Bony Pathology Research Articles

Endoscopic decompression for lumbar spinal canal stenosis

Laminectomy and fusion were surgical options to decompress neural structures and provide more space for the spinal cord in a stenosis patient with severe leg pain and progressive neurologic signs, such as numbness and weakness. The evolution of endoscopic spinal surgery techniques has created advantages for patients who require a laminectomy. The authors present a unique technique for endoscopic access to the central and lateral recess pathology as a minimally invasive procedure, which provides a good visualization. We performed two cases of endoscopic spinal surgery for single-level and consecutive three-level lumbar spinal canal stenosis using an 8 mm outer diameter, 5.5 mm working channel, 10° angled lens spinal endoscopic system (percutaneous stenoscopic lumbar decompression, MaxMore Spine Company, Unterföhring, Germany). Optimized endoscopic drills, forceps, and Kerrison punch were used to remove bony pathology and ligamentum flavum under direct endoscopic visualization. The first case had a narrow canal space in the L4/L5 segment with severe numbness at the same dermatome and did not respond with adequate conventional treatment. The second case had three-level canal stenosis with severe back pain and leg weakness. The purpose of this paper is to describe the technique, the efficacy, and feasibility of unilateral endoscopic laminectomy and bilateral decompression via posterior approach in lumbar spinal canal stenosis. Moreover, in this article, we present the technical details on endoscopic procedures and the prevention of complications and management during operation for spinal canal stenosis.

Clinical outcome of Patella stability after fixation of Osteochondral fracture in Acute Primary Traumatic Patella Dislocation without MPFL Repair or Reconstruction

Introduction: Conservative management is advisable for acute primary traumatic patella dislocation (PTPD). Surgical treatment is reserved for osteochondral fractures (OCF), medial patello femoral ligament (MPFL) avulsion/tear, compound injuries, and any underlying bony abnormalities requiring correction. MPFL repair (at avulsed site) or reconstruction along with underlying bony correction in PTPD is controversial. The purpose of this study is to evaluate patella stability after fixation of OCF in PTPD without performing MPFL repair or reconstruction, even in the presence of any underlying bony abnormalities. Material and Methods: This is a retrospective study of eight patients who had PTPD with OCF along with MPFL injury who presented between 2016 and 2019. Pre-operative X-rays and MRI were done to assess the status of MPFL, identify the presence of OCF and to calculate Insall-Salvati index, Tibial Tuberosity-Trochlear groove distance and Trochlear dysplasia. All patients underwent surgery by open approach and OCF fixation by bioabsorbable pins or suture material. MPFL was neither repaired at avulsed site nor reconstructed and even no bony corrections were done. Results: Average size of OCF fragments is 15*7 mm and all involving medial facet of patella. Lysholm score improved significantly from 32.8 to 94.8 and Kujala score from 49.1 to 96 at the end of 6 months. None of the patient had patella instability till latest follow-up, average follow-up period is 4.5 years (3–6 years). Clinically, apprehension test was negative in all cases with full ROM. Post-operative imaging including X-ray and MRI showed complete healing of the OCF along with complete healing/regeneration of MPFL with same pre-existing bony abnormalities if present preoperatively. Conclusion: This study shows excellent patella stability and full knee function along with complete union of OCF and complete healing/regeneration of MPFL in PTPD even in the presence of underlying bony abnormality. Hence, in PTPD with OCF, there is no need to repair/reconstruct MPFL or to correct underlying bony pathology, only OCF fixation is required.

The Value of SPECT-CT in Diagnosing Complex Non-Arthritic and Non-Neoplastic Conditions of the Foot and Ankle.

There is little information on the value of using single photon emission computerized tomography-computed tomography (SPECT-CT) in non-arthritic and non-neoplastic conditions of the foot and ankle (F&A). The vast majority of studies have investigated the role of SPECT-CT in degenerative conditions, bony pathology, and neoplastic conditions. The diagnostic value of SPECT-CT in purely non-arthritic and non-neoplastic conditions, in the absence of other conclusive radiological findings, is yet to be clarified. The aim of this study was to evaluate the value of SPECT-CT in a cohort of patients with complex F&A pathology, in whom diagnostic uncertainty existed after conventional imaging techniques, and to assess its added value in routine clinical practice. A retrospective analysis of 297 SPECT-CTs from 2010 to 2017 found 18 SPECT-CTs (age = 16-56 years) performed for non-arthritic F&A pathology. Changes in diagnosis, management, and clinical outcome scores were recorded before and after SPECT-CT imaging. The results demonstrated that the provisional diagnosis was different from the SPECT-CT diagnosis in 10 (56%) out of the 18 patients and led to a modified treatment plan, which was successful in 8 (80%) out of the 10 patients. The post-intervention Manchester Oxford Foot Questionnaire (MOX-FQ) and Visual Analogue Scale (VAS) score improved from 76 ± 18 to 58 ± 24 (P = .02), and from 72 ± 17 to 49 ± 32 (P = .01), respectively. The SPECT-CT scan was useful in confirming the provisional diagnosis in the remaining 8 patients where a diagnostic uncertainty existed after conventional imaging techniques. Overall, a total of 15 out of 18 patients (83%) showed an improvement in their symptoms after management led by SPECT-CT diagnosis. Our study highlights the added value of SPECT-CT in patients presenting with non-arthritic and non-neoplastic F&A conditions in which there is diagnostic uncertainty after conventional imaging. In 80% of cases, a change in management driven by the SPECT-CT findings led to a successful outcome. We have found SPECT-CT to be a useful investigative modality in assessing these complex F&A cases. Level IV.

Antibody-induced pain-like behavior and bone erosion: links to subclinical inflammation, osteoclast activity, and acid-sensing ion channel 3-dependent sensitization.

Several bone conditions, eg, bone cancer, osteoporosis, and rheumatoid arthritis (RA), are associated with a risk of developing persistent pain. Increased osteoclast activity is often the hallmark of these bony pathologies and not only leads to bone remodeling but is also a source of pronociceptive factors that sensitize the bone-innervating nociceptors. Although historically bone loss in RA has been believed to be a consequence of inflammation, both bone erosion and pain can occur years before the symptom onset. Here, we have addressed the disconnection between inflammation, pain, and bone erosion by using a combination of 2 monoclonal antibodies isolated from B cells of patients with RA. We have found that mice injected with B02/B09 monoclonal antibodies (mAbs) developed a long-lasting mechanical hypersensitivity that was accompanied by bone erosion in the absence of joint edema or synovitis. Intriguingly, we have noted a lack of analgesic effect of naproxen and a moderate elevation of few inflammatory factors in the ankle joints suggesting that B02/B09-induced pain-like behavior does not depend on inflammatory processes. By contrast, we found that inhibiting osteoclast activity and acid-sensing ion channel 3 signaling prevented the development of B02/B09-mediated mechanical hypersensitivity. Moreover, we have identified secretory phospholipase A2 and lysophosphatidylcholine 16:0 as critical components of B02/B09-induced pain-like behavior and shown that treatment with a secretory phospholipase A2 inhibitor reversed B02/B09-induced mechanical hypersensitivity and bone erosion. Taken together, our study suggests a potential link between bone erosion and pain in a state of subclinical inflammation and offers a step forward in understanding the mechanisms of bone pain in diseases such as RA.

Yield of Plain Radiography in Addition to Ultrasound Among Children with Hip Pain.

Children with limp or hip pain often undergo radiographs and ultrasound as part of their initial evaluation. Previous research suggests that hip radiography may have limited utility, and early use of ultrasound may safely reduce the use of radiographs. We sought to assess the utility of radiography in addition to ultrasound by evaluating the rate of bony abnormalities present on hip radiographs among children with and without effusion on ultrasound. We also assessed the agreement of point-of-care and Radiology-performed ultrasounds for the detection of effusion. This is a retrospective cohort study of children presenting to a pediatric emergency department with acute atraumatic limp or hip pain. Data from patients who received both hip ultrasound and hip radiography as part of their evaluation were analyzed. We included both point-of-care and Radiology-performed hip ultrasounds. We identified 134 patients who received both hip ultrasound and hip radiographs. Sixty-eight patients (51%) had a hip effusion present on ultrasound and none of these had bony abnormalities on radiography (0%, 95% confidence interval 0-5.3%). Of the 66 patients (49%) who had no effusion on hip ultrasound, 2 patients were found to have a bony abnormality (3%, 95% confidence interval 0.4-10.5%). For patients who received both point-of-care and Radiology-performed ultrasound, the overall agreement for diagnosis of effusion was 92.6% (kappa=0.82). We observed that no children with an effusion on ultrasound had bony pathology on plain radiography, suggesting that the routine performance of hip radiography may not be indicated in all children. Future studies are needed to evaluate the negative predictive value of effusion in larger numbers of patients with known bony abnormalities.

Congenital Contracture of the Ulnar Digits and Its Differentiation From Ischemic Contracture

To describe the clinical features, radiologic findings, differential diagnosis, and surgical treatment of a congenital flexion deformity of the middle, ring, and little fingers. The cause of the condition is the aberrant origin of the flexor digitorum profundus, leading to a congenital contracture of the ulnar digits. We reviewed 8 patients with congenital contracture of the ulnar digits. The mean age at the time of surgery was 14 years. An examination revealed a flexion contracture of the middle, ring, and small fingers. Plain radiographs, 3-dimensional computed tomography, magnetic resonance imaging, and ultrasound were used to characterize bony and soft tissue pathology. Surgical treatments included resection of the aberrant origin and a muscle-sliding procedure. Bony prominence on the proximal ulna was seen in the plain radiographs and/or 3-dimensional computed tomography. A cord that extended from this bony prominence to the tendons of flexor digitorum profundus was revealed in the magnetic resonance imaging. The bony prominence and the cord were also seen using ultrasound. The median time of patient follow-up was 1.7 years. A simple resection of the tendinous origin only resulted in a release in 2 patients who were 4 years old. Older patients required a further muscle-sliding procedure. The average grip strength ratio on the contralateral side was 82%. Congenital contracture of the ulnar digits is a new congenital flexion deformity involving the middle, ring, and small fingers. Bony prominence on the proximal ulna is the key finding for establishing its diagnosis and distinguishing it from an ischemic contracture. We recommend treating this surgically at 12 years of age or older after the phase of rapid growth of the extremities. We recommend the resection of the aberrant origin, combined with a muscle-sliding procedure, as the treatment of choice, even for young patients. Diagnostic V.

Multi-Modality Imaging of Craniofacial Fibrous Dysplasia with Orbital Complications and Histopathology Correlation-A case report and short review of literature

Craniofacial fibrous dysplasia [CF-FD] with orbital complications is a known but rare entity. This is a multi-modality imaging Case Report of extensive CF-FD in a 31-year-old male with right eye pain, swelling, and redness, along with histopathology correlation. In this patient, the CT scan demonstrates the classic ground glass bony appearance in great detail and helps with the diagnosis of FD, while excluding other bony pathology. The patient’s corroborative MRI brain with and without contrast and MRI brain perfusion images are presented to further characterize this pathology along with its orbital and ocular complications. Given the significant mass-effect on the ocular structures, the patient underwent orbital surgery with removal of as much of the lesion as possible. On macroscopic pathology evaluation, the affected bone was rubbery and gritty when sectioned. Microscopically, remnant fragments of woven bone of various size and shapes were seen with lack of an osteoblast rim. The bony fragments had a characteristic curvilinear, trabecular, and/or branching pattern. Post-surgical imaging demonstrated improvement in the mass-effect on orbital structures and proptosis, along with residual bony lesion.

English

Schwannomas are relatively rare benign neoplasms of neurogenic origin from the neural sheath of peripheral nerves occurring more commonly in the head and neck. Mandibular bone is the commonest site of occurrence of these nerve lesions. Radiographically, intraosseous schwannoma of mandible is very difficult to differentiate from other bony pathologies such as neurofibroma, ameloblastoma, fibrous dysplasia, myxoma, central giant cell lesion, or periapical lesion, so it should be included in the differential diagnosis of lower jaw swelling. Schwannoma as a pathologic entity was first reported in 1910 by Verocay. Schwannoma (also known as neurinoma, neurolemmoma, neurilemmoma, perineural fibroblastoma, and peripheral nerve sheath tumour) is a rare, slowgrowing, benign neurogenic neoplasm that originated from Schwann cells. Schwann cells cover myelinated sheath of nerve fibres.1 These intraosseous schwannomas account for not more than 1 % of the central neoplasms. More than one third of all schwannomas are found in the head and neck region. 2 Most of these originate from the lower cranial nerve and sympathetic nervous system. Schwannomas from the upper cranial nerves such as trigeminal nerve and its branches are less common. Other commonly reported sites include the vertebra, clavicle, ribs, sacrum, humerus, ulna radius, etc. This painless slow-growing neoplasm may develop at any age.

Arthroscopy of the Pediatric Elbow: Review of the Current Concepts

AbstractAs surgeons have become more familiar with elbow arthroscopy, the indications for arthroscopy of the pediatric elbow have expanded to include contracture releases, fracture fixation, treatment of osteochondritis dissecans (OCD) lesions, correction of elbow deformity, and debridement of soft tissue and bony pathologies. The treatment of various pathologies via an arthroscopic approach demonstrates equal, if not better, efficacy and safety as open surgery for the pediatric elbow. Arthroscopy provides the unique advantage of enabling the performance of extensive surgeries through a minimally-invasive approach, and it facilitates staged interventions in cases of increased complexity. For fracture work, arthroscopy enables direct visualization to assess reduction for percutaneous fixations. While future research is warranted to better evaluate the indications and outcomes of pediatric elbow arthroscopy, this update article presents a review of the current literature, as well as several innovative cases highlighting the potential of arthroscopy.

The Treatment of Bone Marrow Lesions Associated with Advanced Knee Osteoarthritis: Comparing Intraosseous and Intraarticular Injections with Bone Marrow Concentrate and Platelet Products

Bone marrow lesions are a radiographic indication of bony pathology closely associated with advanced osteoarthritis of the adjacent joint. Injection of autologous orthobiologic products, including bone marrow concentrate and platelet-rich plasma, have demonstrated safety and efficacy in treating both advanced osteoarthritis (via intraarticular injection) and associated bone marrow lesions (via intraosseous injection). The relative efficacy of intraarticular versus intraosseous injection of orthobiologics has not been evaluated at the present time. The objective was to evaluate differences in orthobiologic bone marrow lesions treatment, either as a collateral result of intraarticular injection with bone marrow concentrate and platelet products alone, or intraosseous plus intraarticular injection as measured by patient reported outcomes. This study employed a prospective case-matched cohort design. This study took place at a single outpatient interventional orthopedic pain clinic. Using data from a prospective orthobiologic treatment registry of knee patients, a population of knee osteoarthritis with bone marrow lesions patients who had undergone only intraarticular knee injections of bone marrow concentrate and platelets (for symptomatic advanced osteoarthritis) were age, gender, and disease severity case-matched to a series of advanced osteoarthritis and bone marrow lesions patients who underwent intraosseous plus intraarticular injections. Self-reported patient outcomes for Numeric Pain Scale, International Knee Documentation Committee, lower extremity functional scale, and a modified single assessment numeric evaluation were compared between the 2 treatment groups. Eighty patients were included, 40 in each group. Although pain and functional outcome scores were significantly improved in both treatment groups, there was no statistically significant differences in patient reported outcomes based on the type of treatment. There are several limitations to this study, including multiple providers performing the injections, varying onset of symptoms to treatment, and additional injections after their initial treatment, that were not controlled. In addition, increasing the sample size may be beneficial as well, particularly with the large bone marrow lesions group, which did suggest possible improvement with intraosseous plus intraarticular over the intraarticular, although was not statistically significant in our sample. Limited data availability for this cohort as well as some missing data are other limitations to consider. Treating knee bone marrow lesions with intraosseous bone marrow concentrate and platelet products did not affect patient reported outcomes.

Effect of Ulnar Head Offset on Distal Radioulnar Joint Stability

A complete ulnar head replacement may be indicated in cases of distal radial ulnar joint (DRUJ) dysfunction to address bony pathology in lieu of using a constrained total DRUJ prosthesis. Complete ulnar head implants are simple, but they may be unstable if soft tissue tension is not adequately restored. We hypothesized that incorporating an increased offset in the complete ulnar head replacement would lead to increased tension on the distal oblique interosseous ligament, increased contact force at the DRUJ, and improved joint stability. Using a specially designed jig, we measured instability by comparing displacement under load (stiffness) of the DRUJ in 10 cadaveric specimens under 4 different conditions: (1) intact, (2) native head after excision of the triangular fibrocartilage complex, (3) replacement of the ulnar head with a standard offset ulnar head, and (4) replacement of the ulnar head with an increased offset ulnar head. No soft tissue repair was done. We measured anteroposterior displacement under load with maximum translation of 10 mm or maximum loads of 50 N. We tested all specimens with the forearm positioned in neutral, supination, and pronation. Excising the triangular fibrocartilage complex decreased the average stiffness of the DRUJ to 46% of the intact state, creating a simulated state of DRUJ instability. Replacing the ulnar head with the standard offset head increased average stiffness to 54% of the intact state. Increasing the ulnar head offset with the simulated total ulnar head replacement increased average stiffness to 77% of the intact state. An increased offset ulnar head replacement improves DRUJ stability compared with a standard anatomic offset ulnar head replacement. Understanding DRUJ morphology and offset is important in the treatment of DRUJ arthritis and instability.

Three-dimensional assessment of patellofemoral anatomy: Reliability and reference ranges

BackgroundThree-dimensional (3D) imaging and analysis offer new possibilities in preoperative diagnostics and surgical planning. Simultaneous 3D analysis of the joint angles and the patellofemoral anatomy allow for a realistic assessment of bony pathologies in patients with patellofemoral complaints. This study aims to develop a standardized and validated assessment of the 3D patellofemoral morphology and to establish reference ranges. MethodsThirteen patellofemoral anatomic landmarks were defined on 3D bone models of the lower limbs based on computer tomography data and evaluated regarding inter- and intra-observer variability. Further, 60 3D models of the lower limbs of young subjects without any previous knee operation/injury were assessed and rescaled reference values for relevant patellofemoral indices were obtained. ResultsThe mean inter- and intra-observer deviation of all landmarks was below 2.3 mm. The interobserver intraclass correlation coefficient (ICC) was between 0.8 and 1.0 and the intra-observer ICC between 0.68 and 0.99 for all patellofemoral parameters. The calculated reference ranges are: Insall–Salvati index 1.0–1.4; patella tilt 6–18°; patella shift −4 to 3 mm; patella facet angle 118–131°; sulcus angle 141–156°; trochlear depth 3–6 mm; tibial-tuberosity to trochlear groove distance(TT-TG) 2D 14–21 mm; TT-TG 3D 11–18 mm; lateral trochlear inclination 13–23°; trochlear facet angle 43–65°. ConclusionThe demonstrated 3D analysis of the patellofemoral anatomy can be performed with high inter- and intra-observer correlation. Applying the obtained reference ranges and using existing 3D assessment tools for lower limb alignment, a preoperative 3D analysis and planning for complex knee procedures now is possible.

Computer-Aided Rhinoplasty Using a Novel “navigated” Nasal Osteotomy Technique: A Pilot Study

To describe the surgical technique of navigation-guided nasal osteotomies and assess feasibility of this technique for treating complex nasal bone deformities in reconstructive rhinoplasty. A retrospective chart review was performed in order to identify patients who underwent computer-aided rhinoplasty from August 2014 to February 2017. Inclusion criteria were nasal bone deformities on computed-tomography (CT) that correlated with specific nasal complaints. All patients underwent computer-aided rhinoplasty with navigation-guided nasal osteotomies using a standard navigation system. Osteotomies were performed using real-time visualization on the navigation screen. Additional soft tissue procedures were performed as needed. Medical records were reviewed for presenting symptoms, radiologic and operative findings, and postoperative course. Cosmetic outcomes were subjectively based on patients' standard 6-view photo-documentation from pre- and post-operative timepoints. Twenty-one patients were included in the study; 8 were revision cases and 3 had mild-to-moderate hemifacial microsomia. Fifteen were completely closed procedures. No cases were opened because of inadequate visualization or difficulty accessing bony pathology. Mean (range) follow up was 98.6 (6-559) days. There were no intra-operative complications, unplanned admissions or re-admissions, or iatrogenic cosmetic complications (ie, "inverted V" or "saddle nose" deformities). Two patients required revision. One was after suffering nasal trauma within 4 weeks of initial rhinoplasty. The second underwent further correction of a deformity that required a costochondral graft. Both experienced good final results. Computer-aided rhinoplasty is safe and feasible for treating complex nasal deformities using standard navigation systems.

Amputation Revision Surgery – Refining the surgical approach. Ten years of experience and 250 cases, impressions, outcomes, and thoughts for the future

Introduction: The decision for revision amputation surgery requires a multi-disciplinary approach and the evidence on outcome data available in the current literature is limited. The aim of this observational, retrospective study was to investigate in patients undergoing stump revision, whether factors such as pathology and reason for the revision surgery affect surgical ‘success’ rates as primary outcomes. Secondary outcomes of interest include rehabilitation outcomes and complication rates.Methods: From December 2008 to November 2018, 250 amputation revision procedures were performed at our centre. Surgical and rehabilitation outcomes and indication for revision surgery were measured for each patient.Results: There was an overall surgical success rate of 81% and an overall rehabilitation success rate of 63%, with variable outcomes related to the indication for surgery. Revisions for bony pathology had excellent results from a surgical perspective (100%) and good results from a rehabilitation perspective (71%). Revisions for soft tissue pathology and neuroma had satisfactory results from a surgical perspective (81% and 74% respectively) and rehabilitation perspective (56% and 71% respectively). Surgical success rates for those undergoing revision surgery due to non-neuroma pain were poor.Conclusions: We found that revision surgery for defined anatomical abnormalities, such as bone pathology or neuromata are associated with good outcomes. Surgical techniques, specifically related to the management of neuromas are continuing to develop, with promising results from the application of targeted muscle reinnervation (TMR) in the treatment of neuromata. The primary amputation surgeon should exercise caution when considering compromising bone length for soft tissue or skin coverage, as revision surgery can address the excision of skin graft or refashioning of the soft tissue envelope at a later stage. Careful patient selection is key to ensure we advocate offering our patients the right operation at the right time, for the right pathology.

Conventional Radiography and Ultrasound Imaging of Rheumatic Diseases Affecting the Pediatric Population

Juvenile idiopathic arthritis is the most frequent rheumatic disease in the pediatric population, followed by systemic lupus erythematosus, juvenile scleroderma syndromes, juvenile dermatomyositis, chronic recurrent multifocal osteomyelitis, and juvenile vasculopathies. The imaging approach to inflammatory connective tissue diseases in childhood has not changed dramatically over the last decade, with radiographs still the leading method for bony pathology assessment, disease monitoring, and evaluation of growth disturbances. Ultrasonography is commonly used for early detection of alterations within the intra- and periarticular soft tissues, assessing their advancement and also disease monitoring. It offers several advantages in young patients including nonionizing radiation exposure, short examination time, and high resolution, allowing a detailed evaluation of the musculoskeletal system for the features of arthritis, tenosynovitis, enthesitis, bursitis, myositis, as well as pathologies of the skin, subdermis, vessels, and fasciae. In this pictorial essay we discuss radiographic and ultrasound inflammatory features of autoimmune pediatric inflammatory arthropathies: juvenile idiopathic arthritis, lupus erythematosus, juvenile scleroderma, juvenile dermatomyositis and polymyositis.

Three-Dimensional (3D) Animation and Calculation for the Assessment of Engaging Hill–Sachs Lesions With Computed Tomography 3D Reconstruction

PurposeTo dynamically assess for Hill–Sachs engagement with animated 3-dimensional (3D) shoulder models.MethodsWe created 3D shoulder models from reconstructed computed tomography (CT) images from a consecutive series of patients with recurrent anterior dislocation. They were divided into 2 groups based on the perceived Hill–Sachs severity. For our cohort of 14 patients with recurrent anterior dislocation, 4 patients had undergone osteoarticular allografting of Hill–Sachs lesions and 10 control patients had undergone CT scanning to quantify bone loss but no treatment for bony pathology. A biomechanical analysis was performed to rotate each 3D model using local coordinate systems to the classical vulnerable position of the shoulder (abduction = 90°, external rotation = 0-135°) and through a functional range. A Hill–Sachs lesion was considered “dynamically” engaging if the angle between the lesion’s long axis and anterior glenoid was parallel. Results: In the vulnerable position of the shoulder, none of the Hill–Sachs lesions aligned with the anterior glenoid in any of our patients. However, in our simulated physiological shoulder range, all allograft patients and 70% of controls had positions producing alignment.ConclusionsThe technique offers a visual representation of an engaging Hill–Sachs using 3D-animated reconstructions with open-source software and CT images. In our series of patients, we found multiple shoulder positions that align the Hill–Sachs and glenoid axes that do not necessarily meet the traditional definition of engagement. Identifying all shoulder positions at risk of “engaging,” in a broader physiological range, may have critical implications toward selecting the appropriate surgical management of bony defects.Level of Evidencelevel III, case-control study.

Non-surgical management of central giant cell granuloma with calcitonin nasal spray in an 8-year-old patient: Radiographic presentation

The central giant cell granuloma (CGCG) presents as a benign, painless, slow-growing swelling of the jaw. These lesions are reported more frequently in females and most often occur in the mandible. Radiographically, it presents as a distinct delineated bony pathology with a loss of lamina dura around teeth. There can be frequent signs of displacement of teeth and tooth germs. Currently, the usually followed surgical treatment of the CGCG ranges from simple curettage to en -bloc resection. The extensive resection of aggressive and larger lesions inevitably results in the loss of teeth and tooth germs, especially in younger patients. Since, calcitonin has a direct inhibiting effect on osteoclasts and is efficient in controlling diseases with increased osteoclast activity, such as Paget’s disease, and osteoclastic bone metastases, hence serve as a promising alternative. This paper presents the effectiveness and safety of Calcitonin nasal spray, in the management of a CGCG of the jaw, in an 8-year-old patient who was given calcitonin as first-line therapy.

Prevalence and Grading of Rotator Cuff and Labral Injuries in Shoulder Pain and Instability using MRI: ACross-sectional Study

Introduction: Shoulder joint is a highly mobile joint but is prone for rotator cuff injuries and dislocations. It is necessary to accurately diagnose rotator cuff and labral injuries so that appropriate plan of action for treatment can be taken. Magnetic Resonance Imaging (MRI) can be used to diagnose and describe the extent of rotator cuff tendon and labral injuries and any secondary rotator cuff muscle abnormalities. Aim: To study the demographic profile of patients presenting with shoulder pain and instability, identify the various rotator cuff injuries causing shoulder pain, identify the rotator cuff interval lesions causing microinstability, identify the various labral and bony pathologies in instability, describe the MRI features of the rotator cuff, rotator cuff interval, labral and bony injuries. Materials and Methods: This study was a cross-sectional study of patients with symptoms of either shoulder pain or instability who underwent MRI evaluation of the shoulder in the Department of Radiodiagnosis, Rajarajeswari Medical College and Hospital, Bengaluru, Karnataka, India, from July 2018 to December 2020. The study population consisted of 54 patients with either shoulder pain or instability who underwent MRI of shoulder. All the MRI scans of the shoulder in this study were performed using 1.5 Tesla Siemens Magnetom Avanto (Tim 76x18) MR machine using a flex coil. Results: The study population consisted of 54 patients comprising of 38 males and 16 females. The age of the patients ranged from 20-77 years. Majority of the patients were older than 50 years constituting about 33.33% of the total study population. Rotator cuff injury was the commonest cause of pain. Tendinosis was the commonest type of rotator cuff injury followed by partial-thickness and full-thickness tendon tears. The commonest grade of tendinosis was mild or grade 1. Supraspinatus tendon was the most commonly affected tendon followed by subscapularis and infraspinatus tendons. Teres minor tendon was normal in all the cases. Anterior instability was the commonest type of instability with equal prevalence of soft tissue Bankart, bony Bankart and Perthes lesions. Biceps pulley lesions resulted in long head of biceps tendon instability, microinstability and internal impingement. Conclusion: Rotator cuff injuries are the commonest cause of shoulder pain and are seen more frequently after the fifth decade. Shoulder instability is most commonly seen in young male adults. Tendinosis is the commonest type of rotator cuff injury. Supraspinatus tendon is the most commonly injured tendon. Anterior instability is the commonest type of shoulder instability. Biceps pulley lesions result in long head of biceps tendon instability, microinstability and internal impingement. MRI can diagnose interstitial or intrasubstance tendon tears which are not visualised on arthroscopy. MRI description of tendon and labral tears, tendon retraction and muscle atrophy can guide the orthopaedician during arthroscopy and in treatmentplanning.

Natural stain (Kumkum) formulated by the extract of Curcuma aromatica and slaked lime in histostaining of oral tissues: An observational study.

Background:The pharmacological actions of Curcuma aromatica (wild turmeric) such as anti-inflammatory, antitumor, antifungal, antimicrobial and wound healing have been recognized since ages. However, its role as a natural histological stain has not been explored till date.Aim:To evaluate the efficacy of natural substance-Kumkum prepared from the extract of C. aromatica and slaked lime in staining the biopsied oral tissuesMaterials and Methods:A cohort study that used 60 formalin fixed paraffin embedded soft and hard tissue specimens from institutional archives were subjected to sectioning and stained using Kumkum and hematoxylin and eosin (H and E). The slides were evaluated for their staining efficacy and results were statistically analyzed using Wilcoxon signed-rank test and Independent 't' test.Results:The mean of the overall parameters assessed for staining efficacy did not show statistically significant difference between the study groups in normal and pathological specimens for tooth (P = 0.410 and 0.484), bone (P = 0.133 and 0.157) and soft tissues (P = 0.186 and 0.113), respectively. This suggests that Kumkum staining efficacy is equivalent to that of routine H and E for oral tissues. Structures such as dentinoenamel junction, dentinal tubules, incremental lines of cementum, reversal and resting lines, osteocytic canaliculi, mature and immature bone could be appreciated better in Kumkum stained slides, thereby rendering a special staining property to Kumkum stain.Conclusion:To our knowledge, this study is the first of its kind to have used Kumkum stain obtained from C. aromatica for the differentiation of the components of tooth, bone and soft tissue structures in histostaining of oral tissues. The naturally prepared Kumkum stain possesses dual staining property both in routine and differential staining. This facilitates diagnosis of fibro-osseous lesions, bony, collagen and muscular pathologies. The natural stain also finds application in forensic odontology for age estimation.

Arthroscopic Anatomic Glenoid Repair Using Distal Tibial Allograft and an Inferior-to-Superior Capsular Shift

Traumatic anterior dislocation of the shoulder accounts for the vast majority of shoulder dislocations. Recurrence following initial traumatic dislocation is common, and the risk is increased by the presence of both bony and soft-tissue damage. Arthroscopic procedures have been described to address each of these etiologies individually but have not provided a technique to address bony and soft tissue pathology concurrently. This paper describes an all-arthroscopic, anatomic glenoid repair using distal tibial allograft with an inferior-to-superior capsular shift, addressing significant glenoid bone loss and capsular laxity with a single operation.