were detected in 1 patient (1.31%), respectively. The complications were in a direct correlation with injury grade: seven occurred in patients with grade IV injuries (9.21%), five occurred in children with grade III injuries (6.57%), three occurred in patients with grade II injuries (3.94%), and one occurred in a patient with a grade I injury (1.31%). Conclusion: Based on the severity of the spleen injury, it is difficult to predict the further course of developing complications, but complications are more common in high-grade injuries. The implementation of a follow-up ultrasound protocol is mandatory in all patients with NOM of spleen injuries for the early detection of potentially dangerous and fatal complications.

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Retroclival Epidural Hematomas

Neurosurgery ◽

10.1227/01.neu.0000372085.70895.e7 ◽

2010 ◽

Vol 67 (2) ◽

pp. 404-407 ◽

Cited By ~ 29

Author(s):

R. Shane Tubbs ◽

Christoph J. Griessenauer ◽

Todd Hankinson ◽

Curtis Rozzelle ◽

John C. Wellons ◽

...

Keyword(s):

Glasgow Coma Scale ◽

Scale Score ◽

Glasgow Coma Scale Score ◽

Pediatric Patients ◽

Motor Vehicle ◽

Coma Scale ◽

Presenting Symptoms ◽

Cord Injury ◽

The Mean

Abstract BACKGROUND Retroclival epidural hematomas (REDHs) are infrequently reported. To our knowledge, only 19 case reports exist in the literature. OBJECTIVE This study was performed to better elucidate this pathology. METHODS We prospectively collected data for all pediatric patients diagnosed with REDH from July 2006 through June 2009. Data included mechanism of injury, Glasgow Coma Scale score, neurological examination, treatment modality, and outcome. Magnetic resonance imaging was used to measure REDH dimensions. RESULTS Eight children were diagnosed with REDH, and the hematomas were secondary to motor vehicle–related trauma in all cases. The mean age of patients was 12 years (range 4–17 years). The mean REDH height (craniocaudal) was 4.0 cm, and the mean thickness (dorsoventral) was 1.0 cm. At presentation, the mean Glasgow Coma Scale score was 8 (range 3–14), and there was no correlation between hematoma size and presenting symptoms. Two patients died soon after injury, and 2 additional patients had atlanto-occipital dislocation that required surgical intervention. No patient underwent surgical evacuation of the REDH. The mean follow-up was 14 months. At most recent follow-up, 4 patients are neurologically intact, 1 patient has a complete spinal cord injury, and 1 patient has mild bilateral abducens nerve palsy. CONCLUSION To our knowledge, this study of 8 pediatric patients is the largest series of patients with REDH thus far reported. Based on our study, we found that REDH is likely to be underdiagnosed, atlanto-occipital dislocation should be considered in all cases of REDH, and many patients with REDH will have minimal long-term neurological injury.

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Important Factors for a Combined Neurovascular Team to Consider in Selecting a Treatment Modality for Patients with Previously Clipped Residual and Recurrent Intracranial Aneurysms

Neurosurgery ◽

10.1227/01.neu.0000053209.61909.f2 ◽

2003 ◽

Vol 52 (4) ◽

pp. 732-739 ◽

Cited By ~ 32

Author(s):

Brian L. Hoh ◽

Bob S. Carter ◽

Christopher M. Putman ◽

Christopher S. Ogilvy

Keyword(s):

Endovascular Treatment ◽

Treatment Modality ◽

Posterior Circulation ◽

Neurological Deficits ◽

Parent Vessel ◽

Surgical Risk ◽

Fatal Hemorrhage ◽

The Mean ◽

Selection Of

Abstract OBJECTIVE Intracranial residual and recurrent aneurysms can occur after surgical clipping, with risks of growth and rupture. In the past, surgical reoperation, which can be associated with higher risk than the initial operation, was the only available treatment. A combined neurovascular team that uses both surgical and endovascular therapies could maximize efficacy and outcomes while minimizing risks in these difficult cases. The indications for which surgical or endovascular treatment should be used to treat patients with residual or recurrent aneurysms, however, have not been elucidated well. We have reviewed the 10-year experience of our combined neurovascular team to determine in a retrospective manner which factors were important to treatment modality selection for patients with these residual and recurrent lesions. METHODS From 1991 to 2001, the combined neurovascular unit at the Massachusetts General Hospital treated 25 residual and recurrent previously clipped aneurysms (15 had been clipped at other centers). Only patients in whom a clip had been placed were included in the study; patients who did not have a clip placed or whose aneurysms were wrapped or coated were excluded. The radiographic studies and clinical data were reviewed retrospectively to determine the efficacy, outcomes, and factors important to the selection of treatment strategy in these patients. RESULTS The patients' clinical presentations were radiographic follow-up, 17 patients; rehemorrhage, 3; mass effect, 3; and thromboembolism, 2. The mean aneurysm recurrence or residual size was 11 mm (range, 4–26 mm). The mean interval until representation was 6.6 years (range, 1 wk–25 yr). Treatment consisted of: coiling, 11 patients; reclipping, 8; proximal parent vessel balloon occlusion, 2; extracranial-intracranial bypass with coil occlusion of aneurysm and parent vessel, 2; extracranial-intracranial bypass with clip trapping, 1; and extracranial-intracranial bypass with proximal clip occlusion of parent vessel, 1. The mean radiographic follow-up period was 11 months. Complete angiographic occlusion was found in 19 aneurysms (76%), at least 90% occlusion was found in 4 aneurysms (16%), intentional partial coil obliteration was found in 1 fusiform lesion (4%), and intentional retrograde flow was found in 1 fusiform lesion (4%). Clinical outcomes were excellent or good in 19 patients (76%). Twenty-one patients (84%) were neurologically the same after retreatment (13 remained neurologically intact, and 8 had preexisting neurological deficits that did not change). Three patients (12%) had new neurological deficits after retreatment, and one patient (4%) died. There were four complications of retreatment (16%), one of which was a fatal hemorrhage in a patient 1 month after intentional partial coil obliteration of a fusiform vertebrobasilar junction aneurysm. Factors important to the selection of treatment modality were recurrence or residual location (all posterior circulation lesions were treated endovascularly), lesion size (lesions larger than 10 mm were treated endovascularly or with the use of combined techniques), and aneurysm morphology (fusiform and wide-necked lesions were treated endovascularly or with the use of combined techniques). CONCLUSION The proper selection of surgical or endovascular treatment for residual and recurrent previously clipped aneurysms can achieve excellent radiographic efficacy with low mortality. Factors important to the selection of treatment by this combined neurovascular team were posterior circulation location, aneurysm size larger than 10 mm, and fusiform morphology, which were treated endovascularly or with the use of combined techniques because of the higher surgical risk associated with these factors. For aneurysms with lower surgical risk, such as some anterior circulation aneurysms and aneurysms smaller than 10 mm, we prefer to perform a reoperation because of superior radiographic cure without compromising the outcome.

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Usefulness of anterior column release for segmental lordosis restoration in degenerative lumbar kyphosis

Journal of Neurosurgery Spine ◽

10.3171/2021.5.spine202196 ◽

2021 ◽

pp. 1-7

Author(s):

Jin-Sung Park ◽

Chong-Suh Lee ◽

Youn-Taek Choi ◽

Se-Jun Park

Keyword(s):

Sagittal Alignment ◽

Adult Spinal Deformity ◽

Anterior Column ◽

Sacral Slope ◽

High Morbidity ◽

Global Sagittal Alignment ◽

The Mean ◽

Lumbar Kyphosis ◽

Segmental Lordosis

OBJECTIVE Three-column osteotomies (3COs) for surgical correction of lumbar kyphosis show a strong correction capacity, but this procedure carries high morbidity rates. The anterior column release (ACR) technique was developed as a less invasive procedure. In this study the authors aimed to evaluate sagittal alignment restoration using ACR and to determine factors that affect the degree of correction. METHODS This study included 36 patients (68 cases) who underwent ACR of more than one level for adult spinal deformity. Parameters for regional sagittal alignment included segmental lordosis (SL). The parameters for global sagittal alignment included pelvic incidence, lumbar lordosis, sacral slope, pelvic tilt, and sagittal vertical axis (SVA). In addition, the interdiscal height (IDH) and difference of interdiscal angle (DIDA) were measured to evaluate the stiffness of the vertebra segment. The changes in SL were evaluated after ACR and the change of global sagittal alignment was also determined. Factors such as the location of the ACR level, IDH, DIDA, cage height, and additional posterior column osteotomy (PCO) were analyzed for correlation with the degree of SL correction. RESULTS Thirty-six patients were included in this study. A total of 68 levels were operated with the ACR (8 levels at L2–3, 27 levels at L3–4, and 33 levels at L4–5). ACR was performed for 1 level in 10 patients, 2 levels in 20, and 3 levels in 6 patients (mean 1.9 ± 0.7 levels per patient). Mean follow-up duration was 27.1 ± 4.2 months. The mean SL of the total segment was 0.4° ± 7.2° preoperatively and increased by 15.3° ± 5.5° at the last follow-up (p < 0.001); thus, the mean increase of SL was 14.9° ± 8.1° per one ACR. Global sagittal alignment was also improved following SL restoration with SVA from 101.9 mm to 31.4 mm. The degree of SL correction was correlated with the location of ACR level (p = 0.041) and was not correlated with IDH, DIDA, cage height and additional PCO. CONCLUSIONS This study demonstrated that the mean correction angle of SL was 14.9 per one ACR. The degree of disc space collapse and stiffness of segment did not affect the degree of correction by ACR.

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The Use of Patient-Specific 3D Printed Titanium Implants for Complex Foot and Ankle Limb Salvage, Deformity Correction, and Arthrodesis Procedures

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000018 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0000

Author(s):

Samuel Adams ◽

Travis Dekker ◽

John Steele ◽

Kamran Hamid

Keyword(s):

Lower Extremity ◽

Deformity Correction ◽

Titanium Implants ◽

Patient Specific ◽

Allograft Bone ◽

Foot And Ankle ◽

Sf 36 ◽

3D Printed ◽

The Mean

Category: Ankle,Ankle Arthritis,Basic Sciences/Biologics,Trauma Introduction/Purpose: Large lower extremity bony defects, complex foot and ankle deformities, and high-risk arthrodesis situations can be difficult to treat. These challenging pathologies, often require a critical-sizes and/or shaped structural bone void filler which may not be available with allograft bone. The advancement of 3D printing technology has allowed for the use of custom designed implants for foot and ankle surgery. This study reports on the radiographic and functional outcomes of a case series of patients treated with patient-specific 3D printed titanium implants. Methods: Seven consecutive patients who were treated with custom designed 3D printed implant cages for severe bone loss, deformity correction, and arthrodesis procedures were included in this study. A minimum of 1-year follow-up was required. No patients were lost to follow-up. Patients completed preoperative and most recent follow-up VAS for pain, FAAM, and SF-36 outcomes questionnaires. All patients had post-operative radiographs and CT scans to assess bony incorporation. Results: The mean age of these patients was 54.6 (35-73 years of age). The mean follow-up of these seven patients was 17.1 months (range 12 to 31). Radiographic fusion with cage ingrowth and integration occurred in all seven patients verified by CT scan. There was statistically significant improvement in all functional outcome score measures (VAS for pain, FAAM, and SF-36). All patients returned were satisfied with surgery. There were no failures. Case examples are demonstrated in Figure 1. Conclusion: This cohort of patients demonstrated the successful use of custom 3D printed implants to treat complex large bony defects, deformities and arthrodesis procedures of the lower extremity. These implants offer the surgeon a patient specific approach to treat both pain and deformity that is not necessarily available with allograft bone.

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