Vertebra prominence in women: significance in clinical practice and in surface topography.

A sexual dimorphism (SD) of the "vertebra prominens" was found, namely the 7th cervical vertebra (C7) spinous process (SP) is more frequently longer in men and the 1st thoracic (T1) SP in women.[1] We assume that the cause of this SD is the different anatomy of the anterior upper thoracic region (AUTR) between men and women, due to the presence of the breast. One-hundred forty-two women aged 48.1Âs17 years old, who visited the OPD for neck complaints, were studied. Measures included the age, the relationship of C7 and T1 SP length, documented in three types (type 1= [C7>T1], 2 = [C7 = T1], 3 = [C7 < T1]), the breast size, (small, medium and large), the length ratio of C7/T1 SP and the BMI. Breast size and SP length relationship between C7 and T1 was found to be significantly correlated. The results confirm that the cause of the SD of the SP length of C7 and T1 seems to be the different female AUTR anatomy due to the presence of the breast and it is probably the result of the need of the posterior cervical anatomical structures to compensate for the higher torque created by the female AUTR anatomy. These original findings are useful in clinical examination, in breast oncology, for the plastic surgeons, in terms of implantation of the proper breast size implant, after mastectomies for malignancies but also for aesthetic reasons and the software of all surface topography devices should be adjusted accordingly.

A novel surgical tool for the revision hip arthroplasty due to neck stem's fracture.

During revision surgery of total hip arthroplasties, surgeons may come across the challenging complication of a proximally fractured femoral stem, which however maintains sufficient distal fixation. Such cases, although rare, are extremely demanding due to lack of available attachments that would assist surgical explantation of the broken implant. It is herein presented a metal sterilisable surgical tool designed for the removal of the femoral stem broken at the level of the "neck". Hippokratia 2015; 19 (4): 352-355.

Expression of macrophage elastase (MMP12) in rat tail intervertebral disc and growth plate after asymmetric loading.

OBJECTIVES: The aim of this study was to examine whether asymmetric loading influences macrophage elastase (MMP12) expression in different parts of a rat tail intervertebral disc and growth plate and if MMP12 expression is correlated with the severity of the deformity. METHODS: A wedge deformity between the ninth and tenth tail vertebrae was produced with an Ilizarov-type mini external fixator in 45 female Wistar rats, matched for their age and weight. Three groups were created according to the degree of deformity (10°, 30° and 50°). A total of 30 discs and vertebrae were evaluated immunohistochemically for immunolocalisation of MMP12 expression, and 15 discs were analysed by western blot and zymography in order to detect pro- and active MMP12. RESULTS: No MMP12 expression was detected in the nucleus pulposus. Expression of MMP12 in the annulus progressively increased from group I to groups II and III, mainly at the concave side. Many growth plate chondrocytes expressed MMP12 in the control group, less in group I and rare in groups II and III. Changes in cell phenotype and reduction of cell number were observed, together with disorganisation of matrix microstructure similar to disc degeneration. ProMMP12 was detected at the area of 54 kDa and active MMP12 at 22 kDa. CONCLUSIONS: Expression of MMP12 after application of asymmetric loading in a rat tail increased in the intervertebral disc but decreased in the growth plate and correlated with the degree of the deformity and the side of the wedged disc. Cite this article: Bone Joint Res 2014;3:273-9.

Actual evidence in the medical approach to adolescents with idiopathic scoliosis.

Idiopathic scoliosis (IS) is a three-dimensional deformity of the spine and trunk. The most common form involve adolescents. The prevalence is 2-3% of the population, with 1 out of 6 patients requiring treatment of which 25% progress to surgery. Physical and rehabilitation medicine (PRM) plays a primary role in the so-called conservative treatment of adolescents with IS, since all the therapeutic tools used (exercises and braces) fall into the PRM domain. According to a Cochrane systematic review there is evidence in favor of bracing, even if it is of low quality. Recently, a controlled prospective trial including a randomised arm gave more strength to this conclusion. Another Cochrane review shows that there is evidence in favor of exercises as an adjunctive treatment, but of low quality. Three meta-analysis have been published on bracing: one shows that bracing does not reduce surgery rates, but studies with bracing plus exercises were not included and had the highest effectiveness; another shows that full time is better than part-time bracing; the last focuses on observational studies following the Scoliosis Research Society (SRS) criteria and shows that not all full time rigid bracing are the same: some have the highest effectiveness, others have less than elastic and nighttime bracing. Two very important RCTs failed in recruitment, showing that in the field of bracing for scoliosis RCTs are not accepted by the patients. Consensuses by the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) show that there is no agreement among experts either on the best braces or on their biomechanical action, and that compliance is a matter of clinical more than patients' behavior (there is strong agreement on the management criteria to achieve best results with bracing). A systematic review of all the existing studies shows effectiveness of exercises, and that auto-correction is their main goal. A systematic review shows that there are no studies on manual treatment. The SOSORT Guidelines offer the actual standard of conservative care.

Subchondral cyst development and MMP-1 expression during progression of osteoarthritis: an immunohistochemical study.

BACKGROUND: Subchondral bone cyst (SBC) formation is often identified in patients with osteoarthritis. Furthermore, several studies have shown that expression of matrix metalloproteinases (MMPs) is elevated in patients with OA. OBJECTIVES: The aim of our study is to correlate the presence of SBCs and MMP-1 expression with the osteochondral alterations during OA progression. METHODS: We studied the cartilage and subchondral bone of 15 patients who had undergone total knee or hip replacement due to primary OA. As controls, we used the femoral heads of three patients without macroscopic OA changes. We evaluated three specimens per patient. RESULTS: Specimens were divided in four groups based on the Mankin histological severity score. Using immunohistochemistry, we noted SBCs at the site of greatest disease severity. Specifically, these were present more frequently in group III (Mankin score: 6-7) and IV (Mankin: ≥ 8), compared with group I (Mankin: 1-3) and II (Mankin: 4-5). Mild OA stages (Mankin: 1-6) were characterized by degeneration and thinning of the cartilage, followed by increased osteoblast and osteoclast activity of the subjacent bone and the subsequent appearance of SBCs. Simultaneously, we observed expression of MMP-1 in groups I and II in the cartilage and III and IV in both the cartilage and the subchondral bone. Moreover, osteoblast-like cells in the lining of the SBCs showed an increased expression of MMP-1 in stages III and IV. CONCLUSION: Our study provides immunohistological evidence that SBCs accumulate in advanced OA and contain activated cells, which express MMP-1, suggesting that they may thus participate in the osteochondral changes of OA. LEVEL OF EVIDENCE: Level III; prospective comparative study.

Giant lipoma of the thenar--case study and contemporary approach to its aetiopathogenicity.

Giant lipomas of the thenar are rare tumours of the adipose tissue of the hand, with a benign prognosis. Apart from the cosmetic problems they may cause, their most frequent complications include a compromise in functionality and pressure upon the nerves, mainly on the radial nerve. The first step in their management is their differential diagnosis from well-differentiated liposarcomas (WDLPS), as they require a different therapeutic approach. This step is completed with the aid of MRIs, biopsies and modern immunohistochemical methods, which offer high specificity and sensitivity. Our paper presents a case of giant lipoma of the thenar, with a review of the relevant literature, focusing on the disease's molecular genetics, which is a very important field of research today.

Back trunk morphology in 3301 children aged 3-9 years old.

The present cross sectional study reveals trunk asymmetry (TA) in "normal" Mediterranean juveniles for the first time. The scoliometer readings in both standing and sitting forward bending position (FBP) of 3301 children, (1645 boys, and 1656 girls) aged from 3 to 9 years old were studied. TA was quantified by measuring angle of trunk rotation (ATR) and children were divided in two groups. In group I the ATR was 1 degrees to 6 degrees degrees and in group II> or =7 degrees . 71.25% of boys and 73.27% of girls in standing while 81.13% of boys and 80.74% of girls in sitting FBP, were symmetric (ATR=0 degrees ). The symmetry difference at standing minus sitting FBP for boys and girls was 9.88% and 7.43% respectively. Severe asymmetry (ATR> or =7 degrees ) was found in 1.74% of boys and in 1.75% of girls at the standing and in 1.21% and 1.22% at the sitting FBP respectively. Analysing ATR by age it appears that significant TA changes occur between 8-9 years of age for boys and between 6-7 and 8-9 years for girls. The amount of trunk asymmetry in children is the indicator for referral and further orthopaedic assessment. This report provides, for the first time information about the variability of back morphology in "normal" juveniles which is worth knowing when a child is examined for juvenile scoliosis.

The role of the intervertebral disc in correction of scoliotic curves. A theoretical model of idiopathic scoliosis pathogenesis.

Wedging of the scoliotic inter-vertebral disc (IVD) was previously reported as a contributory factor for progression of idiopathic scoliotic (IS) curves. The present study introduces a theoretical model of IVD's role in IS pathogenesis and examines if, by reversing IVD wedging with conservative treatment (full- and night-time braces and exercises) or fusionless IS surgery with staples, we can correct the deformity of the immature spine. The proposed model implies the role of the diurnal variation and the asymmetric water distribution in the scoliotic IVD and the subsequent alteration of the mechanical environment of the adjacent vertebral growth plates. Modulation of the IVD by applying corrective forces on the scoliotic curve restores a close-to-normal force application on the vertebral growth plates through the Hueter-Volkmann principle and consequently prevents curve progression. The forces are now transmitted evenly to the growth plate and increase the rate of proliferation of chondrocytes at the corrected pressure side, the concave. Application of appropriately directed forces, ideally opposite to the apex of the deformity, likely leads to optimal correction. The wedging of the elastic IVD in the immature scoliotic spine could be reversed by application of corrective forces on it. Reversal of IVD wedging is thus amended into a "corrective", rather than "progressive", factor of the deformity. Through the proposed model, treatment of progressive IS with braces, exercises and fusionless surgery by anterior stapling could be effective.

Aetiology of Idiopathic Scoliosis. What have we learned from school screening?

The value of school screening as a research tool for Idiopathic Scoliosis (IS) aetiology has not been recognized adequately in the literature. The aim of the present study is to summarize the contribution of school screening in research of IS aetiology. All the relative publications about research of IS aetiology which originated from our scoliosis school screening program were analyzed. Information is provided about a) the influence of environmental factors in IS prevalence, b) the IS prevalence in girls with visual deficiency, c) the role of melatonin in IS pathogenesis, d) the age at menarche in IS girls and its relation to laterality of the curve, e) the role of the brain in trunk asymmetry and IS pathogenesis, f) the role of the thoracic cage in IS pathogenesis, g) the impact of the lateral spinal profile, h) the role of the intervertebral discs in IS pathogenesis, i) the association of cavus foot with IS and j) anthropometric data in IS patients. The present study provides evidence to support that school screening programs should be continued not only for early detection of IS or for health care purposes, but also as a basis for epidemiological surveys until we learn much more about the aetiology of IS.

Suggestions for improvement of school screening for idiopathic scoliosis.

There is skepticism and the worth of school screening for the purposes of health care has been challenged. Numerous reasons are raised by the negativists to abandon these programs, even though the value of school screening is well documented in the literature. The aim of the present study is to update the evidence based recommendations for the improvement of school screening effectiveness, in order to support its continuation. All the relative research papers which originated from our scoliosis school screening program were analyzed. Specific suggestions for a) the organization, b) the optimal age of screening according to the geographical latitude, c) the best examined position, d) the standardization of referrals, e) the follow up of younger referrals with trunk asymmetry and f) the reduction of the financial cost are made. Today there is evidence that the incidence of surgery can significantly be reduced in areas where idiopathic scoliosis can be detected at an early stage through these programs. The introduction of these recommendations to all the existing school screening programs is strongly suggested, to reduce the negative impact they may have on families and on the health system and to improve their effectiveness.

'SOSORT consensus paper on brace action: TLSO biomechanics of correction (investigating the rationale for force vector selection)'.

BACKGROUND: The effectiveness of orthotic treatment continues to be controversial in international medical literature due to differences in the reported results and conclusions of various studies. Heterogeneity of the samples has been suggested as a reason for conflicting results. Besides the obvious theoretical differences between the brace concepts, the variability in the technical factors can also explain the contradictory results between same brace types. This paper will investigate the degree of variability among responses of scoliosis specialists from the Brace Study Ground of the International Society on Scoliosis Orthopedic and Rehabilitation Treatment SOSORT. Ultimately, this information could be a foundation for establishing a consensus and framework for future prospective controlled studies. METHODS: A preliminary questionnaire on the topic of 'brace action' relative to the theory of three-dimensional scoliosis correction and brace treatment was developed and circulated to specialists interested in the conservative treatment of adolescent idiopathic scoliosis. A particular case was presented (main thoracic curve with minor lumbar). Several key points emerged and were used to develop a second questionnaire which was discussed and full filed after the SOSORT consensus meeting (Milano, Italy, January 2005). RESULTS: Twenty-one questionnaires were completed. The Chêneau brace was the most frequently recommended. The importance of the three point system mechanism was stressed. Options about proper pad placement on the thoracic convexity were divided 50% for the pad reaching or involving the apical vertebra and 50% for the pad acting caudal to the apical vertebra. There was agreement about the direction of the vector force, 85% selecting a 'dorso lateral to ventro medial' direction but about the shape of the pad to produce such a force. Principles related to three-dimensional correction achieved high consensus (80%-85%), but suggested methods of correction were quite diverse. CONCLUSION: This study reveals that among participating SOSORT specialists there continues to be a strongly held and conflicting if not a contentious opinion regarding brace design and treatment. If the goal of a 'treatment consensus' is realistic and achievable, significantly more effort will be required to reconcile these differences.

School screening in the heavily industrialized area--Is there any role of industrial environmental factors in idiopathic scoliosis prevalence?

INTRODUCTION: School-screening programs contributed greatly to the study of idiopathic scoliosis (IS) prevalence. A similar program confined to a highly industrialized area is being performed in our Department. Thus the comparison of the findings of IS prevalence of this program with those of programs performed in non-industrialized areas of the same country could imply the significance of special industrial environmental factors on IS aetiology. MATERIALS AND METHODS: 3039 schoolchildren (1506 boys, 1533 girls), aged 5,5 to 17,5 years, have been screened for IS. These children comprise 20% of a total population of 20000 schoolchildren, who live in the region. The detection of the scoliotic children was attained utilizing the criterion of the angle of trunk inclination (ATI). The Prujis scoliometer was used to assess ATI. A cut off point of > or = 7 degrees ATI was used as a criterion for children's referral to hospital. 262 (8,6%) were referred for further evaluation, whereas 118 (3,9%) among these children underwent radiological examination. RESULTS: 90 children were found to have a Cobb angle of > or = 10 degrees at their standing PA spinal radiographs (2,9 % of the screened population). A Cobb angle of 10 degrees -20 degrees was found in 74 (2,4%) children. Sixteen (0,5%) children, who had scoliotic curves with a Cobb angle of > or = 20 degrees, underwent conservative treatment by means of spinal orthosis. Relatively to their location on the vertebral column, 20% of the scoliotic curves were thoracic, 26,7% thoracolumbar, 20% lumbar, 24,4% double and 8,9% miscellaneous. DISCUSSION: The screened area represents a place of particular interest because it experienced considerable environmental pollution during the past decades without any improvement of the available Health Services. A quite diverse population in relation to its occupation and its origin inhabits this area as well. The scoliosis incidence found in this area is similar to the incidence observed (2,9%) at other non-industrialized geographical departments of this country (2,6%). This implies that industrial environmental factors probably do not significantly influence the prevalence of AIS.

Pathogenesis of idiopathic scoliosis. The Nottingham concept.

There is no generally accepted scientific theory for the etiology of idiopathic scoliosis. Hence, current treatment is pragmatic and not based on knowledge of causation of the deformity. In Nottingham, we have evaluated data from studies of the hips, pelvis, spine, rib cage and trunk muscles in scoliotic (pre- and post operative) and control patients, cadavers and a mechanical model to formulate a new theory of etiology for idiopathic scoliosis (figs. 18 & 19 of ref. 15). Evidence is summarized for the view that idiopathic scoliosis results, in part, from a developmental abnormality in the central nervous system creating rib-vertebra angle asymmetry which leads to a cyclical failure of mechanisms of rotation control in the trunk; these involve rotation-inducing (pelvic) and rotation-defending (discal, ligamentous and costal) mechanisms acting mainly in gait. The mechanical breakdown of rotation occurs in association with a lateral spinal curvature and a lordotic segment to create the initial deformity of idiopathic scoliosis. Then, growth, both abnormal (secondary to vertebral hyper-pressures) and normal (linear spinal growth) with gravity adds to the initiating and continuing neuromuscular mechanisms to augment curve progression. This theory views the spine in the wider perspective of function in the trunk, evolution and development, all in relation to bipedalism. The goal of etiological research is ultimately to base a treatment on some knowledge of causation of the deformity.

A segmental analysis of thoracic shape in chest radiographs of children. Changes related to spinal level, age, sex, side and significance for lung growth and scoliosis.

Thoracic ratios (TRs) were measured segmentally (T1-12) in the chest radiographs of 412 children aged 0-17 years attending hospital with minimal disorder or diseases (boys 193, girls 219). A new method for measuring TRs was used which calculates the width of the left hemithorax, the right hemithorax and the total thorax relative to T1-T12 distance. The data were analysed in 3 age groups--infancy, childhood and puberty, after the classification of Karlberg (1989). The findings are as follows. 1. The chest broadens from T1 to about T10-11. 2. Between infancy and childhood, relative to its length the chest narrows from above downwards and particularly in the lower chest (T5-12 average diminution, boys 9.5%, girls 9.8%). In the upper chest, the narrowing is more marked in girls than boys (T1-4 average diminution, boys 5.1%, girls 8.2%). 3. Between childhood and puberty, the girl's but not the boy's chest narrows further in its lower half (below T6 average diminution 3.3%). At T6 and above there is no detectable change in the relative width of the chest in either boys or girls. 4. The relative narrowing of the chest during growth appears to result from several mechanisms: (1) elevation of upper rib-vertebra angles (above 90 degrees); (2) drooping of lower rib-vertebra angles (below 90 degrees); and (3) linear rib growth being impaired relative to thoracic spinal growth in the lower ribcage (T6-12) of girls between childhood and puberty (Grivas et al. 1991 d). 5. The hypothesis is suggested that the relative narrowing of the lower chest with increasing age reduces the rotational inertia of the thorax in gait. There is a greater need for such reduction in girls because of the greater rotational inertia generated by the mass of their larger pelves. This hypothesis provides a mechanical explanation for the proportionate change in the girl's lung in the later stages of growth (Simon et al. 1972). 6. Developmentally, the left hemithorax is ahead of the right hemithorax in childhood. 7. Thoracic asymmetry favouring the right chest is found, and more so in puberty than childhood which is connected with the larger size of the thorax and lung in the adult. 8. The evidence suggests that hemithoracic development is caudocranial; this is consistent with an adaptation of the human ribcage to control spinal rotation and counterrotation when bipedal gait was acquired in evolution. 9. In progressive infantile idiopathic scoliosis, the upper chest is funnel-shaped.(ABSTRACT TRUNCATED AT 400 WORDS)