A 3-Dimensional Suture Technique for Flexor Tendon Repair: A Biomechanical Study.

PURPOSE: Flexor tendon injury continues to pose a number of challenges for hand surgeons. Improving mechanical properties of repairs should allow for earlier and unprotected rehabilitation. A 3-dimensional (3D) 4-strand suture technique has been proposed to combine high tensile strength and low gliding resistance without causing suture pullout due to tendon delamination. Our hypothesis is that the 3D technique can result in better mechanical properties than the Adelaide technique. METHODS: Four groups of 10 porcine flexor tendons were sutured using the 3D or Adelaide technique with a 3-0 polypropylene or ultrahigh molecular weight polyethylene (UHMWPE) suture. The axial traction test to failure was performed on each tendon to measure 2-mm gap force and ultimate tensile strength. RESULTS: The mean 2-mm gap force was 49 N for group A (3D + polypropylene), 145 N for group B (3D + UHMWPE), 47 N for group C (Adelaide + polypropylene), and 80 N for group D (Adelaide + UHMWPE). Failure mode was caused by suture breakage for group A (10/10) and mainly by suture pullout for the other groups (8/10 up to 10/10). With the UHMWPE suture, the mean ultimate tensile strength was 145 N for the 3D technique and 80 N for the Adelaide technique. CONCLUSIONS: Porcine flexor tendons repaired using the 3D technique and UHMWPE suture exceeded a 2-mm gap force and tensile strength of 140 N. The ultimate tensile strength was superior to that of the Adelaide technique, regardless of the suture material. CLINICAL RELEVANCE: This in vitro study on porcine flexor tendon suture highlights that the mechanical properties of 3D repair are better than those of 3D repair using the Adelaide technique when a UHMWPE suture is used.

Comparison of four correction techniques for posterior spinal fusion in adolescent idiopathic scoliosis.

INTRODUCTION: When performing posterior spinal fusion for adolescent idiopathic scoliosis (AIS), it is of major importance to address both coronal and sagittal deformities. Although several techniques have been described, few data exist comparing them. Our objective was to compare four techniques (in situ bending (ISB), rod derotation (RD), cantilever (C) and posteromedial translation (PMT)) for the correction of spinal deformity in AIS including thoracic deformity. MATERIAL AND METHODS: We conducted a multicenter retrospective study including 562 AIS patients with thoracic deformity with at least 24-month follow-up. Radiographic analysis was performed preoperatively, postoperatively and at last follow-up. The main outcomes were main curve correction and thoracic kyphosis restoration (TK). RESULTS: Coronal correction rate was significantly different among the four treatment groups (ISB 64% vs C 57% vs RD 55% vs PMT 67%, p < 0.001). Multivariate regression revealed that correction technique did not influence correction rate, whereas implant density, convex side compression and use of derotation connectors did. TK increase was significantly higher in the PMT group (average + 13°) than in DR (+ 3°), while ISB (-3°) and cantilever (-13°) resulted in TK decrease (p < 0.001). Multivariate analysis revealed that TK increase was only influenced by the reduction technique (p < 0.001) and preoperative TK (p < 0.001). DISCUSSION: The four techniques had the same ability to correct spinal deformity in the coronal plane. Three factors were identified to improve correction rate: implant density, convex compression and use of derotation connectors. On the other hand, PMT was more effective in restoring TK, particularly in hypokyphotic patients.

Variation of cervical sagittal alignment parameters according to gender, pelvic incidence and age.

PURPOSE: The aim was to describe radiographic cervical sagittal alignment variations according to age, gender and pelvic incidence (PI) and to investigate relationships with thoracic alignment. METHODS: A total of 2599 individuals (5-93 years) without spinal deformity were studied. Cranial cervical parameters were: McGregor slope, occipita-C2 angle, McGregor-C2 lordosis and C1-C2 lordosis. Caudal cervical parameters were: C2-C7, cranial arch and caudal arch lordosis and C7- and T1-slope. A Bayesian inference compared parameter distributions. Correlations with spinopelvic and global alignment parameters were investigated. RESULTS: Among cranial cervical parameters, variations of McGregor slope were non-significant. McGregor-C2 lordosis and C1-C2 lordosis were smaller in males and increased significantly during growth, whereas the occipito-C2 angle decreased (Pr > 0.95). The occipito-C2 angle was larger and McGregor-C2 lordosis was smaller in low PI (Pr > 0.95). Among caudal cervical parameters, C2-C7 lordosis and C7- and T1-slope were larger in males and increased after 50 years (Pr > 0.95). Lordosis changes were non-significant in the cranial arch, whereas values increased in the caudal arch after 35 years (Pr > 0.95). Caudal parameter differences were non-significant between PI groups. Strong correlations existed between C2-C7, caudal arch lordosis, C7-slope, T1-slope and thoracic kyphosis. The sagittal vertical axis C2 correlated with caudal arch lordosis and T1-slope (ρ > 0.5; Pr > 0.95). CONCLUSION: Cervical alignment parameters vary according to age, gender and PI. In the cranial cervical spine, changes occur mainly during growth. In the caudal cervical spine, lordosis increases in the caudal arch, which is related to thoracic kyphosis increase with age. The caudal cervical arch acts as a compensatory segment by progressive extension, allowing horizontal gaze.

Congenital pseudarthrosis of the clavicle: a systematic review.

PURPOSE: There is no consensus on the type of surgical treatment of congenital pseudarthrosis of the clavicle due to its rarity. The purpose of this study is to provide evidence in favor of a surgical technique and to explore factors correlated with bone consolidation. METHODS: Systematic review of the literature and an analysis of the data for each subject, including all available subjects from the published series and clinical cases since 1990. Fisher's exact tests or T-tests were used to evaluate the effect of independent variables (age at surgery and type of treatment) on bone healing. RESULTS: The literature search provides 305 articles; 30 were selected, reporting 191 patients and 194 clavicles. One hundred and fifty-one clavicles were operated on at a mean age of nine years and four months (from 8 months to 21 years). Thirteen clavicles (8, 6%) had not consolidated at the last follow-up. Concerning the type of fixation, the rate of healing was similar for plates and pins (p = 0.27). The rate of consolidation was higher with autograft than with allograft, xenograft, or no graft (p = 0.00001), and was 100% for vascularized graft. The mean age at surgery was higher for patients who healed at the last follow-up (118 vs. 61 months, p = 0.001). CONCLUSION: In the event of surgical indication for congenital pseudarthrosis of the clavicle, it is recommended to perform autograft and stable fixation (level 4) after seven years old (level 4).

Clinical predictive model of lumbar curve Cobb angle below selective fusion for thoracic adolescent idiopathic scoliosis: a longitudinal multicenter descriptive study.

PURPOSE: To implement a clinically applicable, predictive model for the lumbar Cobb angle below a selective thoracic fusion in adolescent idiopathic scoliosis. METHODS: A series of 146 adolescents with Lenke 1 or 2 idiopathic scoliosis, surgically treated with posterior selective fusion, and minimum follow-up of 5 years (average 7) was analyzed. The cohort was divided in 2 groups: if lumbar Cobb angle at last follow-up was, respectively, ≥ or < 10°. A logistic regression-based prediction model (PredictMed) was implemented to identify variables associated with the group ≥ 10°. The guidelines of the TRIPOD statement were followed. RESULTS: Mean Cobb angle of thoracic main curve was 56° preoperatively and 25° at last follow-up. Mean lumbar Cobb angle was 33° (20; 59) preoperatively and 11° (0; 35) at last follow-up. 53 patients were in group ≥ 10°. The 2 groups had similar demographics, flexibility of both main and lumbar curves, and magnitude of the preoperative main curve, p > 0.1. From univariate analysis, mean magnitude of preoperative lumbar curves (35° vs. 30°), mean correction of main curve (65% vs. 58%), mean ratio of main curve/distal curve (1.9 vs. 1.6) and distribution of lumbar modifiers were statistically different between groups (p < 0.05). PredictMed identified the following variables significantly associated with the group ≥ 10°: main curve % correction at last follow-up (p = 0.01) and distal curve angle (p = 0.04) with a prediction accuracy of 71%. CONCLUSION: The main modifiable factor influencing uninstrumented lumbar curve was the correction of main curve. The clinical model PredictMed showed an accuracy of 71% in prediction of lumbar Cobb angle ≥ 10° at last follow-up. LEVEL OF EVIDENCE IV: Longitudinal comparative study.

PredictMed: A Machine Learning Model for Identifying Risk Factors of Neuromuscular Hip Dysplasia: A Multicenter Descriptive Study.

Neuromuscular hip dysplasia (NHD) is a common and severe problem in patients with cerebral palsy (CP). Previous studies have so far identified only spasticity (SP) and high levels of Gross Motor Function Classification System as factors associated with NHD. The aim of this study is to develop a machine learning model to identify additional risk factors of NHD. This was a cross-sectional multicenter descriptive study of 102 teenagers with CP (60 males, 42 females; 60 inpatients, 42 outpatients; mean age 16.5 ± 1.2 years, range 12-18 years). Data on etiology, diagnosis, SP, epilepsy (E), clinical history, and functional assessments were collected between 2007 and 2017. Hip dysplasia was defined as femoral head lateral migration percentage > 33% on pelvic radiogram. A logistic regression-prediction model named PredictMed was developed to identify risk factors of NHD. Twenty-eight (27%) teenagers with CP had NHD, of which 18 (67%) had dislocated hips. Logistic regression model identified poor walking abilities (p < 0.001; odds ratio [OR] infinity; 95% confidence interval [CI] infinity), scoliosis (p = 0.01; OR 3.22; 95% CI 1.30-7.92), trunk muscles' tone disorder (p = 0.002; OR 4.81; 95% CI 1.75-13.25), SP (p = 0.006; OR 6.6; 95% CI 1.46-30.23), poor motor function (p = 0.02; OR 5.5; 95% CI 1.2-25.2), and E (p = 0.03; OR 2.6; standard error 0.44) as risk factors of NHD. The accuracy of the model was 77%. PredictMed identified trunk muscles' tone disorder, severe scoliosis, E, and SP as risk factors of NHD in teenagers with CP.

Prevention of surgical site infections in pediatric spines: a single-center experience.

PURPOSE: To describe the potential issues in the methodology of surgical site infection (SSI) prevention and how it was investigated and corrected in a single institution. METHODS: A pediatric orthopedic unit experienced an increase of SSI, concerning up to 10% of scoliosis surgery cases from 2011 to 2013. An institutional procedure of multimodal and interdisciplinary risk evaluation was initiated, including a review of the literature, a morbi-mortality meeting, internal and external audits concerning the hygiene conditions in the operating room, the antibiotic prophylaxis, patients, and sterile material pathways. Several preventive actions were implemented, including the improvement of air treatment in the operating room, wound irrigation with 2L of saline before closure, application of topic vancomycine in the wound, verification of doses and timing of antibiotics injection, and use of waterproof bandages. We compared the rates of spine SSI before (retrospective group, 2011-2013) and after the implementation of various preventive measures (prospective group, 2014-2018). RESULTS: SSI occurred in 12 patients (6 idiopathic and 6 neuromuscular) out of 120 operated on (93 idiopathic, 18 neuromuscular, 9 others) in the retrospective group and 2 (both neuromuscular) out of 196 (150 idiopathic, 33 neuromuscular,13 others) in the prospective group (10% vs 1%, odds ratio=9.7, p=0.001). The groups were comparable for age, etiology, duration of surgery, body mass index, American Society of Anesthesiologists score, number of levels fused, and blood loss (p>0.2). CONCLUSION: The systematic analysis of SSI allowed for the understanding of the failures and correcting them. The current process is effectively preventing SSI. LEVEL OF EVIDENCE: 3: prospective series with case-control analysis.

Surgical increase in thoracic kyphosis predicts increase of cervical lordosis after thoracic fusion for adolescent idiopathic scoliosis.

PURPOSE: The modification of cervical lordosis (CL) after adolescent idiopathic scoliosis (AIS) surgery is influenced by the correction of thoracic hypokyphosis. The quantification of the increase of CL as a function of the increase of thoracic kyphosis (TK) has never been calculated. METHODS: A total of 92 consecutive AIS patients who underwent a posterior thoracic selective fusion, corrected by simultaneous translation on 2 rods technique, with minimum 24-month follow-up, were analyzed from a prospective database. We evaluated global sagittal kyphosis and lordosis. CL was divided by the horizontal line in proximal (PCL) and distal cervical lordosis (DCL), likewise TK in proximal (PTK) and distal TK (DTK), and lumbar lordosis (LL) in proximal (PLL) and distal LL (DLL). RESULTS: The mean TK gain was 16°, 14° and 28° in the whole cohort, normokyphosis group and hypokyphosis group, respectively. The mean DCL gain was, respectively, 9°, 7° and 20° and the mean CL gain 8°, 5° and 21°. There was a strong correlation between TK gain and CL gain (coefficient = 0.86) and between TK gain and DCL gain (coefficient = 0.74). The regression equation was defined as DCLgain = - 3 + 0.75 × TKgain (p < 0.0001) corresponding on average to 60% of the TK gain. CONCLUSION: 60% of the TK gain was transferred to DCL gain. Correlations reflect the geometrical equivalence between PTK and DCL. The use of sagittal global measurements shows that DCL is equivalent to PTK and can be expressed as a function of pelvic parameters (DCL = PT + LL-PI). DCL must be considered to optimize the postoperative sagittal alignment of the spine.

Proximal junctional kyphosis is a rebalancing spinal phenomenon due to insufficient postoperative thoracic kyphosis after adolescent idiopathic scoliosis surgery.

PURPOSE: Many authors tried to explain proximal junctional kyphosis (PJK) after adolescent idiopathic scoliosis (AIS) surgery by looking for risk factors. Latest publications focus on sagittal alignment. Each healthy adolescent has a specific thoracic kyphosis (TK) depending on their pelvic parameters and lumbar lordosis (LL). The objective of this work is to determine if the difference between TK at follow-up (TKFU) and the patient-specific TK (PSTK) plays a role in PJK occurrence after AIS surgery. The secondary objective was to find other risk factors. METHODS: We analyzed retrospectively 570 thoracic AIS who underwent a posterior thoracic fusion from nine centers. The series was separated in two groups: with and without PJK. PSTK was calculated with the formula PSTK = 2(PT + LL-PI). TK Gap was the difference between TKFU and PSTK. Logistic regression was utilized to test the impact of TK Gap and other known risk factors on PJK occurrence. RESULTS: Univariate analysis showed 15 factors significantly different between the groups. In a multivariate analysis, three factors had a strong significant influence on PJK: TKFU, TK Gain and TK Gap. Four additional factors affected the rate of PJK: Posterior translation on two rods, preoperative TK, preoperative LL and number of instrumented vertebrae. CONCLUSION: PJK is related to the insufficient TK at follow-up, compared to the specific TK that every patient should have according to their pelvic parameters. PJK incidence is significantly reduced by a strong gain in TK and a thoracic selective fusion which leaves the proximal lumbar vertebrae free. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Botulinum Toxin in Children with Cerebral Palsy: An Update.

Injected in a muscle, the botulinum toxin causes localized and temporary paralysis by acting on the neuromuscular synapse. Currently, it is widely prescribed for the treatment of limb spasticity in children from the age of 2 years. Combined with rehabilitation and other treatments, it helps to progress in motor learning, promotes functional progression, and delays orthopaedic degradations.Numerous randomized, placebo-controlled studies have shown efficacy in reducing spasticity, improving passive and active mobility, reducing pain, and improving upper limb comfort care. The side effects are rare and commonplace.The injection technique is accessible after specific training and practice. The indication is better evaluated by a multidisciplinary team. A precise clinical evaluation, assisted by an instrumental analysis (videography, spatiotemporal parameters, kinematics, kinetics, and electromyography), makes it possible to determine the aims of the treatment and to evaluate the outcome.The objective of this review is to present current evidence base and practices regarding the use of botulinum toxin in children with cerebral palsy.

Lumbopelvic parameters can be used to predict thoracic kyphosis in adolescents.

PURPOSE: Distal thoracic kyphosis (DTK) equivalent to proximal lumbar lordosis (PLL) is the sum of pelvic tilt (PT) and the difference (Δ) between lumbar lordosis (LL) and pelvic incidence (PI): PLL = DTK = PT + Δ. With the assumption that proximal thoracic kyphosis (PTK) is similar to DTK, we propose the equation TK = 2(PT + LL - PI) to express the relationship between thoracic kyphosis (TK) and pelvic parameters. The objective of this work is to verify this relationship in a normal population. METHODS: Full spine radiographs of 100 adolescents and young adults (13 to 20 years old), free from vertebral pathology, were analyzed. Measurements included pelvic parameters, LL, PLL, DLL, TK, PTK, DTK and C7 global tilt. The measured global TK was compared with the theoretical TK calculated according to the formula TK = 2(PT + LL - PI). RESULTS: The difference between measured TK and calculated TK was + 2.3° and correlated with the C7 global tilt (r = 0.86). There was a significant linear regression between TK and PT + ∆ (p < 0.0001). Given radiographs' inter-rater reliability of 5° for angled measurements, the p value (0.047) between measured TK and calculated TK is statistically significant to support the hypothesis. CONCLUSION: This work validates the formula TK = 2(PT + LL - PI) which allows the calculation of global TK as a function of PT, LL and PI. This calculated TK can be used as a target for sagittal correction of adolescents with spine deformities. These slides can be retrieved under Electronic Supplementary Material.

Using Artificial Intelligence to Identify Factors Associated with Autism Spectrum Disorder in Adolescents with Cerebral Palsy.

Autism spectrum disorder (ASD) is common in adolescents with cerebral palsy (CP) and there is a lack of studies applying artificial intelligence to investigate this field and this population in particular. The aim of this study is to develop and test a predictive learning model to identify factors associated with ASD in adolescents with CP. This was a multicenter controlled cohort study of 102 adolescents with CP (61 males, 41 females; mean age ± SD [standard deviation] = 16.6 ± 1.2 years; range: 12-18 years). Data on etiology, diagnosis, spasticity, epilepsy, clinical history, communication abilities, behaviors, intellectual disability, motor skills, and eating and drinking abilities were collected between 2005 and 2015. Statistical analysis included Fisher's exact test and multiple logistic regressions to identify factors associated with ASD. A predictive learning model was implemented to identify factors associated with ASD. The guidelines of the "transparent reporting of a multivariable prediction model for individual prognosis or diagnosis" (TRIPOD) statement were followed. Type of spasticity (hemiplegia > diplegia > tri/quadriplegia; OR [odds ratio] = 1.76, SE [standard error] = 0.2785, p = 0.04), communication disorders (OR = 7.442, SE = 0.59, p < 0.001), intellectual disability (OR = 2.27, SE = 0.43, p = 0.05), feeding abilities (OR = 0.35, SE = 0.35, p = 0.002), and motor function (OR = 0.59, SE = 0.22, p = 0.01) were significantly associated with ASD. The best average prediction model score for accuracy, specificity, and sensitivity was 75%. Motor skills, feeding abilities, type of spasticity, intellectual disability, and communication disorders were associated with ASD. The prediction model was able to adequately identify adolescents at risk of ASD.

Pseudoaneurysm of the Brachial Artery after Reduction and Fixation of a Displaced Supracondylar Elbow Fracture in a Child.

About 10% of supracondylar humerus fractures in children are associated with distal ischemia. In case of acute limb ischemia after reduction and fixation, it is recommended to explore the brachial artery surgically without delay. However, there is no consensus on the management of intermediate situations, like a perfused hand with a weak pulse after fracture fixation. A 6-year-old boy presented a displaced Gartland type III supracondylar humerus fracture with no radial or ulnar pulse and hand ischemia. Immediately after closed reduction and internal fixation, the pulses were still missing. A duplex ultrasound of the radial artery showed an arterial flow, although diminished compared to the contralateral limb. Ten minutes later, a weak radial pulse was noticed and the hand perfusion was progressively increasing. Therefore, we suspected an arterial spasm. At 48 hr, distal pulse was present and the saturometer showed 98% of O2. The patient was discharged. At day 11, the patient complained about a painful tumefaction above the elbow. An injected computed tomography scan showed a pseudoaneurysm of the brachial artery surrounded by an hematoma. Forearm arteries were patent. The injured segment of the brachial artery was resected and replaced by a venous graft. At 2-month follow up, there were no vascular or cutaneous complications, duplex ultrasound examination was normal and the fracture was healed. This case highlights a "gray zone" between complete ischemia and complete recovery after supracondylar fracture fixation with initial ischemia. In such situations, a full duplex ultrasound examination, or a contrast computed tomography scan of the upper limb arteries seem appropriate.

Surgical increase in thoracic kyphosis increases unfused lumbar lordosis in selective fusion for thoracic adolescent idiopathic scoliosis.

PURPOSE: In adolescent idiopathic scoliosis (AIS), there is a close relationship between thoracic kyphosis (TK) and proximal lumbar lordosis (PLL). The hypothesis states correction of hypokyphosis increases lumbar lordosis (LL) through increase in PLL after surgical correction of TK. METHODS: 111 consecutive thoracic AIS, Lenke 1 or 2 who underwent posterior selective thoracic fusion with reduction by simultaneous translation on 2 rods and 2 years follow-up have been prospectively selected and analyzed. Instrumentations below L1 and anterior releases were excluded. Global TK and LL were measured by a dedicated software. Mean values were compared through T test, correlations assessed through Pearson's coefficient. RESULTS: Global TK increased from 27° to 46° at the last follow-up (p < 0.0001) and LL from 58° to 65° (p < 0.0001). PLL increased by 8° (15°-23°), and distal lumbar lordosis remained stable (42°). The gains were higher for the Hypo-Kyphosis group than for the Normo-Kyphosis group (p < 0.001). There was a strong correlation (coef = 0.65) between TK and PLL as well as between the gain of TK and the gain of PLL (coef = 0.70). LL increased after the first postoperative month. At 1 month, there was a significant increase in pelvic tilt and decrease in sacral slope, offsetting the LL increase, and indicating a temporary pelvic retroversion. CONCLUSIONS: Increase in TK led to increase in uninstrumented LL through increase in PLL with a continuous correlation between TK and PLL. These results allow surgeons to calculate the TK required during surgical correction of thoracic AIS to adapt LL to pelvic incidence. These slides can be retrieved under Electronic Supplementary Material.

A simulation model of nail bed suture and nail fixation: description and preliminary evaluation.

BACKGROUND: Wounds of the finger nail bed represent a frequent injury, especially in children. Residents often learn nail bed repair on patients without prior training. We aimed to develop and evaluate a "low-fidelity" simulation model of nail bed repair. METHODS: The model consists of a false nail on a plastic finger and a hydrocolloid dressing, which is pasted on the nail bed site and cut horizontally. This model allows nail bed suture and nail fixation. The cost of each model is about $1. Thirty-three doctors evaluated this model on 10 items, rated out of five, concerning the realism, the difficulty of the procedure, and the educational value. The duration of the procedure was also noted. We evaluated the clinical effectiveness by comparing through Fisher's exact test the ratio of unsuitable events (revision surgeries, surgical site infections, and complaint letters) on two periods-3 y before and 18 mo after the implementation of this model in our institution, respectively. RESULTS: Average mark was 4.16/5. The model was considered reliable, reproducible, and realistic. All the testers recognized a big educational value. The overall duration of the procedure averaged 23 min for residents and 11 min for surgeons. We collected 17 unsuitable events out of 84 patients from the period "before" and 2 out of 54 patients from the period "after" (P = 0.005). Revision surgeries were 10/84 from the period before and 2/54 from the period after (P = 0.04). CONCLUSIONS: The results of the internal and clinical evaluations are encouraging. We suggest integration of this model into the training program of residents.

Legg-Calvé-Perthes disease: classifications and prognostic factors.

INTRODUCTION: Legg-Calvé-Perthes Disease (LCPD) represents idiopathic avascular necrosis of femoral head in pediatric population. Indications for treatment depend mostly on prognosis about femoral head sphericity and hip congruence at the end of growth. The aim of this review is to highline prognostic factors of LCPD. METHODS: Bibliographic search in PubMed allowed selection of 33 articles concerning prognostic factors and/or classification of LCPD. CONCLUSION: Clinical factors of poor prognosis are overweight, female sex, age exceeding 6 years old, and lack of hip abduction. Radiologically, Herring's classification is consensual because of its high prognostic value and very good reproducibility. The other signs of femoral head "at-risk" and the assessment of the reduction in abduction of the femoral head in the acetabulum are also prognostic of late evolution. MRI seems to be a future tool in assessing the fate of hips in LCPD. It is likely that a better understanding of LCPD etiology would precise the prognosis of this disease.

Infantile myofibromatosis of the iliac bone.

INTRODUCTION: Solitary infantile myofibromatosis (IM) of bone is a rare benign osseous tumor of childhood with low rate of recurrence. Well documented within the multicenter form, its solitary intraosseous location is less well described. CASE REPORT: We present a rare case of intraosseous myofibromatosis arising the iliac bone of a 11-year-old girl, who was operated at 2 months of life for a retroauricular subcutaneous MF with unbalanced translocation t(9;16). She presented with a limping associated to a stiffness of the hip without pain. Imaging disclosed a 4×4×1cm intraosseous, lytic and heterogeneous mass with a soft tissue component on the medial cortical of the left iliac bone. Open biopsy was performed. Histology revealed proliferation of fusiform cells with eosinophil cytoplasm embedded in a myxoid and fibrous stroma without mitotic figures. On immunohistochemistry, cells were positive for actin, PS100, KL1, focally positive for EMA, CD34, P63, rarely CD31, which indicated diagnosis of new localization of IM. Cytogenetic analysis revealed absence of translocation t(9;16), which was found in the first tumor. Subsequent total resection was performed. The patient recovered normal function without recurrence of tumor at 3 years follow-up. CONCLUSION: To our knowledge, this is the first case of solitary IM of the iliac bone, occurring 12 years after the first localization. Total resection resulted in excellent outcome. However recurrence can happen even long time after the first resection and new localization is possible, as in our case. This suggests close follow-up and clear information about the risk of recurrence.

Safety and efficacy of vertebroplasty in the treatment of osteoporotic vertebral compression fractures: a prospective multicenter international randomized controlled study.

BACKGROUND: Vertebral compression fractures (VCFs) treated non-operatively can diminish function and quality of life, and lead to chronic health effects. The short-term safety and effectiveness of vertebroplasty for symptomatic VCFs are well-documented, but long-term follow-up is needed. PURPOSE: The aim of this paper was to analyse a multicenter international experience of 200 compression fractures treated with percutaneous vertebroplasty (VP) and compare the results of this procedure with the result of 200 patients treated conservatively. To estimate cost-effectiveness of VP compared to conservative care in terms of: pain reduction, quality of life, complications, secondary fractures and mortality. MATERIALS AND METHODS: 400 patients have been enrolled in a prospective randomized controlled study with painful VCFs with bone edema on MR imaging, local back pain for 6 weeks or less, osteoporosis and aged 55 years or older; after obtaining informed consent patients are included and randomized for VP or conservative care. Before treatment and at follow-up with regular intervals during 1-year period were administered to patients standard questionnaires addressing: clinical symptoms, pain medication, Visual Analogue Scale (VAS) score for pain, Oswestry Disability Index (ODI) score to evaluate functional activity. RESULTS: 200 patients treated with PV compared with 200 patients treated conservatively had significantly better VAS and used less analgesics 1 day after treatment. Twenty-four hours after VP, there was a reduction in pain scores and an improvement in physical functions, whereas remain unchanged in the patients treated conservatively. CONCLUSIONS: Pain relief and improvement of mobility and function after PV is immediate and significantly better in the short term compared with non-surgical care treatment.

Denosumab is really effective in the treatment of osteoporosis secondary to hypogonadism in prostate carcinoma patients? A prospective randomized multicenter international study.

INTRODUCTION: Osteoporosis is a complication of androgen deprivation therapy (ADT) in men with prostate carcinoma. The best defense against osteoporosis in prostate cancer is to identify patients with a high risk for fracture during the first clinical visit, select an effective anti-osteoporosis agent, and advise the patient to change his lifestyle and diet to prevent further bone loss. New agents include denosumab, a human monoclonal antibody that inhibits the RANK ligand (RANKL). RANKL promotes the formation, activity, and survival of osteoclasts and, thus, supports the breakdown of bone. PURPOSE: This is a multicenter, randomized, double-blind prospective study on use of denosumab versus alendronate in the therapy of secondary osteoporosis related to ADT in prostate cancer patients in three European countries (Italy, France, Switzerland). PATIENTS AND METHODS: In this 24-month observation study we enrolled 234 patients with diagnosis of osteoporosis underwent ADT for prostate cancer. All patients aged ≥55 years and had a dual-energy X-ray absorptiometry (DEXA) T-score <-1.0 (hip or spine, measured within last 2 years) and ≥ 1 fragility fracture. Patients were randomly assigned 1:1 to receive denosumab 60 mg subcutaneously every 6 months or alendronate (70 mg weekly) for 2 years. All patient received supplemental vitamin D (600 IU per day) and supplemental calcium to maintain a calcium intake of 1200 mg per day. Effectiveness of therapy in both groups (denosumab group and alendronate group) was assessed by changes in bone turnover markers (BTMs), Bone Mineral Density (BMD), fracture incidence, Visual Analogue Scale (VAS) score for back pain, and Short Form-8 (SF-8TM) health survey score for health-related quality of life (HRQoL). Percent changes from baseline in BTMs and BMD were assessed using the paired t test; a P-value 0.05). Mean changes in BMD at final follow-up differed significantly between two groups. BMD changes at the lumbar spine at 24 months were 5.6% with denosumab vs -1.1% with alendronate (P<0.001). New vertebral fractures developed in fewer patients in the denosumab group than in the alendronate group during the 24-month period, although this difference was not significant (P=0.10). Back pain significantly (P<0.001) improved from baseline at all time points during the study in both study groups. SF-8 health survey scores significantly improved following treatment with both drugs. Incidence of adverse drug reactions were similar in both groups. CONCLUSION: In our study denosumab and alendronate showed similar clinical efficacy in the therapy of ADT-related osteoporosis in men with prostate carcinoma; both drugs provided significant improvements in back pain and general health conditions. Denosumab showed significant increase of BTMs and BMD than alendronate with lower rate of new vertebral fractures.