Long Bones Of Lower Limbs Research Articles

Bone Transport through Induced Membrane Technique versus Conventional Bone Transport Technique in Management of Bone Defects of Lower Limbs

Abstract Objectives To assess whether Bone transport through induced membrane (BTM) has better outcomes regarding docking site union and infection recurrence than conventional bone transport (BT) or not in the treatment of infected lower limb long bones defects. Methods A prospective randomized controlled study in a single institution was conducted. A total of 30 patients with infected non united fractures of long bones of lower limbs were divided into 15 patients (10 femurs, 5 tibias) treated by BTM and 15 patients (3 femurs,12 tibias) treated by BT. The outcome measures includes external fixation time (EFT), external fixation index (EFI), docking time (DT), bone and functional outcomes evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, postoperative complications evaluated by Paley classification and number of additional operations. Results The mean docking time (DT) was significantly lower in BTM group in comparison to BT group (3.67 ± 0.82 months vs 4.80 ± 0.86 months respectively) (p value 0.001). Docking site nonunion and infection recurrence were significantly lower in BTM group in comparison to BT group (0% vs 40% respectively) (p value 0.02) and (0% vs 33.3% respectively) (p value 0.04). Mean number of additional operations per patient was significantly lower in BTM group in comparison to BT group (0 vs 0.80 ± 1.08 operations respectively) (p value 0.01) Conclusion Both BTM and BT achieved satisfactory postoperative bone and functional outcomes in patients with infected long bones defects of lower limbs, while BTM had significantly faster docking site union, lower incidence of postoperative complications including docking site nonunion and infection recurrence rates and lower number of additional operations needed at the expense of 2 staged procedure in comparison to BT.

Small cell osteosarcoma: An NCDB analysis of demographic and socioeconomic factors of diagnosed patients.

e23504 Background: Small cell osteosarcoma (SCOS) is a rare subtype of osteosarcoma accounting for roughly 1.5% of all osteosarcomas. Its prognosis is slightly worse than conventional osteosarcoma. Exploring demographic trends in patients with a confirmed SCOS diagnosis may provide insight into its epidemiology and allow for earlier diagnosis. The National Cancer Database (NCDB) was analyzed to research the demographic factors in patients diagnosed with SCOS. Methods: A retrospective cohort analysis utilizing the 2004–2020 National Cancer Database (NCDB) included patients with a histologically-confirmed diagnosis of SCOS (ICD-O-3 9185). Demographic factors (age, sex, race, Hispanic status, educational attainment, insurance status, facility type, distance from facility, and Charles-Deyo score) were analyzed via descriptive statistics. Incidence trends were interpreted in regression analysis. The mean survival was compared using the Log Rank (Mantel-Cox) test. Results: A cohort of 102 cases of SCOS were retrieved from the NCDB between 2004–2020. The primary sites for SCOS were the long bones of the lower limb (41%). Most patients were male (69%), White (63%), non-Hispanic (84%) with a mean age for diagnosis of 28 (SD = 18). The mean survival for males was 117 months (95% CI [93,141]), more than twice as long as females with 58 months (95% CI [31,85]). The Log Rank (Mantel-Cox) test reported a chi-square (χ²) value of 6.434, indicating a statistically significant difference between survival curves of males and females (p = 0.01). Residence in a metropolitan area (86%) was more common than other rural or urban areas. The greatest proportion of patients lived in the Middle or South Atlantic region of the United States (68%). The majority of patients were insured (86%), with the most covered by private insurance (64%) or Medicaid (22%). The median household income for each patient was most commonly in the highest quartile of over $74,063 (29%). Patients were diagnosed with SCOS at a steady rate between 2004 to 2020 (R² = 0.0956). Using the AJCC Cancer Staging System, most patients were Stage II (40%) or Stage IV (21%) at diagnosis. As a primary treatment, 87% of patients received chemotherapy. Most patients (91%) had no comorbidities with a Charlson-Deyo score of 0. Conclusions: This is the first time that demographic and socioeconomic factors of SCOS patients have been analyzed from the NCDB, revealing that the mean survival time of patients after receiving a diagnosis was more than double for males than females. SCOS patients are also more likely to live in metropolitan areas, particularly within the Middle or South Atlantic United States. Consistent with earlier reports, SCOS is typically diagnosed in young adults in the long bones of lower limbs. To better understand the impact of demographic factors on the diagnosis, treatment, and overall survival of patients with SCOS, further research is recommended.

Analysis of demographic and socioeconomic factors in adamantinoma using data from the National Cancer Database (NCDB).

e23501 Background: Adamantinoma is a rare low-grade primary malignant bone tumor accounting for less than 1% of all malignant bone tumors. It largely presents in the tibia of young adults, is locally aggressive, and can metastasize. Definitive diagnosis is primarily established by histopathological examination. This rare tumor with uncertain histogenesis remains under-studied. Therefore, exploring trends in diagnoses may provide insight into its epidemiology. The National Cancer Database (NCDB) was examined to reveal the demographic factors in patients diagnosed with Adamantinoma. Methods: A retrospective cohort analysis utilizing the 2004–2020 NCDB included 206 patients with a histologically-confirmed diagnosis of adamantinoma (ICD-O-3 Code 9261). Demographic factors such as age, sex, race, Hispanic status, insurance status, facility type, distance from facility, and Charlson-Deyo score were analyzed via descriptive statistics. Trends in incidence were interpreted using regression analysis. Results: A total of 206 patients were identified in the NCDB with a confirmed diagnosis of adamantinoma of long bones between 2004-2020. Incidence remained relatively stable over this time period (R² = 0.009). The most common primary site of diagnosis were the long bones of lower limb and associative joints (97%). Most individuals (88%) had a Charlson-Deyo comorbidity score of 0. The majority of patients (66%) were classified as Stage 1 AJCC staging. Men were more likely to be diagnosed (56%) compared to women (44%). Most patients were White (78%) and non-Hispanic (85%). A higher percentage of patients were privately insured (67%) and lived in metropolitan areas (87%). Treatment facilities primarily were academic programs (74%). Almost all of the patients were treated surgically (92%) with the most common approach being lymph node dissection (61%) more so than local tumor excision or removal of adjacent organs. Following surgery, the patients observed had a very good prognosis, with a 99% ninety-day survival, a 93% five-year survival, and an 89% ten-year survival. Conclusions: Adamantinoma has a risk for recurrent and metastatic disease. This first NCDB analysis on adamantinoma’s demographics addresses a significant knowledge gap on this topic. The primary site of diagnosis were lower extremity long bones, most commonly treated with surgical intervention, and had a high survival rate which is consistent with earlier studies. The majority of patients included in this study tend to be White, non-Hispanic, and privately insured. This may suggest a demographic and socioeconomic factor that plays a part in diagnosis, prognosis, and treatment of individuals with adamantinoma. Future research should focus on the understanding of factors that impact the course of one’s health and the etiology of this rare pathology.

Variability of BMP-2 content in DBM products derived from different long bone.

Demineralized bone matrix (DBM) has been regarded as an ideal bone substitute as a native carrier of bone morphogenetic proteins (BMPs) and other growth factors. However, the osteoinductive properties diverse in different DBM products. We speculate that the harvest origin further contributing to variability of BMPs contents in DBM products besides the process technology. In the study, the cortical bone of femur, tibia, humerus, and ulna from a signal donor were prepared and followed demineralizd into DBM products. Proteins in bone martix were extracted using guanidine-HCl and collagenase, respectively, and BMP-2 content was detected by sandwich enzyme-linked immunosorbent assay (ELISA). Variability of BMP-2 content was found in 4 different DBM products. By guanidine-HCl extraction, the average concentration in DBMs harvested from ulna, humerus, tibia, and femur were 0.613 ± 0.053, 0.848 ± 0.051, 3.293 ± 0.268, and 21.763 ± 0.344, respectively (p < 0.05), while using collagenase, the levels were 0.089 ± 0.004, 0.097 ± 0.004, 0.330 ± 0.012, and 1.562 ± 0.008, respectively (p < 0.05). In general, the content of BMP-2 in long bones of Lower limb was higher than that in long bones of upper limb, and GuHCl had remarkably superior extracted efficiency for BMP-2 compared to collagenase. The results suggest that the origin of cortical bones harvested to fabricate DBM products contribute to the variability of native BMP-2 content, while the protein extracted method only changes the measured values of BMP-2.

Ghosal Hematodiaphyseal Dysplasia: Implications of Late Diagnosis and Unusual Presentation in Adults

Ghosal Hematodiaphyseal Dysplasia (GHDD) is a rare autosomal recessive disorder characterized by bone modeling failure, resulting in thickening of bone cortices with predominant diaphyseal involvement and responsive anemia to steroids. Late diagnosis of GHDD in adulthood can lead to significant morbidity and suboptimal response to steroids. Moreover, GHDD often mimics more common hematological disorders like myelodysplastic syndrome and myelofibrosis, leading to treatments such as transfusions, splenectomy, and hematopoietic stem cell transplantation. Early diagnosis is critical to enable the patient to receive the appropriate treatment. We present a case series of three Indian patients from different families with genetically proven GHDD. Despite experiencing symptoms from early childhood, all patients were diagnosed in adulthood. None of them were born out of a consanguineous marriage . Two of them, aged 43 and 56, are the oldest reported GHDD patients to date. They initiated steroid treatment in their 5th and 6th decades of life, respectively. Unlike previously reported cases, these two patients required additional drugs like Thalidomide along with steroids, and their response to treatment was not as rapid. The first patient, a 43-year-old male, had a history of anemia since childhood and became transfusion dependent after 15 years of age. He developed bicytopenia and later pancytopenia with hypocellular bone marrow , along with splenohepatomegaly and extramedullary hematopoiesis in the paravertebral and presacral areas, a novel finding in GHDD cases. Whole exome sequencing revealed a missense mutation in the TBXA2 gene. The second patient, a 56-year-old male, had a history of anemia since childhood and underwent splenectomy at 46 due to massive splenomegaly and transfusion dependency. However, his transfusion dependency persisted, and bone marrow biopsy suggested myelofibrosis. However he was negativefor myeloid mutations including JAK2. Subsequently, genetic testing revealed a homozygous missense mutation in the TBXAS1 gene. He also developed paraplegia and bladder incontinence, attributed to extramedullary hematopoiesis, which improved with steroid treatment The third patient a 23 year old man with history of anemia, lower limb tenderness and ecchymosis at 14 months of age. Evaluation then had shown hyperostosis of diaphysis of long bones of lower limbs with sparing of metaphysis and bicytopenia. Was on regular transfusions till 9 years. Re-evaluation with bone marrow studies at 9 years revealed a varying cellular marrow with dysplastic megakaryocytes and diagnosed as pediatric myelodysplatic syndrome ,He was on steroids till 13 years and he did not require further transfusions.He stopped steroids for 1 year following which there was a fall in Hb levels and recurrence of pain in both lower limbs with inability to squat. In view of history of steroid responsive anemia and thickening of diaphysis in X-rays GHDD was suspected and confirmed by genetic testing. He was restarted on steroids and there was a good response to steroids within 4 week with normalisation of hemoglobin levels . Late diagnosis of GHDD in adulthood can lead to severe complications and suboptimal treatment response. These cases highlight the importance of early diagnosis to prevent unnecessary interventions and improve patient outcomes. Unusual presentations, like extramedullary hematopoiesis, can further complicate the diagnostic process. Clinicians should maintain a high index of suspicion for GHDD in cases of refractory anemia or myelofibrosis-like features, especially in adults with an earlier history of anemia. Early recognition and appropriate management are crucial to mitigate morbidity and improve patients' quality of life

Hemilateral bone longitudinal transport technique for the treatment of hemilateral defects of long bones of lower limbs

To explore clinical efficacy of Ilizarov hemilateral bone longitudinal transport technique in treating hemilateral bone defects associated with chronic osteomyelitis of lower extremity long bones. Clinical data of 13 patients with hemilateral bone defects caused by chronic osteomyelitis of lower extremity long bones and treated by Ilizarov hemilateral bone longitudinal transport technique were retrospective analyzed, including 10 males and 3 female, aged from 14 to 55 years old;4 patients occurred femoral and 9 patients occurred tibial;10 patients were diagnosed as traumatic osteomyelitis and 3 patients as hematogenous osteomyelitis. The anatomical classification of Cierny-Mader in 13 patients was type Ⅲ. Bone and wound healing, postopertaive complication, and bony and functional results were observed by Paley evaluation standard. After removing external fixator, all patients were followed up from 6 to 70 months. Transporting time ranged from 54 to 158 d. And the time in external fixation ranged from 6.8 to 19.5 months. External fixation index (EFI) ranged from 1.23 to 1.6 months/cm. According to Paley's evaluation criteria, bony results were excellent in 13 patients;functional results showed excellent in 12 patients and good in 1 patient. Two patients occurred poor union on the docking sites and healed with autogenous iliac bone graft. The callus at the extended area was poorly mineralized and improved significantly when treated with low-intensity pulsed ultrasound in one patient. All patients had good wound healing without recurrence of osteomyelitis and refracture. There was no vascular and nerve injury and axial deviation in all patients and they were satisfied with the appearance and function of lower limbs. The range of motion of knee and ankle joint before operation was 120 ° to 150 ° and 35 °to 80 ° respectively, and at the latest follow-up was 110 ° to 140 ° and 30 ° to 75 ° . Ilizarov hemilateral bone longitudinal transport technique is effective in treating infective hemilateral bone defects of lower extremity long bones, which could not only simplify architecture of external fixation, but also reduce the number of fixation pins, shorten the time in external fixator and decrease the incidence of pin tract infection. However, this technique is highly demanding, and the growth of callus in extended region and healing of bone apposition should be noticed.

Familial Incomplete Hypertrophic Osteoarthropathy: A Rare Disorder

Dear Editor, Hypertrophic osteoarthropathy is a condition in which there is abnormal proliferation of skin and soft tissue, particularly around the periosteal tissues. It is a very rare condition which is mainly described as two types, in which the common form is secondary hypertrophic osteoarthropathy caused by underlying disease and the rare primary idiopathic form. Here, we present a case of incomplete familial form of hypertrophic osteoarthropathy where a young male presented with multiple joint pains and Grade 4 clubbing and large patella. A 24-year-old male presented with multiple joint pains predominantly involving both knees, elbows, and shoulders. There was no history of any joint swelling or morning stiffness. There was no other history suggestive of connective tissue disorder. On examination, Grade 4 clubbing was present [Figure 1]. Systemic examination was unremarkable. Musculoskeletal (MSK) examination revealed a significantly large patella on both sides [Figure 1]. There were no signs of inflammation. On further probing, the patient gave a history of similar clubbing and joint pains for his sister, brother, and grandfather. His father also has similar complaints but with less severity (pedigree charting below mentioned) [Figure 2]. On investigations, blood counts and liver and kidney function tests were normal. C-reactive protein was negative. Thyroid profile was normal. To rule out acromegaly, growth hormone levels and magnetic resonance imaging brain were done which were normal. X-ray hands and both knees were done suggestive of periostosis. MSK ultrasonography of the knees was done suggestive of zigzag appearance of the patella [Figure 3]. A diagnosis of incomplete familial hypertrophic osteoarthropathy was made as there was no skin thickening and no coarse facial features and no other systems such as hematological or endocrine are involved. He was prescribed etoricoxib, and on follow-up, he was symptomatically better. Genetic testing was not done in our patient as he is not willing for that.Figure 1: Digital clubbing with large patellaFigure 2: Pedigree chart showing affected individuals in three generationsFigure 3: X-ray showing periosteal reaction involving the terminal phalanges, both bones of forearm, and long bones of lower limbs. USG image showing Zigzag appearance of the patella. USG: UltrasonographyPrimary or idiopathic form of hypertrophic osteoarthropathy is very rare and constitutes only 2%–3% of cases. It is inherited as autosomal dominant or recessive disorder, and it was thought to be caused by impaired metabolism of prostaglandin E2.[1] Pachydermoperiostosis is an another name given to this disorder due to the presence of coarse facial features with underlying thickening and furrowing of skin.[2] If both skin involvement and periosteal components are present then it is called complete form. The other two forms are incomplete with prominent periosteal with less skin involvement (like our case) and fruste form with more skin features and less periosteal features. The diagnostic criteria for PDP (pachydermo-periostosis) include major criteria and minor criteria. Major consists of pachyderma, periostosis, and finger clubbing and minor criteria includes hyperhidrosis, arthralgia, gastric ulcer, cutis verticis gyrata, blepharoptosis, joint effusion, edema, seborrhea, acne, and flushing.[3] Endocrine disorders like acromegaly, hypothyroidism, acropathy and other conditions like multifocal periostitis to be ruled out before labeling this condition. The other mimic of this condition is psoriatic onycho-pachydermo-periostitis except for the presence of psoriatic lesions.[4] Nonsteroidal anti-inflammatory drugs are the main stay of treatment as they act by blocking prostaglandin synthesis. They can have a good prognosis and normal life span.[5] Other treatment modalities available are corticosteroids, colchicine, or bisphosphonates.[6] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A comparative study between bone transport technique using Ilizarov/LRS fixator and induced membrane (Masquelet) technique in management of bone defects in the long bones of lower limb.

In earlier times due to difficulty in managing segmental long bone defects, amputation was the preferred treatment. Nonunion with bone loss of long bones is a challenging problem, requiring serious attention. Post-traumatic segmental bone defects can have severe long-term ill impact on patient's lives. Reconstruction is more difficult and functional outcome is usually less satisfactory compared to bony outcome. Distraction osteogenesis and induced membrane technique are the techniques that can be used. To find out and compare clinical, radiological, and functional outcome of bone transport technique and induced membrane technique in management of bone defects in the long bones of lower limb. A comparative study was conducted on 24 patients (22 males and 2 females) of lower extremity fractures with bone defect more than 3 cm. Patients were divided into two groups according to the method of reconstruction used, that is, either bone transport technique in 12 patients (group A) or masquelet in the other 12 patients (group B). The mean age of the patients was 44 years in group A and was 38 years in group B. Regular follow-up was done with a mean period of follow up of 18.35 ± 5.58 months in group A and 18.25 ± 3.95 months in group B. In group A (bone transport), 67% showed union, 25% showed union with bone graft and 8% showed delayed union. In group B (masquelet), 75% showed union and 25% showed delayed union. bone transport technique showed excellent results in 58.3% and good in 41.7% while Masquelet technique showed excellent result in 50% and good in 50%. For an orthopaedic surgeon, long bones defects with a substantial loss of bone volume are one of the most challenging bone defects encountered in clinical practice. Induced membrane technique and bone transport both offer successful options for filling of bone defects. Both techniques have its own pros and cons and provide varied option for healing. In our study, both methods have comparable results statistically although induced membrane technique required soft tissue reconstructive procedures.

Variations in nutrient foramen in the long bones of lower limb

Morphology and morphometry of nutrient foramen of bones vary from country to country and from place to place. Objective was to study the number, position, location, directions, distance of nutrient foramen from the proximal end of femur, tibia and fibula in eastern Indian region. In a descriptive study, 393 bilateral lower limb long bones (138 femur, 132 tibia &amp; 123 fibulae) were studied. Total nutrient foramen calculated; 178 in femur, 137 in tibia, 121 in fibula. Most had single foramen; femur (66%), tibia (96%) and fibula (94%). Number of foramina ranged from 0-3 in femur, 1-2 in tibia and 0-2 in fibula. Foramina were present mainly on the posterior surface of the bones [linea aspera in femur (96), below soleal line and lateral to the vertical line in tibia (90) and peroneal crest in fibula (74)]. The mean length, mean distance of nutrient foramen from the proximal end of the bones measured. Most foramina found on the middle third, with foraminal index ranging from 33% to 66%; though on tibia it’s not a common finding. The 't' test value of foraminal index was significant for tibia. Mean foraminal index was measured for femur 42.28%, tibia 35.91%, fibula 41.54%. The knowledge of anatomical variations of nutrient foramen is very important as preservation of vascularization of long bones is essential in fracture repair, tumor resection, bone grafting.

D1 MTE1 Case 3: A hypogonad with weak bones

A 22 years old male, one of the identical twin brothers, born out of 3rd degree consanguinity, presented with delayed dentition, ASD closure in childhood, multiple surgeries for recurrent fractures of long bones of lower limbs, correctional surgery for genu valgum, renal stones, delayed puberty and with similar history in his twin brother. On examination he was pale, had synophrys, hypotelorism, micrognathia, gynecomastia Tanner B3, A+, P2, SPL of 5cm and bilateral TV < 2 ml. Investigations revealed anemia, hypokalemia (K 3.1 mEq/L), hypophosphatemia and elevated alkaline phosphatase (PO4 1.26 mg/dl, calcium 8.7 mg/dl, ALP 450 U/L, Vit D 37 ng/ml, iPTH 32 pg/ml), normal urea and creatinine and hypergonadotrophic hypogonadism with 46 XY karyotype (FSH >150 mIU/ml, LH 106 mIU/ml, Total testosterone 0.15 ng/ml).

Surgical and functional outcomes of infective non union of femur and tibia using ilizarov ring fixator

Introduction: Nonunion of long bone fractures is a common condition encountered by an orthopedic surgeon in daily practice. For effective treatment of nonunion, internal fixation with or without bone grafting can be done but, an infected non union can prove to be a tough challenge. The aim of our study is to assess the surgical and functional outcomes of infected nonunion of femur and tibia treated with debridement, corticotomy and Ilizarov ring fixator. Materials and Method: This was a multi-centric prospective study of twenty patients in a time span of three years from May 2017 till April 2020. Observations and Results: Patients were assessed using clinical and functional results as per Association for the Study and Application of Methods of Ilizarov (ASAMI) Scoring System. Conclusion: The Ilizarov method remains one of the most successful and versatile means of achieving bone-healing in infected nonunion of long bones of lower limbs with benefits of correcting deformities, bone defects and limb length discrepancy.

Erdheimova-Chesterova choroba – kazuistika

Summary Erdheim-Chester disease (ECD) belongs to the malignant polyostotic sclerotic forms of non-Langerhans histiocytosis. During abnormal prolipheration of pathologic histiocytes (foam cells), involved structures become hypertrophic with increased density followed by scarring. Mostly the diaphysis and metaphysis of long bones of lower limbs with typical pain are involved. According to the WHO, the disease is classified as histiocytic neoplasia. We refer on a 74-year-old female patient with expansive process in the region of upper clivus and sphenoidal bone on the right side. Histological testing confirmed this very rare disease that affects about 600 patients over the world. Key words Erdheim-Chester – foamy histiocytes – sclerosis – fibrosis

ANTHROPOMETRIC STUDY OF FEMUR IN SOUTH INDIA

Background: Anthropometry provides scientic method and technique for taking various measurements in different geographic regions and races. The femur is the weight bearing typical long bone of lower limb which extends from the pelvis to the knee. The anatomical knowledge of different dimensions of femur specially head and neck of the femur is very essential in anthropological and medico-legal practice for sex determination and as well as to radiologists, rheumatologists and orthopaedic surgeons for diagnosis and planning of treatment. Objectives: The objectives of present study to nd out the measurements of Platymeric index,Robusticity index and Foraminal index. Materials And Methods: In present study have used 250 femurs from different colleges in south India. The following measurements were conducted Platymeric index, Robusticity index and Foraminal index for both right and left femur. Results: The results of present study are the Physiological length of left femur was 44.15+2.35 and right was 43.98+2.15, the Rubusticity index of left femur was 15.26+1.17 and right was 14.34+1.21the Platymetric index of left femur was 85.70+6.35 and right was 86.32+6.15, the Foraminal index of left femur was between 37-65% and right was 35-62%. Conclusion: The present study shows that there is signicance different in between right and left femurs measurements. The anatomical knowledge of different dimensions of femur is very essential in anthropological and medico-legal practice for sex determination and as well as to radiologists, rheumatologists and orthopedic surgeons for diagnosis and planning of treatment.

Study on the Nutrient Foramen of Long Bones of Lower Limb

Study on the Nutrient Foramen of Long Bones of Lower Limb

Osteoid Osteoma in Talus: Our Experience in Radioguided Surgery

The osteoid osteoma (OO) is the third most frequent benign bone tumor, whose location is more frequent in long bones of lower limbs. Its presence in the distal lower limb is uncommon, with the talus the most common reported location. Surgical treatments with radioguided surgery of OO of foot and ankle in our hospital were reviewed. We present a retrospective cohort study of 4 patients with clinical and radiologic findings suspicious OO with at least 1 year of follow-up. We used radioguided surgery for surgical resection after the injection of a dose of 99mTc-hydroxydiphosphonate. The nidus was located with the help of a portable gamma camera and gamma detection probe, concluding the surgical resection when its activity decreased to the levels present in healthy tissues. Samples were sent for pathologic anatomy for further examination. Lesions were localized in all patients. The cure rate, based on the absence of relapse of symptoms, was 100%. On the basis of our experience and on the available literature, we suggest that radioguided surgery is an effective and safe method for the treatment of OO in the foot and ankle. Although radiofrequency ablation is the first choice treatment for OO, radioguided surgery offers a number of advantages: an accurate delimitation of the nidus, allowing a more precise excision of the lesion; a decrease in postoperative complications; and the possibility of confirmation in histopathologic studies. Because of the small number of cases, a multicenter study could be useful to increase the number of cases and therefore provide more evidence to this type of treatment. Level of Evidence: Level V. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Wear of Milling Cutters for Drilling of Nail Holes Used for Osteosynthesis of Long Bones of Lower Limbs

Abstract This paper deals with wear of intramedullary milling cutters for the drilling of nail holes used for osteosynthesis of lower limbs long bones. After the physician’s complaints about the increasing resistance and total change of its properties that are caused by the reuse the instrument, we have designed a suitable methodology to verify and quantify this problem. The experiment was carried out on three types of milling cutters, differing in their diameter. Using statistical tests, we compared pressure force and torque before and after wear.

Study of Nutrient Foramina in Human Typical Long Bones of Lower Limb

Abstract Background and Aim Nutrient foramina form important landmarks on human bones as they form portal of entry for nutrient artery. Nutrient artery is an important source of blood supply for a growing bone. Different parameters of nutrient foramina are important in various procedures such as vascularized bone grafting, tumor resections, fracture repair, and other surgical procedures in orthopedics. The objective of the present study was to report the number, position, direction, size, and foraminal index of nutrient foramen in the femur, tibia, and fibula. Materials and Methods The present study analyzed the location, direction, size, and the number of nutrient foramina in the diaphysis of 180 long bones of the lower limbs of adults: 60 femurs, 60 tibiae, and 60 fibulae. Result The location of the nutrient foramina is predominant on the posterior aspect of the lower limb long bones. Single nutrient foramen found in the tibia (100%), femur (48.3%), and fibula (60%) may represent as a single source of blood supply. The majority of the femur (50%) and few fibulae (5%) had a double nutrient foramen. The mean foraminal index for the lower limb bones was 40.5% for the left and 38.2% for the right side of the femur, 31.69% for the left and 32.3% for the right side of the tibia, and 32.7% for the left and 31.7% for the right side of the fibula. Conclusion The present study provides information on the number, size, position, and direction of nutrient foramina of the femur, tibia, and fibula bones.

Detecting reasons for recurrent deformity in treatment of patients with vitamin D–resistant rickets using diagnostic imaging

PurposeTo assess age related manifestations of the femur and tibia in patients with vitamin D-resistant rickets (VDR) and explore causes for recurrent deformity using imaging modalities. MethodsComputed tomography (CT), magnetic resonance imaging (MRI) and dual energy X-ray densitometry (DEXA) were used to assess conditions of long bones of lower limbs in patients with vitamin D-resistant rickets aged from 4 years to 30 years preoperatively and after limb lengthening. ResultsAge related MRI findings showed specific structure of the femur and tibia in patients with VDR preoperatively and after operative treatment. Abundant irregular osteoid formed in femoral and tibial physes was shown to reveal complicated nature of bone deformity causing recurrence in patients with VDR at childhood. CT findings allowed us to detect early cortical injury, measure its length with forming Looser's zones, examine significant differences in density measurements of Looser's zones preoperatively and after deformity correction using transosseous osteosynthesis. ConclusionRecurrent deformity can develop in patients with VDR due to progression of the disease, irregular osteoid deposited in the medial and lateral metaepiphysis, osteoid area measuring over 50% of epiphyseal cross section, insufficient regenerate mineralization, and formation of Looser's zones.

Use of flexible intramedullary nailing in treating diaphyseal fractures of long bone of lower limb in children

Background: Management of diaphyseal fractures of long bones of the lower limb in the age group of preschool to early teenage has multiple methods of treatment ranging from conservative management to internal fixation using open/closed reduction methods. Objective: The study was performed to know the potential of using principles of intramedullary nailing in treating diaphyseal fractures of long bones of the lower limb in preschool to early teenage population. Materials and Methods: Patients with diaphyseal long bones fractures of tibia and femur in between the age group ranging from 5 to 14 years were treated by closed reduction and internal fixation using titanium elastic nailing system (TENS) nail. The results were evaluated on the basis of radiological signs of union and Flynn's criteria. The average time after which surgery was done is 2 days. Results: Of 14 patients, eight patients had diaphyseal femur fracture and remaining six had diaphyseal tibia fracture treated by TENS nailing.Thirteen patients achieved union in a mean time of 8 weeks with full-weight-bearing in around 10 weeks. The average time duration of hospital stay was 6 days and follow-up period was up to 24 weeks. Conclusion: The use of flexible intramedullary nailing in properly selected patients in the preschool to early teenage population is an effective method of treating diaphyseal fractures of long bones of the lower limb.

Expression and functional proteomic analyses of osteocytes from Xenopus laevis tested under mechanical stress conditions: preliminary observations on an appropriate new animal model.

Hitherto, the role of the osteocyte as transducer of mechanical stimuli into biological signals is far from settled. In this study, we used an appropriate model represented by the cortex of Xenopus laevis long bone diaphysis lacking (unlike the mammalian one) of vascular structures and containing only osteocytes inside the bone matrix. These structural features allow any change of protein profile that might be observed upon different experimental conditions, such as bone adaptation to stress/mechanical loading, to be ascribed specifically to osteocytes. The study was conducted by combining ultrastructural observations and two-dimensional electrophoresis for proteomic analysis. The osteocyte population was extracted from long bones of lower limbs of amphibian skeletons after different protocols (free and forced swimming). The experiments were performed on 210 frogs subdivided into five trials, each including free swimming frogs (controls) and frogs submitted to forced swimming (stressed). The stressed groups were obliged to swim (on movable spheres covering the bottom of a pool on a vibrating plate) continuously for 8 h, and killed 24 h later along with the control groups. Long bones free of soft tissues (periosteum, endosteum and bone marrow), as well as muscles of posterior limbs, were processed and analyzed for proteins differentially expressed or phosphorylated between the two sample groups. The comparative analysis showed that protein phosphorylation profiles differ between control and stressed groups. In particular, we found in long bones of stressed samples that both Erk1/2 and Akt are hyperphosphorylated; moreover, the different phosphorylation of putative Akt substrates (recognized by specific Akt phosphosubstrates-antibody) in stressed vs. control samples clearly demonstrated that Akt signaling is boosted by forced swimming (leading to an increase of mechanical stress) of amphibian long bones. In parallel, we found in posterior limb muscles that the expression of heat shock protein HSP27 and HSP70 stress markers increased upon the forced swimming condition. Because the cortexes of frog long bones are characterized by the presence of only osteocytes, all our results establish the suitability of the X.laevis animal model to study the bone response to stress conditions mediated by this cell type and pave the way for further analysis of the signaling pathways involved in these signal transduction mechanisms.