Differences of bone mineral mass, volumetric bone mineral density, geometrical and structural parameters and derived strength of the tibia between premenopausal and postmenopausal women of different age groups: a peripheral Quantitative Computed Tomography (pQCT) study.

Menopause constitutes a significant cause of bone loss, and it is currently debated whether bone mass is preserved or begins to decline substantially before that time in women. We used pQCT of the tibia to estimate differences of bone mineral mass, bone geometry and derived strength between premenopausal and postmenopausal Caucasian women of different age-groups per decade of age (20-79y). For each individual, we assessed total, trabecular and cortical bone mineral content (BMC, mg) and volumetric bone mineral density (BMD, mg/cm3); total and cortical cross-sectional areas (CSA, mm2); periosteal circumference (PERI_C, mm); endosteal circumference (ENDO_C, mm); mean cortical thickness (CRT_THK, mm); and Stress-Strain Index (SSI) . Comparisons were made both between premenopausal (N=84) and postmenopausal (N=231) women as distinct groups, and among women of the different age-groups. Our results indicated that premenopausal women had significantly higher trabecular and cortical BMC and vBMD, with higher cortical CSA, CRT_THK and SSI than postmenopausal women. Moreover, significant differences of trabecular but not cortical BMC, vBMD or SSI were found between women of the younger (<48y) age-groups. PERI_C, ENDO_C displayed lower values in the 20-29y group and higher values in the 70-79y group, denoting significant differences of bone geometry with aging.

Median nerve biodegradable wrapping : Clinical outcome of 10 patients.

Nerve wrap protectors are bioabsorbable synthetic materials made of collagen or extracellular matrix that provide a non-constricting encasement for injured peripheral nerves. They are designed to be used as an interface between the nerve and the surrounding tissue. After hydrated, they transform into a soft, pliable, nonfriable, easy to handle porous conduit. The wall of the nerve wrap has a longitudinal slit that allows to be placed around the injured nerve. Τhis article presents the surgical technique for median nerve neurolysis and nerve coverage using a collagen or an extracellular matrix nerve wrap protector in 10 patients with recurrent or persistent carpal -tunnel syndrome. All patients had a mean of three previous open carpal tunnel operations, which were not successful. The mean follow-up was 3 years. -Under axillary nerve block anaesthesia with the use of -pneumatic tourniquet, a standard open carpal tunnel approach was done incorporating the previous incision. Scar tissue was excised in a healthy bed and the median nerve was thoroughly released with external neurolysis. An appropriate length of nerve wrap protector was cut longitudinally according to the length of nerve release. The nerve wrap was loosely sutured with separate polypropylene sutures No. 7-0. A volar splint was applied for a mean of 2 weeks followed by progressive passive and active range of motion rehabilitation exercises of the wrist and fingers. At the last follow-up, all patients showed improvement of clinical symptoms, static two-point discrimination test and median nerve conduction studies, and absence of Tinel sign. Differences in outcome and complications with respect to the nerve wrap materials used were not observed.

Improving health-related quality of life in middle-age children with cerebral palsy following selective percutaneous myofascial lengthening and functional physiotherapy.

INTRODUCTION AND OBJECTIVES: Children with cerebral palsy (CP) experience decreased health-related quality of life (HRQOL). This study aimed to assess the HRQOL of children with CP before versus after a combined program of minimally invasive selective percutaneous myofascial lengthening (SPML) and functional physiotherapy. MATERIAL AND METHODS: A single-group pre-posttest design was used. Twenty-six middle childhood children with spastic CP, aged 5-7 years, with Gross Motor Function Classification System levels II-IV underwent SPML surgery and 9 months of postoperative functional strength training therapy. The proxy version of the DISABKIDS-Smiley questionnaire was completed by one parent of each child. Dependent t-tests were used to compare mean pre- and post-measurement scores. RESULTS: After the 9-month intervention, the children with CP had significantly higher quality of life scores (mean difference, 11.06±9.05; 95% confidence interval [CI], 7.40-14.71; p<0.001). CONCLUSIONS: This study demonstrated that children with CP had better HRQOL after a combined program of minimally invasive SPML surgery and functional physiotherapy (ACTRN12618001535268).

Improving health-related quality of life in middle-age children with cerebral palsy following selective percutaneous myofascial lengthening and functional physiotherapy. / [Artículo traducido] Mejora de la calidad de vida relacionada con la salud en niños de mediana edad con parálisis cerebral después de un alargamiento miofascial percutáneo selectivo y fisioterapia funcional.

INTRODUCTION AND OBJECTIVES: Children with cerebral palsy (CP) experience decreased health-related quality of life (HRQOL). This study aimed to assess the HRQOL of children with CP before versus after a combined program of minimally invasive selective percutaneous myofascial lengthening (SPML) and functional physiotherapy. MATERIAL AND METHODS: A single-group pre-posttest design was used. Twenty-six middle childhood children with spastic CP, aged 5-7 years, with Gross Motor Function Classification System levels II-IV underwent SPML surgery and 9 months of postoperative functional strength training therapy. The proxy version of the DISABKIDS-Smiley questionnaire was completed by one parent of each child. Dependent t-tests were used to compare mean pre- and post-measurement scores. RESULTS: After the 9-month intervention, the children with CP had significantly higher quality of life scores (mean difference, 11.06 ± 9.05; 95% confidence interval [CI], 7.40-14.71; p < 0.001). CONCLUSIONS: This study demonstrated that children with CP had better HRQOL after a combined program of minimally invasive SPML surgery and functional physiotherapy (ACTRN12618001535268).

Heterotopic ossification following traumatic brain injury and spinal cord injury: insight into the etiology and pathophysiology.

Neurogenic heterotopic ossification (HO) is the ectopic formation of lamellar bone in non-osseous tissues following traumatic brain or spinal cord injury. The associated complications affect greatly their quality of life. This fact has shifted the focus of scientific effort towards the investigation and understanding of related risk factors and the pathophysiological mechanisms. Recent advancements include the investigation for genetic predisposition and association various biomarkers. In the present article we will analyze the current concepts on this topic, based on clinical and physiological evidence and we will discuss the potential areas for future research on this field.

Effect of two sitting postures on lumbar sagittal alignment and intervertebral discs in runners.

PURPOSE: We evaluated in vivo changes in lumbar lordosis and intervertebral discs in runners and assessed the relationship between these changes and degenerative disc disease in runners with and without a history of low back pain. MATERIALS AND METHODS: Using open upright magnetic resonance (MR) imaging, we prospectively studied changes in lumbar lordosis and intervertebral discs of 25 elite long-distance runners in two sitting postures (neutral and extended) before and after 1 h of running and compared the results with disc height and dehydration/degeneration. Seventeen of the 25 runners had a history of low back pain. RESULTS: After 1 h of running, mean lordosis in neutral posture reduced by 4°; reduction was significant in runners with a history of low back pain. A significant reduction in mean lordosis in extension was not observed. Mean disc height significantly reduced in both postures, without, however, any statistical significance between runners with and without a history low back pain in any posture. Variable degrees of disc dehydration/degeneration were observed in 23 runners (57 discs), more commonly at L5-S1. A significant difference of disc dehydration/degeneration between runners with and without a history of low back pain was not observed. CONCLUSIONS: Intervertebral discs undergo significant strain after 1 h of running that in the long term may lead to low back pain and degenerative disc disease. Runners, especially those with low back pain and degenerative disc disease, should be evaluated after training to preserve the normal lumbar lordosis.

Palliative treatments for advanced osteosarcoma.

Advances in diagnostic imaging, interventional radiology, chemotherapy and surgery greatly improved the outcome of patients with osteosarcoma, and made limb salvage possible without compromising survival. In these patients, the prognosis is influenced by the site and resectability of the tumor, prior malignancy, and histological response to preoperative chemotherapy. Unfortunately, the progress has not been as significant in the treatment of advanced osteosarcoma, namely metastatic, recurrent and unresectable tumor. Yet, although advanced and forecasting a dismal prognosis, advanced osteosarcoma is not necessarily untreatable. Aggressive local and medical treatments, including surgical removal of primary and/or metastatic disease are currently available; however, yet, most treatments aim at palliation. Palliative local treatments including isolated limb perfusion, radiation therapy, embolization, chemoembolization, thermal ablation and cryoablation, all have an important role for these patients. The aim of palliative treatments is to achieve a mild response by offering the least discomfort to the patient with the minimum possible complications, and possibly increase of survival.

Expandable tumor prostheses in children.

Any surgical resection in the lower extremities in children will cause a leg length discrepancy from physeal resection. To avoid the resulting functional deficit, leg length discrepancy must be reconciled with surgical techniques to approximate equal leg lengths at skeletal maturity. Currently there are several manufacturers who offer options for prosthetic reconstruction with expandable implants. These implants can be expanded to a length projected on the basis of three factors: the length of bone resected, the anticipated future growth of the contralateral extremity, and the estimated discrepancy of limb length at skeletal maturity. In this article, we review the basic principles and guidelines for prediction of remaining bone growth and planning lengthening in children, and present the currently available expandable prostheses and the evolution performed over time.

The impact of bone mineral density on the degree of curvature of the lumbar spine.

OBJECTIVE: The prevailing perception is that one of the causes of postural deformities is osteoporosis. Nonetheless, studies of the correlation between bone mineral density (BMD) and spinal curvatures have produced contradictory results. This study was undertaken in order to determine whether (BMD) is associated with the curvature of the lumbar spine. METHODS: 105 postmenopausal women, aged 45-76 years (average= 57.3 years), were examined. All the participants underwent DXA scanning and spinal radiography using the same equipment and techniques. Lumbar curvatures were measured using the Cobb method. Subjects were divided according to their T-score into osteoporosis patients (n=54) and controls (n=51). Statistical analysis was performed using one way ANOVA, Mann-Whitney as well as Pearson and Spearman rank correlations. RESULTS: There were no statistically significant correlations between BMD and lumbar curvature angles either in the total sample or in either group individually. Furthermore, these angles were not significantly different between patients with osteoporosis and controls. CONCLUSIONS: The reduction in BMD and the alteration of the lumbar curvature that are observed in elderly individuals are concurrent but not related phenomena. The findings of this study contradict the claim that reduced bone mineral density is the cause of postural deformities.

Functional and radiographic outcome after tumor limb salvage surgery using STANMORE megaprostheses.

PURPOSE: To report the clinical and radiological outcome of limb salvage surgery with the STANMORE megaprostheses. METHODS: We retrospectively studied 33 patients with musculoskeletal tumor limb salvage surgery using STANMORE megaprostheses. Clinical evaluation was done using the Enneking and the Toronto Extremity Salvage Score (TESS). Radiographic evaluation was done using the International Society of Limb Salvage (ISOLS) score. RESULTS: At a mean follow-up of 18 months, 21 patients were alive with no evidence of disease and two patients were alive with metastatic disease; 9 patients died of metastatic disease and one patient of causes unrelated to the primary tumor. Local recurrence was not observed in any of the patients. The mean Enneking and TESS scores were 76 and 88.4%, respectively. The ISOLS score was excellent or good in 30 cases for bone remodelling, 30 cases for the interface, in 30 cases for anchorage, in 32 cases for the implant body, and in 33 cases for the articulation. Extracortical bone bridging greater than 25% was observed in 8 prostheses. Mechanical survival of the megaprostheses was 97% (32 megaprostheses). Complications included seroma and hematoma formation (12%), skin necrosis and dehiscence at the knee wound (9%), aseptic loosening and infection (6%), quadriceps tendon rupture and peroneal nerve palsy (3%). CONCLUSION: The local recurrence-free survival in this series supports limb salvage surgery. The 97% survival rate of the megaprostheses suggests that the STANMORE modular megaprostheses are valuable for reconstruction of bone defects after tumor resection.

Criteria and outcome of limb salvage surgery.

When sufficient margins of resection surrounding the tumor can be achieved, limb salvage surgery, as opposed to amputation, has become the standard of care in treating patients with bone and soft tissue sarcoma of the extremities. Currently, 90-95% of patients with primary malignant bone and soft-tissue tumors involving the extremities can be treated safely with wide resection and limb salvage surgery with a low risk of recurrence and the same disease-free survival rate as amputative surgery. However, discussions persist regarding the indications and criteria, and whether limb salvage provides superior functional results and quality of life for cancer patients. In this study we aimed to review and update the current criteria, indications and contraindications of limb salvage surgery and discuss its role in the quality of life of cancer patients.

Prevention of heterotopic ossification in cases of hypertrophic osteoarthritis submitted to total hip arthroplasty. Etidronate or Indomethacin?

We present a study comparing etidronate or indomethacin for the prevention of heterotopic ossification after total hip arthroplasty in patients with hypertrophic osteoarthritis. 52 patients were divided in two groups. Group A (26 patients) received etidronate (20 mg/kg/day for 12 weeks) and Group B (26 patients) indomethacin 75 mg/day for 2 weeks. Mean follow up was 36 months (range, 18 to 50 months). The incidence of side effects was 15.4% in group A and 30.8% in group B (p=0.324). At 6 months there was no statistically significant difference in terms of clinical (p=0.532) and radiographic evaluation between the two groups (p=0.303). However, the cost of etidronate which may be as much as six times more expensive than that of indomethacin could not justify its routine prophylactic use.

Influence of acute anterior cruciate ligament deficiency in gait variability.

The objective of this study was to compare the gait variability of patients with isolated anterior cruciate ligament (ACL) deficiency (experimental group) with that of healthy individuals (control group). The hypothesis was that the gait variability of the experimental group would be higher than the control group. The experimental group consisted of 20 men with an ACL tear and the control group consisted of 20 healthy men without any neurological and/or musculoskeletal pathology or injury. The gait acceleration signal was analysed using the Gait Evaluation Differential Entropy Method (GEDEM). The GEDEM index of the experimental group in the medio-lateral axis was significantly higher than that of the control subjects. A receiver operating characteristic (ROC) analysis was used to assess the diagnostic value of the method and to determine a cut-off entropy value. The GEDEM cut-off value had a 95.6% probability of separating isolated ACL patients from healthy subjects.

Can Initial Hematocrit Predict Blood Transfusions, Hospital Cost, and Mortality in Polytrauma Patients?

Knowing the initial hematocrit of a polytrauma patient can assist his trauma management. This paper describes a four-year study of 88 polytrauma patients. Fifty-nine were transfused, and eight were women (13.5%). The mean cost of the first hospitalization of patients who were transfused was 14,503 €; the mean cost of patients who were not transfused was 5,718 €. HCT did not correlate with ICU stay; nor did days of hospitalization. The mean HCT of those who died was not much different from that of survivors (33.23 with standard deviation [SD] 7.43 versus 32.37 with SD 5.89). This study showed that initial HCT does not correlate with days of hospitalization or days in ICU, but that transfusion can predict higher total cost.

Insights in clinical examination and diagnosis of Athletic Pubalgia.

Athletic pubalgia presents with groin and/or pubic pain mainly in athletes. The purpose of this review is to analyze, by evaluating current literature, the clinical examination and differential diagnosis of athletic pubalgia, in an effort to better understand this clinical entity. Diagnosis is challenging due to the anatomical complexity of the groin area, the biomechanics of the pubic Romasymphysis region and the large number of potential sources of groin pain. Clinical examination and medical history are of utmost importance. Differential diagnosis includes intra-and-extra-articular hip and intra-abdominal pathology, as well as non-myoskeletal disorders, such as femoroacetabular impingement (FAI), acetabular labral tears, osteitis pubis, adductor muscles injuries and true inguinal hernia. A thorough clinical examination should be performed in such cases, including the "Resisted sit-up" and the "Single or Bilateral Resisted Leg Adduction" test. Regarding imaging, Magnetic resonance imaging (MRI) should be performed when athletic pubalgia is suspected, especially in athletes. Other imaging techniques, such as plain radiographs and ultrasonography may add to the diagnostic process.

Adamantinoma of the tibia treated with a new intramedullary diaphyseal segmental defect implant.

In this case report, a 75-year old male presented with a mass on the anterior surface of the mid-shaft of the right tibia. Imaging studies showed a well-circumscribed radiolucent lesion in the anterior tibial cortex, without soft tissue extension. Plain radiographs and computed tomography scan of the chest were negative. Histological diagnosis was consistent with adamantinoma, a rare primary bone tumour. Wide tumour resection of approximately 16 cm of the tibial diaphysis with a surrounding cuff of normal tissue was performed. The bone defect was reconstructed using an intramedullary diaphyseal segmental defect fixation system. At 26 months post-operatively the patient is alive with no evidence of local recurrence, distant metastases or implant failure. The intramedullary diaphyseal segmental defect fixation system is associated with excellent oncological and functional outcomes. Intra-operative modularity, ease of application, immediate post-operative stability and rapid rehabilitation are the major advantages of this diaphyseal prosthesis.

Accelerometry for evaluation of gait pattern in healthy soccer athletes.

An accelerometer system was used to measure the characteristics of the motion of 133 healthy male soccer athletes in a 30-s walking test and the data obtained were analysed using the gait evaluation differential entropy method (GEDEM). GEDEM processes gait acceleration data and calculates an index that provides a quantitative evaluation of a subject's gait, at low cost and with negligible effect on the subject. The GEDEM index was not significantly correlated with age, body weight, body mass index, or the number of years of active training. The GEDEM value for the anterior-posterior axis showed a small negative statistically significant correlation with height and the vertical axis was moderately and statistically significantly positively correlated with the time spent training per week. The triaxial accelerometry system described here is easy for subjects and testers to use, and enables measurements to be made on the sports field to evaluate an athlete's musculoskeletal condition with respect to gait stability.

Polytrauma: Treatment, Cost, and Associated Factors.

Trauma is a multifactor problem with economic, social, and political burdens. In this article, we estimate its economic extension. This 3-yr study includes 69 patients above 14 yr of age, who experienced multiple traumatic injuries. We review their economic impact on the National Health System of Greece. Mean patient age is 38.91 yr, and most are male (85.5%), nonsmoking (69.6%), and without open fractures (78.3%). As a result of their injuries, most patients (76.8%) stayed in the intensive care unit (ICU), underwent surgery (76.8%), were transfused (68.1%), and became infected (63.8%). Mean cost was 16,365.65€, median cost 10,399.07€, minimum value 554.17€, and maximum value 89,243.52€. Of the 69 patients, 12 died. The number of polytrauma patients is relatively small compared to the total amount of patients in hospital care, but their impact on health services is very high. Patients admitted to the ICU are at great risk of infection, which can almost triple financial cost and increase hospital stay.

Mechanoreceptors of the posterior cruciate ligament.

The mechanical role of the anterior and posterior cruciate ligaments in the passive and functional stability of the knee joint has been well documented. Both these knee joint ligaments contain Ruffini, Pacinian, Golgi and free nerve endings with different capabilities of providing the central nervous system with information regarding movement and position as well as chemical events. The posterior cruciate ligament provides 95% of the restraining force to a posterior tibial displacement, is significantly stronger than the other knee ligaments, and sensory nerve endings are located in the tibia and femoral bone insertions. This report aims to review the anatomy and physiology of the various mechanoreceptors of the posterior cruciate ligament, placing special emphasis on their role in knee joint stability. It concludes that the posterior crude ligament may not only serve as a 'mechanical stabilizer' of the knee joint, but also probably has an important 'sensory function' that should be taken into account when dealing with injuries to it.

Bone loss and mechanical properties of tibia in spinal cord injured men.

AIM: The effects of Spinal Cord Injury (SCI) on bone in paralyzed areas are well documented but there are few data for the importance of the level of injury in the decrease of mechanical strength in paralyzed legs. The aim of the present study was to describe bone loss of the separate compartments of trabecular and cortical bone in spinal cord injured men and to compare possible changes in mechanical properties of tibia with the neurological level of injury. MATERIALS AND METHODS: Fifty men were included in this study: 39 had complete SCI in chronic stage. As chronic stage, we considered paraplegia >1.5 years (yrs). Men were separated as follows: Group A (18 men, high paraplegia: Thoracic (T)4-T7 level, mean age: 33 yrs, duration of paralysis: 5.9 yrs) and group B (21 men, low paraplegia: T8-T12 level, mean age: 39 yrs, duration of paralysis: 5.6 yrs) in comparison with 11 healthy men as a control group (C) of similar age, height, and weight. None of the subjects was given bone acting drugs. The neurological profile of each patient was assessed according to the American Spinal Injury Association (ASIA). All subjects were measured by peripheral quantitative computed tomography (pQCT). Measurements were performed at the tibia with a Stratec XCT 3000 (Stratec Medizintechnik, Pforzheim, Germany) scanner. The distal end of the tibia was used as an anatomical marker. The bone parameters, bone mass density (BMD) trabecular, BMD total, BMD cortical, and cortical thickness have been measured at 4% and 38%, respectively, of the tibia length proximal to this point, and the periosteal and endocortical was measured at 14% of the tibia. We calculated stress strain index (SSI), a bone strength estimator derived from the section modulus, and the volumetric density of the cortical area at 14% (SSIPol2) and 38% (SSIPol3) of the tibia length proximal to the distal end of the tibia. RESULTS: In both groups A and B most bone mass parameters were statistically decreased in comparison with controls. In each group we calculated the median deltaSSI(3-2) (SSIPol3 - SSIPol2). In the paraplegic groups Spearman correlation coefficient between duration of paralysis and deltaSSI(3-2) was in group A: r=-0.178, p=N.S. and group B: r=0.534, p=0.027, respectively. CONCLUSION: Despite the similar paralytic effect on bone in all paraplegic patients in our study and because of the non-significant duration of paralysis between paraplegic groups (p=0.87), the two paraplegic groups act differently in mechanical properties of the tibia. In addition, group A patients in respect to the level of injury, are susceptible to autonomic dysreflexia as a result of the disruption of the autonomic nervous system pathways. These results suggest that neurogenic factors are influencing geometric bone parameters.