Future studies using histomorphometry in type 1 diabetes mellitus.

PURPOSE OF REVIEW: This article reviews the current state of research in type 1 diabetes and bone, focusing on human bone turnover markers and histomorphometry. RECENT FINDINGS: Bone turnover markers have been used for decades to document static bone turnover status in a variety of diseases but especially in diabetes. Two new studies focus on dynamic testing conditions to examine the acute effects of insulin and exercise on bone turnover. Publications of human bone histomorphometry in type 1 diabetes are few but there are several new studies currently underway. SUMMARY: Here, we review the most recent literature on human bone turnover markers and histomorphometry. Low bone turnover is thought to be a major underlying factor in bone fragility in T1DM. Further studies in human transilial bone biopsies will be helpful in determining the mechanisms.

Prominent Anterior Inferior Iliac Spine Morphologies Are Common in Patients with Acetabular Dysplasia Undergoing Periacetabular Osteotomy.

BACKGROUND: The anterior inferior iliac spine (AIIS) prominence is increasingly recognized in the setting of femoroacetabular impingement (FAI). The AIIS prominence may contribute to decreased hip flexion after acetabular reorientation in patients with acetabular dysplasia. AIIS morphologies have been characterized in numerous populations including asymptomatic, FAI, and athletic populations, but the morphology of the AIIS in patients with symptomatic acetabular dysplasia undergoing periacetabular osteotomy (PAO) has not been studied. In acetabular dysplasia, deficiency of the anterosuperior acetabular rim is commonly present and may result in the AIIS being positioned closer to the acetabular rim. Understanding morphological variation of the AIIS in patients with symptomatic dysplasia, and its relationship to dysplasia subtype and severity may aid preoperative planning, surgical technique, and evaluation of postoperative issues after PAO. QUESTIONS/PURPOSES: In this study, we sought to determine: (1) the variability of AIIS morphology types in hips with symptomatic acetabular dysplasia and (2) whether the differences in the proportion of AIIS morphologies are present between dysplasia pattern and severity subtypes. METHODS: Using our hip preservation database, we identified 153 hips (148 patients) who underwent PAO from October 2013 to July 2015. Inclusion criteria for the current study were (lateral center-edge angle [LCEA] < 20°), Tönnis Grade of 0 or 1 on plain AP radiographs of the pelvis, preoperative low-dose CT scan, and no prior surgery, trauma, neuromuscular, ischemic necrosis, or Perthes-like deformity. A total of 50 patients (50 hips) with symptomatic acetabular dysplasia undergoing evaluation for surgical planning of PAO remained for retrospective evaluation; we used these patients' low-dose CT scans for analysis. The median (range) age of patients in the study was 24 years (13 to 49). Ninety percent (45 of 50) of the hips were in female patients, whereas 10% (5 of 50) were in male patients. The morphology of the AIIS was classified on three-dimensional CT reconstructions according to a previously published classification to define the relationship between the AIIS and the acetabular rim. The morphology of the AIIS was classified as Type I (AIIS well proximal to acetabular rim), Type II (AIIS extending to level of acetabular rim), or Type III (AIIS extending distal to acetabular rim). Acetabular dysplasia subtype was characterized according to a prior protocol as either predominantly an anterosuperior acetabular deficiency, a posterosuperior acetabular deficiency, or a global acetabular deficiency. Acetabular dysplasia severity was distinguished as mild (LCEA 15° to 20°) or moderate/severe (LCEA < 15°). To answer our first question, regarding the proportions of each AIIS morphology in the dysplasia population, we calculated proportions and 95% CI estimates. To answer our second question, regarding the proposition of AIIS type between subtypes of dysplasia type and severity, we used a chi-square test or Fisher's exact test to compare categorical variables. A p value of < 0.05 was considered significant. RESULTS: Seventy-two percent (36 of 50; 95% CI 58% to 83%) of patients had a Type II or III AIIS morphology. Type I AIIS morphology was found in 28% of patients (14 of 50; 95% CI 18% to 42%), Type II AIIS morphology in 62% (31 of 50; 95% CI 48% to 74%), and Type III AIIS/morphology in 10% (5 of 50; 95% CI 4% to 21%). A Type I AIIS was seen in seven of 15 of patients with anterosuperior acetabular deficiency, three of 18 of patients with global deficiency, and four of 17 patients with posterosuperior deficiency (p = 0.08). There was no difference in the variability of AIIS morphologies between the different subtypes of acetabular dysplasia pattern and no difference in AIIS morphology variability between patients with mild versus moderate/severe dysplasia. CONCLUSIONS: The morphology of the AIIS in patients with acetabular dysplasia is commonly prominent, with 72% of hips having Type II or Type III morphologies. CLINICAL RELEVANCE: The AIIS is often prominent in patients with acetabular dysplasia undergoing PAO, regardless of dysplasia pattern or severity. Prominent AIIS morphologies may affect hip flexion ROM after acetabular reorientation. AIIS morphology is a variable that should be considered during preoperative planning for PAO. Future studies are needed to assess the clinical significance of a prominent AIIS on intraoperative findings and postoperative status after PAO.

Osteitis Condensans ILII: An Unusual Case Of Severe Back Pain During Pregnancy.

BACKGROUND: Lower back pain is a common complaint in pregnancy which often impacts quality of life. An uncommon aetiology of lower back pain is Osteitis Condensans Ilii (OCI), a condition characterized by a triangular area of sclerosis of ilium adjacent to the sacroiliac joint. It is thought to be associated with pregnancy, but also affects non-pregnant women and men. We discuss a case of a 23-year-old woman, who presented during the 8th month of her first pregnancy with debilitating pain in her lower back. Several differential diagnoses were explored, including autoimmune aetiologies and pregnancy associated osteoporosis, before OCI was diagnosed via an MRI. The patient was managed conservatively with intravenous analgesics and physiotherapy, after which her pain abated gradually. On her 3rd day of admission, the patient went into premature labour and gave birth to a healthy child via vaginal delivery. Her pain resolved completely within days of delivering her baby.

A Secondary Injury of the Anterolateral Structure Plays a Minor Role in Anterior and Anterolateral Instability of Anterior Cruciate Ligament-Deficient Knees in the Case of Functional Iliotibial Band.

PURPOSE: To analyze the contribution of a secondary anterolateral structure (ALS) deficiency to knee instability based on anterior cruciate ligament (ACL) deficiency, in the condition of a functional iliotibial band (ITB). METHODS: Nine freshly-frozen cadaveric knees were sectioned sequentially to create ACL deficiency and ACL-ALS deficiency, using intact knees before sectioning as controls. When ITB was tensioned with 30 N, 4 separate aspects of knee instability were tested as follows: anterior translation in 90 N anterior load, isolated internal rotation in 5 N·m internal rotational torque from 0° to 90° in 15° increments, and anterolateral translation and internal rotation during a simulated pivot-shift test at 0°, 15°, 30°, and 45°. The contribution of ACL deficiency alone and additional ALS deficiency to knee instability were evaluated. RESULTS: The addition of an ALS lesion produced no significant exacerbation of either anterior translational or pivot shift instability in ACL-deficient knees. Additional ALS deficiency in an ACL-deficient knee resulted in a significant increase in isolated internal rotation from 45° to 90° (P = .001 at 45° and P < .001 in other cases). After sequentially sectioning, the contribution to instability of additional ALS deficiency to the entire instability in ACL-ALS-deficient knees was significantly smaller than that of ACL deficiency alone during anterior load and pivot-shift test (P < .001 in all cases), but significantly contributed more to isolated internal rotational instability at 60° (P = .011) and 90° (P = .015). CONCLUSIONS: When ITB was tensioned, ALS played a minor role in controlling both anterior or pivot shift stability in ACL-deficient knees but a major role in restraining isolated internal rotation from 45° to 90°. CLINICAL RELEVANCE: In the condition of functional ITB, concomitant ALS injury might not exacerbate anterior and pivot-shift instability after ACL rupture, while affecting isolated internal rotation stability at higher flexion.

Tricortical iliac crest allograft with anterolateral single rod screw instrumentation in the treatment of thoracic and lumbar spinal tuberculosis.

To assess the effectiveness of tricortical iliac crest allografts with anterolateral instrumentation after single-stage surgery for thoracic and lumbar spinal tuberculosis (TB). Fifty-six patients with thoracic and lumbar spinal TB underwent single-stage anterior radical debridement, interbody fusion with tricortical iliac crest allografts and anterolateral single rod instrumentation. All patients were given 18 months of antituberculosis chemotherapy. The patients were followed up regularly, and their clinical manifestations, roentgenogram results, erythrocyte sedimentation rate (ESR) and liver function test were the results to be concerned. Radiographs were analysed before surgery, immediately after surgery, and at the final follow-up examination. Mean follow-up period was 37.5 months in 52 patients, and 4 patients were lost to follow-up. No patients had superficial wound infections, and all the incisions healed within 2 weeks. No graft fracture, collapse, or sliding was observed. The average bony fusion time was 10.6 months. Bony fusion was observed in all 52 patients within 18 months. The average degrees of kyphotic correction loss for thoracic and lumbar spine were 6.71° and 2.78° respectively. Although it took a long time to achieve solid fusion, tricortical iliac crest allografts were found to be convenient and safe to be used in spinal TB surgery. They may be effective options for interbody fusion, deformity correction and correction maintenance with anterolateral single rod instrumentation.

The prevalence of a prominent anterior inferior iliac spine.

INTRODUCTION: Impingement of the prominent anterior inferior iliac spine (AIIS) against the femoral neck has recently been described as another type of impingement. The purpose of this study is to provide a distribution of AIIS types using the classification proposed by Hetsroni and thus report on the prevalence of prominent types. MATERIALS AND METHODS: A total of 400 patients were included in the study with an average age 27.3 ± 6.9 years (range 18-40). All patients received a whole-body polytrauma computer tomography (CT) scan in the emergency room (ER) upon arrival. The classification of AIIS proposed by Hetsroni et al., which describes three morphological types, was used. Type II and III were grouped as prominent types. The measurements were performed in all three planes by two examiners. RESULTS: Male to female ratio was 71:29. Type I was observed in 367 (91.7%) patients. Type II was observed in 31 (7.8%) patients and type III was observed in 2 (0.5%) patients, unilaterally. Prominent types were much more prevalent in men (10.5%) than in women (2.6%). The CT assessment demonstrated excellent intra- and interreliability (overall: 0.926, I/II: 0.906, III: 1.000). CONCLUSION: A young population demonstrates a prevalence of a prominent AIIS of 11.5%. Prominent AIIS is more common in men than in women.

Divertículo de Meckel. A propósito de un caso / Meckel's diverticulum. Apropos of a case

RESUMEN El divertículo de Meckel es una evaginación en dedo de guante del borde antimesentérico del íleon, constituido por sus capas, debido a una persistencia embriológica del extremo proximal del conducto onfalomesentérico. Forma una bolsa a manera de tubo y que puede extenderse hasta la región umbilical, su inflamación (diverticulitis) produce un cuadro clínico semejante al de la apendicitis aguda, por lo que su diagnóstico preoperatorio es raro. Por lo infrecuente, los médicos no piensan seriamente en esta patología y su diagnóstico definitivo se realiza durante el transoperatorio. Se presentó un caso por lo infrecuente que resulta lo cual aporta conocimiento a la comunidad médica sobre el tema. Paciente de 68 años, acude al centro con dolor tipo cólico, taquicardia y fiebre de 38.5C°, con 24 h de evolución. Refiere que el dolor se le hizo fijo hacia fosa iliaca derecha, el cual se fue intensificando. Se decidió su ingreso para tratamiento quirúrgico. Se realizó apendicectomia y resección y anastomosis en la zona del divertículo. Se recibió biopsia informando diverticulitis de Meckel (AU).

ABSTRACT Meckel's diverticulum is an evagination resembling a glove finger of the ileum anti-mesenteric edge, formed by layers due to an embryologic persistence of the proximal end of omphalo-mesenteric duct. It forms a sac like a tube that may extend up to the umbilical region; its inflammation (diverticulitis) has clinical characteristics similar to the acute appendicitis ones, making its pre-surgery diagnosis very unusual. Due to its frequency, doctors often do not take this disease into account, and it is definitely diagnosed during the trans-operative. The case was presented due to its infrequency, bringing knowledge on the theme to medical community. A patient aged 68 years assisted the hospital with a colic-like pain, tachycardia and fiver of 38.5oC after 24 hours of evolution. He refers that the pain became fixed in the right iliac fosse and got more intensity. The decision was entering him for surgical treatment. Appendectomy, resection and anastomosis were carried out in the area of the diverticulum. The received biopsy informed Meckel's diverticulum (AU).

Divertículo de Meckel. A propósito de un caso / Meckel's diverticulum. Apropos of a case

RESUMEN El divertículo de Meckel es una evaginación en dedo de guante del borde antimesentérico del íleon, constituido por sus capas, debido a una persistencia embriológica del extremo proximal del conducto onfalomesentérico. Forma una bolsa a manera de tubo y que puede extenderse hasta la región umbilical, su inflamación (diverticulitis) produce un cuadro clínico semejante al de la apendicitis aguda, por lo que su diagnóstico preoperatorio es raro. Por lo infrecuente, los médicos no piensan seriamente en esta patología y su diagnóstico definitivo se realiza durante el transoperatorio. Se presentó un caso por lo infrecuente que resulta lo cual aporta conocimiento a la comunidad médica sobre el tema. Paciente de 68 años, acude al centro con dolor tipo cólico, taquicardia y fiebre de 38.5C°, con 24 h de evolución. Refiere que el dolor se le hizo fijo hacia fosa iliaca derecha, el cual se fue intensificando. Se decidió su ingreso para tratamiento quirúrgico. Se realizó apendicectomia y resección y anastomosis en la zona del divertículo. Se recibió biopsia informando diverticulitis de Meckel.

ABSTRACT Meckel's diverticulum is an evagination resembling a glove finger of the ileum anti-mesenteric edge, formed by layers due to an embryologic persistence of the proximal end of omphalo-mesenteric duct. It forms a sac like a tube that may extend up to the umbilical region; its inflammation (diverticulitis) has clinical characteristics similar to the acute appendicitis ones, making its pre-surgery diagnosis very unusual. Due to its frequency, doctors often do not take this disease into account, and it is definitely diagnosed during the trans-operative. The case was presented due to its infrequency, bringing knowledge on the theme to medical community. A patient aged 68 years assisted the hospital with a colic-like pain, tachycardia and fiver of 38.5oC after 24 hours of evolution. He refers that the pain became fixed in the right iliac fosse and got more intensity. The decision was entering him for surgical treatment. Appendectomy, resection and anastomosis were carried out in the area of the diverticulum. The received biopsy informed Meckel's diverticulum.

Young's modulus and hardness of human trabecular bone with bisphosphonate treatment durations up to 20 years.

Bone modulus from patients with osteoporosis treated with bisphosphonates for 1 to 20 years was analyzed. Modulus increases during the first 6 years of treatment and remains unchanged thereafter. INTRODUCTION: Bisphosphonates are widely used for treating osteoporosis, but the relationship between treatment duration and bone quality is unclear. Since material properties partially determine bone quality, the present study quantified the relationship between human bone modulus and hardness with bisphosphonate treatment duration. METHODS: Iliac crest bone samples from a consecutive case series of 86 osteoporotic Caucasian women continuously treated with oral bisphosphonates for 1.1-20 years were histologically evaluated to assess bone turnover and then tested using nanoindentation. Young's modulus and hardness were measured and related to bisphosphonate treatment duration by statistical modeling. RESULTS: All bone samples had low bone turnover. Statistical models showed that with increasing bisphosphonate treatment duration, modulus and hardness increased, peaked, and plateaued. These models used quadratic terms to model modulus increases from 1 to 6 years of bisphosphonate treatment and linear terms to model modulus plateaus from 6 to 20 years of treatment. The treatment duration at which the quadratic-linear transition (join point) occurred also depended upon trabecular location. Hardness increased and peaked at 12.4 years of treatment; it remained constant for the next 7.6 years of treatment and was insensitive to trabecular location. CONCLUSIONS: Bone modulus increases with bisphosphonate treatment durations up to 6 years, no additional modulus increases occurred after 6 years of treatment. Although hardness increased, peaked at 12.4 years and remained constant for the next 7.6 years of BP treatment, the clinical relevance of hardness remains unclear.

Revisiting the Anteroinferior Iliac Spine: Is the Subspine Pathologic? A Clinical and Radiographic Evaluation.

BACKGROUND: Subspine impingement is a recognized source of extraarticular hip impingement. Although CT-based classification systems have been described, to our knowledge, no study has evaluated the morphology of the anteroinferior iliac spine (AIIS) with plain radiographs nor to our knowledge has any study compared its appearance between plain radiographs and CT scan and correlated AIIS morphology with physical findings. Previous work has suggested a correlation of AIIS morphology and hip ROM but this has not been clinically validated. Furthermore, if plain radiographs can be found to adequately screen for AIIS morphology, CT could be selectively used, limiting radiation exposure. QUESTIONS/PURPOSES: The purposes of this study were (1) to determine the prevalence of AIIS subtypes in a cohort of patients with symptomatic femoroacetabular impingement; (2) to compare AP pelvis and false profile radiographs with three-dimensional (3-D) CT classification; and (3) to correlate the preoperative hip physical examination with AIIS subtypes. METHODS: A retrospective study of patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome was performed. Between February 2013 and November 2016, 601 patients underwent hip arthroscopy. To be included here, each patient had to have undergone a primary hip arthroscopy for the diagnosis of femoroacetabular impingement syndrome. Each patient needed to have an interpretable set of plain radiographs consisting of weightbearing AP pelvis and false profile radiographs as well as full documentation of physical findings in the medical record. Patients who additionally had a CT scan with 3-D reconstructions were included as well. During the period in question, it was the preference of the treating surgeon whether a preoperative CT scan was obtained. A total of 145 of 601 (24%) patients were included in the analysis; of this cohort, 54% (78 of 145) had a CT scan and 63% (92 of 145) were women with a mean age of 31 ± 10 years. The AIIS was classified first on patients in whom the 3-D CT scan was available based on a previously published 3-D CT classification. The AIIS was then classified by two orthopaedic surgeons (TGM, MRK) on AP and false profile radiographs based on the position of its inferior margin to a line at the lateral aspect of the acetabular sourcil normal to vertical. Type I was above, Type II at the level, and Type III below this line. There was fair interrater agreement for AP pelvis (κ = 0.382; 95% confidence interval [CI], 0.239-0.525), false profile (κ = 0.372; 95% CI, 0.229-0.515), and 3-D CT (κ = 0.325; 95% CI, 0.156-0.494). There was moderate to almost perfect intraobserver repeatability for AP pelvis (κ = 0.516; 95% CI, 0.284-0.748), false profile (κ = 0.915; 95% CI, 0.766-1.000), and 3-D CT (κ = 0.915; 95% CI, 0.766-1.000). The plane radiographs were then compared with the 3-D CT scan classification and accuracy, defined as the proportion of correct classification out of total classifications. Preoperative hip flexion, internal rotation, external rotation, flexion adduction, internal rotation, subspine, and Stinchfield physical examination tests were compared with classification of the AIIS on 3-D CT. Finally, preoperative hip flexion, internal rotation, and external rotation were compared with preoperative lateral center-edge angle and alpha angle. RESULTS: The prevalence of AIIS was 56% (44 of 78) Type I, 39% (30 of 78) Type II, and 5% (four of 78) Type III determined from the 3-D CT classification. For the plain radiographic classification, the distribution of AIIS morphology was 64% (93 of 145) Type I, 32% (46 of 145) Type II, and 4% (six of 145) Type III on AP pelvis and 49% (71 of 145) Type I, 48% (70 of 145) Type II, and 3% (four of 145) Type III on false profile radiographs. False profile radiographs were more accurate than AP pelvis radiographs for classification when compared against the gold standard of 3-D CT at 98% (95% CI, 96-100) versus 80% (95% CI, 75-85). The false profile radiograph had better sensitivity for Type II (97% versus 47%, p < 0.001) and specificity for Types I and II AIIS (97% versus 53%, p < 0.001; 98% versus 90%, p = 0.046) morphology compared with AP pelvis radiographs. There was no correlation between AIIS type as determined by 3-D CT scan and hip flexion (rs = -0.115, p = 0.377), internal rotation (rs = 0.070, p = 0.548), flexion adduction internal rotation (U = 72.00, p = 0.270), Stinchfield (U = 290.50, p = 0.755), or subspine tests (U = 319.00, p = 0.519). External rotation was weakly correlated (rs = 0.253, p = 0.028) with AIIS subtype. Alpha angle was negatively correlated with hip flexion (r = -0.387, p = 0.002) and external rotation (r = -0.238, p = 0.043) and not correlated with internal rotation (r = -0.068, p = 0.568). CONCLUSIONS: The findings in this study suggest the false profile radiograph is superior to an AP radiograph of the pelvis in evaluating AIIS morphology. Neither preoperative hip internal rotation nor impingement tests correlate with AIIS type as previously suggested questioning the utility of the AIIS classification system in identifying pathologic AIIS anatomy. LEVEL OF EVIDENCE: Level III, diagnostic study.

Analysis of foot kinematics wearing high heels using the Oxford foot model.

Wearing high heels is thought to lead to various foot disorders and injuries such as metatarsal pain, Achilles tendon tension, plantar fasciitis and Haglund malformation. However, there is little available information explaining the specific mechanisms and reasons why wearing high heels causes foot deformity. Therefore, the purpose of this study was to investigate the foot kinematics of high heel wearers and compare any differences with barefoot individuals using the Oxford Foot Model (OFM). Fifteen healthy women aged 20-25 years were measured while walking barefoot and when wearing high heels. The peak value of angular motion for the hallux with respect to the forefoot, the forefoot with respect to the hind foot, and the hind foot with respect to the tibia were all analyzed. Compared to the barefoot, participants wearing high heels demonstrated larger hallux dorsiflexion (22.55∘± 1.62∘ VS 26.6∘± 2.33∘ for the barefoot; P= 0.001), and less hallux plantarflexion during the initial stance phase (-4.86∘± 2.32∘ VS -8.68∘± 1.13∘; P< 0.001). There were also greater forefoot adduction (16.15∘± 1.37∘ VS 13.18∘± 0.79∘; P< 0.001), but no significant differences were found in forefoot abduction between the two conditions. The hind foot demonstrated a larger dorsiflexion in the horizontal plane (16.59∘± 1.69∘ VS 12.08∘± 0.9∘; P< 0.001), greater internal rotation (16.72∘± 0.48∘ VS 7.97∘± 0.55∘; P< 0.001), and decreased peak hind foot extension rotation (-5.49∘± 0.69∘ VS -10.73∘± 0.42∘; P= 0.001). These findings complement existing kinematic evidence that wearing high heels can lead to foot deformities and injuries.

S-1 alar/iliac screw technique for spinopelvic fixation.

Spinopelvic fixation provides an important anchor for long fusions in spinal deformity surgery, and it is also used in the treatment of other spine pathologies. Iliac screws are known to sometimes require reoperation due to pain resulting from hardware prominence and skin injury. S-2 alar/iliac (S2AI) screws do not often require removal, but they may provide inadequate fixation in select cases. In this paper the authors describe a technique for S-1 alar/iliac screws that may be used independently or as a supplement to S2AI screws. A preliminary biomechanical analysis and 2 clinical case examples are also provided.

Pelvic musculoskeletal dysfunctions in women with and without chronic pelvic pain.

AIM: This study aimed to compare the prevalence of pelvic musculoskeletal dysfunctions in women with and without Chronic Pelvic Pain (CPP). MATERIALS &METHODS: A total of 84 women with and without CPP (42 in each group), participated in this cross-sectional analytical study. After collecting demographic information, clinical examinations were carried out to compare pelvic musculoskeletal dysfunctions between two groups. Kolmogorov-Smirnov (K-S) goodness-of-fit, Independent t, X2 and Pearson correlation tests were used for data analysis. Values of p < 0.05 were considered statistically significant. FINDINGS: Significant differences were found in the asymmetric iliac crest and pubic symphysis height (45.2% vs 9.5%), positive sacroiliac provocation and positive Carnett's tests (50% vs 4.8%), (p < 0.05). CPP Patients exhibited more tenderness at Levator ani, Piriformis, and Obturator Internus muscles, also higher degrees of pelvic inclination (p < 0.05). CONCLUSION: Higher frequency of pelvic musculoskeletal dysfunctions in women with CPP suggests the value of routine musculoskeletal examinations for earlier diagnosis of musculoskeletal originated CPP and effective management of these patients.

Postinfectious heterotopic ossification of the ilium involving the iliacus muscle.

Heterotopic ossification in soft tissue or muscle is rare in the pediatric and adolescent age group. Most cases are associated with musculoskeletal injury and trauma to the central nervous system. Here, we describe an adolescent patient without a history of trauma or lesions in the central nervous system who presented with a painful limp with limited motion of the left hip. Investigations indicated unusually large heterotopic ossification extending from the inner aspect of the ilium down to the anterior part of the hip, highly likely to have developed after an unrecognized periacetabular pyomyositis primarily involving the iliacus muscle. Surgical excision was performed successfully without perioperative complications. No recurrence was detected at the final follow-up.

Is a Modular Pedicle-hemipelvic Endoprosthesis Durable at Short Term in Patients Undergoing Enneking Type I + II Tumor Resections With or Without Sacroiliac Involvement?

BACKGROUND: Functional reconstruction after Enneking Type I + II resections of the pelvis (those involving both the ilium and the acetabulum) is challenging, especially if resection of part of the sacrum is included. To assess the clinical outcomes of a newly designed modular pedicle-hemipelvic endoprosthesis, we performed a preliminary retrospective study on its clinical use in a small group of patients. QUESTIONS/PURPOSES: The purposes of this study were (1) to evaluate in a small case series whether the new endoprosthesis restored lower limb function and lumbopelvic stability in the short term; (2) to identify the complications associated with use of the new prosthesis; and (3) to assess the 5-year cumulative survival, the cumulative incidence of a major postoperative event, and the cumulative incidence of implant failure in this group of patients. METHODS: Between August 2012 and August 2014, our center performed 274 internal hemipelvectomies for oncologic indications. Among these, 20 were treated with the new endoprosthesis, which was designed for fixation both to the residual sacrum as well as the lumbar spine. An earlier version of the device had been removed from the market because of an unacceptable risk of serious complications. All of the 20 tumors were sarcomas necessitating en bloc resection. The implant is modular and can meet the different-sized defects in each patient. The general indication for use of the new implant was a total acetabular defect with extensive iliac involvement or total loss of the sacroiliac joint and/or hemisacrum. All 20 patients were followed up for a minimum of 24 months or until death in those patients who survived < 2 years (median, 36 months; range, 6-60 months). The clinical data were retrieved from the database and the study endpoints (function according to the Musculoskeletal Tumor Society [MSTS] score, complications, and survivorship of patients and implants) were ascertained by chart review. Lumbopelvic stability was defined as an excellent or good rating according to the International Society of Limb Salvage radiologic implant evaluation system. The cumulative survival of patients was estimated using the Kaplan-Meier approach. The cumulative incidence of major postoperative events including local recurrence, metastasis, and reoperation was estimated using a competing events analysis; the cumulative incidence of implant failure, including mechanical failure or deep infection, in patients who underwent reoperation was also estimated using a competing events analysis. RESULTS: In the 16 patients who survived > 12 months, the median MSTS score was 19 of 30 (range, 5-26). Radiographic assessments demonstrated lumbopelvic stability in all of the 16 patients. Twelve of 20 patients developed postoperative complications, primarily including deep infection (one), hip dislocation (two), and local recurrence (three). Major revision surgery was performed in five of 20 patients. The estimated 5-year Kaplan-Meier patient survival rate was 69% (95% confidence interval [CI], 59%-79%), whereas the cumulative incidence of major postoperative events and implant failure using the competing risk estimator was 42% (95% CI, 23%-60%) and 15% (95% CI, 4%-34%) at 5 years, respectively. CONCLUSIONS: Preliminary results with hemipelvic reconstruction using this new endoprosthesis achieved fair functional results and the complications that were observed appeared comparable to other reconstruction options at short-term followup. Longer-term surveillance is called for to see whether this implant will be durable compared with other available reconstructive alternatives such as a custom-made megaendoprosthesis or an autograft/allograft-prosthetic composite. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Bone Formation Parameters of the Biopsied Ilium Differ between Subtrochanteric and Diaphyseal Atypical Femoral Fractures in Bisphosphonate-Treated Patients.

Atypical femoral fractures (AFFs) are defined as atraumatic or low-trauma fractures located in the subtrochanteric or diaphyseal sites. Long-term bisphosphonates (BPs) are administered to prevent fragility fractures in patients with primary osteoporosis or collagen diseases who are already taking glucocorticoids (GCs). Long-term BP use is one of the most important risk factors for AFFs. Its pathogenesis is characterized by severely suppressed bone turnover (SSBT), but whether the characteristics of patients are different regarding to location of fracture site remains unknown. In this study, we compared the characteristics and bone histomorphometric findings between subtrochanteric and diaphyseal sites in patients with BP-associated AFFs. Nine women with BP-associated AFFs were recruited, including 3 with systemic lupus erythematosus, 2 with rheumatoid arthritis, 2 with primary osteoporosis, 1 with polymyalgia rheumatica, and 1 with sarcoidosis. Patients were divided into the subtrochanteric group (n = 5; average age, 52 years; BP treatment, 5.9 years) and the diaphyseal group (n = 4; average age, 77 years; BP treatment, 2.6 years). Compared with the diaphyseal group, the subtrochanteric group had significantly higher daily GC doses (average, 10.9 vs. 2.3 mg/day) and significantly lower serum 25-hydroxyvitamin-D levels (17.8 vs. 25.6 ng/mL). Bone histomorphometry of the biopsied iliac bone showed SSBT in 3 cases (subtrochanteric, n = 1; diaphyseal, n = 2). Osteoid volume and trabecular thickness were significantly lower in the subtrochanteric group than in the diaphyseal group. Bone formation was inhibited more severely in subtrochanteric than in the diaphyseal group due to the higher GC doses used.

Is the evaluation of the anterior inferior iliac spine (AIIS) in the AP pelvis possible? Analysis of conventional X-rays and 3D-CT reconstructions.

INTRODUCTION: A hypertrophic AIIS has been identified as a cause for extraarticular hip impingement and is classified according to Hetsroni using 3D-CT reconstructions. The role of the conventional AP pelvis X-ray, which is the first standard imaging step for the evaluation of hip pain, has not been investigated yet. MATERIALS AND METHODS: AP pelvis X-rays and 3D-CT reconstructions of patients were evaluated regarding their morphology of the AIIS. The conventional X-rays were categorized into three groups according to the projection of the AIIS: above (A) or below (B) the acetabular sourcil or even exceeding the anterior acetabular rim (C). They were compared to the morphologic types in the 3D-CT reconstruction (Hetsroni type I-III). RESULTS: Ninety patients with an equal distribution of type A, B or C projection in the AP pelvis were evaluated and compared to the morphology in the 3D-CT reconstruction. The projection of the AIIS below the acetabular sourcil (B + C) showed only moderate sensitivity (0.76) and specificity (0.64) for a hypertrophic AIIS (Hetsroni type II + III), but if the AIIS exceeds the anterior rim, all cases showed a hypertrophic AIIS in the 3D-CT reconstructions (Hetsroni type II + III). CONCLUSIONS: Distinct differentiation of the AIIS morphology in the AP pelvis is not possible, but the projection of the AIIS below the anterior acetabular rim represented a hypertrophic AIIS in all cases and should, therefore, be critically investigated for a relevant AIIS impingement.

Chronic head-down-tilt sleeping as physiological regulator of bone remodelling during diminished muscular activity in humans.

OBJECTIVES: Head-down-tilt (HDT) sleeping with periodic fluid redistribution (PFR) assumes a significant importance by the possibility of regulating bone remodelling. We hypothesized that HDT sleeping with chronic PFR which expands fluid volume would contribute to and/or increase bone formation. Therefore, we studied the potential benefits of osteogenesis with HDT sleeping of chronic PFR during diminished muscular activity (hypokinesia; HK). METHODS: Studies were conducted on 40 male healthy volunteers. They were divided into four groups: head-down-tilt sleeping control subjects (HDTSCS), head-down-tilt sleeping hypokinetic subjects (HDTSHS), active control subjects (ACS) and hypokinetic subjects (HKS). The iliac crest cancellous bone and trabecular bone volume and cortical thickness were measured during pre-experimental period of 390 days and experimental period of 360 days. RESULTS: Iliac crest cancellous bone and trabecular bone volume and cortical thickness were increased (P<0·05) in the HDTSHS group compared to the HKS group. Iliac crest cancellous bone volume, cortical thickness and trabecular bone volume were reduced (P<0·05) in the HKS group compared to their pre-experimental values and the level in the other groups. In the HDTSCS group, iliac crest cancellous bone volume, cortical thickness and trabecular bone volume were increased much less than in the HDTSHS group. Bone mineral density was not affected in the ACS group compared to their pre-experimental values. CONCLUSION: The current study shows the impact of chronic HDT sleeping with PFR on increases formation of bone demonstrating osteogenesis of bone during diminished muscular activity.

The Diagnosis of Iliac Bone Destruction in Children: 22 Cases from Two Centres.

Iliac bone destruction in children is uncommon and presents various imaging features. Correct diagnosis based on clinical and imaging features is difficult. This research aimed to retrospectively explore the clinical features, imaging, and histopathological diagnosis of children with iliac bone destruction. A total of 22 children with iliac bone destruction were enrolled in this retrospective analysis from two children's hospitals during July 2007 to April 2015. Clinical features, imaging, and histopathological findings were analysed. The mode of iliac bone destruction, lesion structure, and the relationship between the range of soft tissue mass and cortical destruction were determined based on imaging data. The data were analysed using descriptive methods. Of the iliac bone destruction cases, eight cases were neuroblastoma iliac bone metastasis, seven cases were bone eosinophilic granuloma, two cases were Ewing's sarcoma, two cases were osteomyelitis, one case was bone cyst, one case was bone fibrous dysplasia, and one case was non-Hodgkin's lymphoma. Iliac bone destruction varies widely in children. Metastatic neuroblastoma and eosinophilic granuloma are the most commonly involved childhood tumours.

Bone Regeneration in Iliac Crestal Defects: An Experimental Study on Sheep.

Background. Oral rehabilitation of partially fully edentulous patients with dental implants has become a routine procedure in clinical practice. In a site with a lack of bone GBR is a surgical procedure that provides an augmentation in terms of volume for the insertion of dental implants. Materials and Methods. In the iliac crest of six sheep 4 defects were created where an implant was inserted, three of them with different biomaterials and a control site. All animals were sacrificed after a 4-month healing period. All specimens were processed and analyzed with histomorphometry. Statistical evaluation was done to evaluate percentage of bone defect filled by new bone. Results. All experimental groups showed an increase of the new bone. Higher and highly statistically significant differences were found in the percentages of bone defect filled by new bone in group filled with corticocancellous 250-1000 microns particulate porcine bone mix. Conclusions. This study demonstrates that particulate porcine bone mix and porcine corticocancellous collagenate prehydrated bone mix when used as scaffold are able to induce bone regeneration. Moreover, these data suggest that these biomaterials have higher biocompatibility and are capable of inducing faster and greater bone formation.