Periosteal New-bone Formation Research Articles

Medieval monastic health: Variation in skeletal signs of inflammation and developmental stress between religious orders in London.

Previous bioarchaeological analyses of medieval monastic and nonmonastic cemeteries in London revealed evidence of lower risks of mortality, and thus better health, in the monastic settings. However, comparison of the two monastic communities, Bermondsey Abbey and Merton Priory, which adhered to different religious ideals, suggested lower risks of mortality in the former. This study examines patterns of skeletal biomarkers, which reflect developmental stress or inflammation, in an attempt to clarify the possible underlying mechanisms producing apparent health differences in these monastic communities. This study uses skeletal data on age-at-death, periosteal new bone formation (PNBF), and cribra orbitalia from 558 adults (18 years of age and older) estimated to be male from Bermondsey Abbey and Merton Priory. Biomarker age patterns are assessed via Kaplan-Meier survival analysis and binary logistic regression. Differences in frequencies of biomarkers between the monastic sites are evaluated using Chi-square and hierarchical log-linear analyses. In general, PNBF is positively associated with age, and cribra orbitalia is negatively associated with age. The frequency of PNBF formation is significantly higher and that of cribra orbitalia is significantly lower in Bermondsey Abbey compared with Merton Priory. The differences in frequencies of these skeletal biomarkers support previous findings suggesting that health conditions were better in Bermondsey Abbey than in Merton Priory. The age patterns of cribra orbitalia suggest that these differences reflect conditions and the greater health-promoting effects of religiosity or isolation from the lay community in Bermondsey Abbey rather than differences in selective admissions processes.

The macroscopic and histomorphological properties of periosteal rib lesions and its relation with disease duration: evidence from the Luis Lopes Skeletal Collection (Lisbon, Portugal).

Periosteal new bone formation (PNBF) is a common finding in a large spectrum of diseases. In clinical practice, the morphology and location of periosteal lesions are frequently used to assist in the differential diagnosis of distinct bone conditions. Less commonly reported is the presence of PNBF on the ribs. This contrasts with the data retrieved from the study of skeletonized human remains that shows a high frequency of cases and a strong, albeit not specific, association between periosteal rib lesions and pulmonary conditions (e.g. tuberculosis). Despite that, an overall disagreement regarding the specificity and non-specificity of periosteal reactions exists in the study of dry bone remains. The insufficient number of clinical models exploring the morphology and the pathophysiology of PNBF's and the lack of systematic studies of pathological samples with a known diagnosis are claimed as major reasons for the disagreements. This study aimed to describe and compare the macroscopic and the histomorphologic appearance of periosteal rib lesions and to discuss their usefulness as diagnostic indicators. To pursue this goal, an assemblage of 13 rib samples (males=11, females=2, mean age-at-death=36.6years old) was collected from the Luis Lopes Skeletal Collection (Museu Nacional de História Natural e da Ciência, Universidade de Lisboa, Portugal). The assemblage belongs to individuals who died from pulmonary-TB (group 1), non-TB pulmonary infections (group 2) and other conditions (group 3). Prior to sample preparation, the ribs were visually inspected and the PNBF described according to its thickness, the degree of cortical integration and the type of new bone formed (e.g. woven, lamellar or both). After sampling, each bone sample was prepared for histological analysis under plane and polarized light microscopy. Macroscopically, the results showed no differences in the new bone composition between cause-of-death groups. Only slight differences in the degree of cortical integration, which was most frequently classified as mild to high in the pulmonary-TB group, were observed. Histologically, no distinguishing features were identified by pathological group. However, new bone microarchitectures were observed compatible with (1) acute, fast-growing processes (e.g. spiculated reactions), (2) long-standing processes with a rapid bone formation (e.g. appositional layering of bone) and/or (3) chronic, slow-growing processes (e.g. layers of compact lamellae). To some extent, these distinct rates of disease progression resonate with the cause-of-death listed for some individuals. Despite the small sample size, the results of this investigation are in agreement with previous studies, according to which the macroscopic and histological appearance of periosteal formations are not specific for a particular pathological conditions. Nevertheless, the results support the conclusion that the morphology of periosteal lesions is a good biological indicator for inferring the rate of progression and duration of pathological processes. This study provides important reference data regarding the histomorphology of periosteal lesions that can be used for comparative purposes, as well as to narrow down the differential diagnosis in unidentified skeletal remains.

An unusual bone reaction to a retained organic foreign body in the hand

Penetrating wounds of the hand with an embedded foreign body are common in active children and manual workers. Organic material, particularly thorns, can cause an inflammatory tissue reaction, ranging from a localized foreign body granuloma to a severe soft tissue and osseous reaction. We report the case of a 57-year-old man presented to our emergency department with a painful swelling of his fourth right finger. He had fallen into bushes 4 month prior to his presentation. Plain radiographs showed a solid periosteal new-bone formation along the second phalanx, interrupted by a rounded well-limited radiolucent area at the mid-phalangeal level that we described like a “crab claw periosteal reaction”. The osteoblastic reaction to an organic foreign body is very rare, we report an exceptional case of an unusual osteoblastic reaction to a retained organic foreign body in the hand that has been to our knowledge only once reported in the literature.

Osteopatia hipertrófica secundária a osteossarcoma condroblástico extraesquelético em um cão

Background: hypertrophic osteopathy is a periosteum disturb characterized by diffuse new bone formation which leads to significant thickening and deformity of members. Secondary in nature, it usually follows large pulmonary lesions such as abscesses and neoplasms. Extraskeletal osteosarcomas are rare and extremely malignant mesenchymal neoplasms. They comprise approximately 1% of all domestic animals’ osteosarcomas and develop in the absence of a primary bone lesion. The aim of this paper was to describe a case of hypertrophic osteopathy, involving joints and upper limbs bones including ilium, secondary to a mediastinal chondroblastic osteosarcoma with pulmonary metastasis.Case: A 10-year-old spayed female mixed breed dog, weighing 9 kg, was presented with painful limbs, lameness, hind limbs swelling and a four-month history of weight loss. Radiographic examination revealed bilateral and asymmetric periosteal reactions on diaphyseal and/or epiphyseal areas of all proximal phalanges; metacarpal, metatarsal, carpal and tarsal bones; radius; ulna; tibia; fibula; humerus; femur and right ilium. An increased soft tissue radiopacity was noted on the lateral side of the right knee joint. Thoracic radiographies and ultrasonography suggested the presence of a 5-cm neoplasm or abscess in the left caudal lung lobe. At necropsy, the lobe showed a firm and solid, oval white mass measuring 5.2 x 2.9 cm. Another mass was found in the caudal mediastinum, near the diaphragm, with same color and more irregular aspect, measuring 3.3 cm of diameter. Intense periosteal new-bone formation was seen in the entire length of the four limbs bones, characterized by thickening of the bone surface and formation of irregular trabeculae perpendicular to the cortex. Significant swelling and thickening of the joint capsule was noted in the right knee. There was no microbial growth on aerobic or anaerobic cultures from the masses samples sent to culture. Histopathological examination showed areas of chondroid differentiation, osteoidtissue formation and cell morphology suggestive of chondroblastic osteosarcoma in mediastinal region, with invasion and involvement of the diaphragm and lungs. The analyzed bone fragment had large foci of tissue compaction, peritrabecular bleeding and mineralization of osteoid tissue, permeated by plasma cells and typical lymphocytes.Discussion: Although hypertrophic osteopathy is often characterized as a disease which affects the diaphysis of distal long bones, this case presented a proximal progression of the disease. There was an unusual involvement of joints and ilium, which reinforces the importance of radiographic evaluation of these regions. Further studies on the pathogenesis of the syndrome are required, as its exact mechanisms remain obscure. It is suggested that the term hypertrophic osteoarthropathy should not be consider a misnomer since joint involvement is not exclusive of human form of the disease. Mediastinal masses are important cause of hypertrophic osteopathy. However, this is the first paper the authors are aware of that reports the occurrence of hypertrophic osteopathy secondary to mediastinal osteosarcoma. Finally, although rare, extra skeletal osteosarcoma should be considered in the differential diagnosis of intrathoracic masses in dogs with hypertrophic osteopathy. Timely diagnosis of hypertrophic osteopathy, whose signs of lameness and painful limbs draw the owner’s attention, may favor the diagnosis of severe concomitant diseases.

Possible scurvy in the prisoners of Old Quebec: A re-evaluation of evidence in adult skeletal remains

Scurvy is known to have been present in many past communities but recognising the condition in adult skeletal remains poses significant challenges. Fifty skeletons of Protestant prisoners who died between 1746 and 1747 were excavated in 1986–1987 from the walls of Old Quebec, Canada. Documentary sources indicate scurvy was present, and those considered the most likely candidates (n=9) were selected for re-evaluation using recently published macroscopic diagnostic criteria. Cranial porosity, hypertrophy and periosteal new bone formation (PNBF) were compared. The non-specific nature of skeletal changes in adult scurvy has a considerable effect on the potential to suggest a diagnosis. It is conceivable that all individuals had scurvy close to the time of death, but just two displayed probable evidence of scurvy and a further two had possible evidence of scurvy. Remaining cases had insufficient evidence for diagnosis. Although not straightforward, significantly more information was obtained by combining the results of the three types of pathological changes considered. Recent work has highlighted the difficulties of using PNBF in paleopathology, but careful evaluation of location and approximate stage of healing at the time of death contributes useful information that can be used to indicate level of disease burden and possible co-occurrence of conditions.

Papel de la neoformación ósea perióstica en el desempeño de los criterios CASPAR para diagnóstico de artritis psoriásica

ObjectivesTo determine the changes in the diagnostic performance of the CASPAR criteria when a different radiological finding is included: the periosteal new bone formation (PoBF) in proximal or distal phalanges in conventional X-ray. MethodsA total of 72 patients with psoriasis were evaluated, of whom 25 had psoriatic arthritis (PsA). With the participation of one radiologist and one rheumatologist the interobserver agreement was calculated in order to assess the presence of PoBF. The sensitivity, specificity and predictive values were calculated for: juxta-articular new bone formation (JaBF), PoBF, CASPAR criteria, and CASPAR modified (CASPARm), which included the PoBF as radiological criteria. The reference standard for PsA diagnosis was the clinical judgment of the rheumatologist. ResultsThere was an 87% inter-observer agreement, with a Kappa of 0.56 with 95% CI: 0.311-0.818. PoBF was the most frequent radiological finding in 24/25 compared to JaBF in 7/25 patients. In isolation PoBF had a better sensitivity but lower specificity for discriminating PsA than JaBF. There was no difference between the sensitivity and specificity of CASPAR vs. CASPARm. ConclusionsThe PoBF in the CASPAR criteria may be useful for the classification of PsA. Because there is no difference in sensitivity, specificity and predictive values between CASPAR and CASPARm, the two set of criteria may be used in the diagnosis of psoriatic arthritis. Due to the high frequency of PoBF in patients with PsA and the little impact of this finding in the sensitivity and specificity, the weight given to radiological component in CASPAR criteria should be reassessed, allowing them to adapt better to the behavior of the disease in our environment.

Beyond the visible world: the role of microscopy in the study of past human conditions

Paleopathology, summarily defined as the study of past diseases, has on the differential diagnosis a major challenge. Histological techniques offered the possibility to look inside the microstructure of both normal and abnormal body tissues to diagnose diseases that affected past populations, leading to the development of a new field of research - paleohistology or paleohistopathology. However, and contrary to paleopathology whose journey is well-established, in paleohistopathology there are many gaps that need to be filled. This occurrence is probably the result of a nonsystematic and non-standardized approach to the microscopic study of skeletal abnormalities, especially those of infectious origin involving periosteal new bone formation (PNBF). The aims of this work were: (1) to search for differences in the microstructure of PNBF with regard to the cause of death of the individual; (2) to infer differences between the macroscopic and microscopic proprieties of bone lesions, and (3) to ascertain the impact of diagenetic changes in the bone microstructure. For histological examination under transmitted and polarized light, a total of 34 dry bone specimens: 26 belonging to 23 individuals from the Human Identified Skeletal Collection from the Bocage Museum (Lisbon, Portugal), and eight from archaeological skeletons were prepared. The documented bone samples were collected from individuals who died from tuberculosis-TB (Group 1), non-TB infectious diseases (Group 2), and conditions other than those of TB and non-TB infectious origin (Group 3).With regard to the diagnosis of pathological conditions, differences in the microstructure of PNBF were seen between Group 1 and Group 2 of cause of death and within groups. Multiple layers of “appositional bone” enclosing numerous primary vascular canals were the pattern most commonly observed (n=4) in the samples from Group 1. This type of PNBF seems to mimic the appositional growth that characterizes the modeling process of the periosteal and endosteal membranes (PEM) during rapid growth periods. An abnormal stimulation of growth factors, especially of the vascular endothelial growth factor (VEGF) may eventually explain the extensive hypervascularization observed (Fig. 1 A-B). Periosteal lesions on ribs are normally associated with pulmonary infection (e.g. TB) disseminated from the lungs (via pleura) to the ribs. However, three samples (one from Group 1, two from Group 2) presented a microstructure compatible with subperiosteal hematomas (Fig. 1 C-D). Repetitive microtrauma (e.g. chest wall vibration) that causes detachment of the periosteum may have leaded to subperiosteal bleeding and hematoma formation. These observations suggest that beyond pulmonary diseases other mechanisms may stimulate PNBF on the visceral surface of ribs. Histological analysis was also fundamental in the description and characterization of bone changes. For example, of the five samples with “consolidated” fracture callus, only two presented a truly mature and remodeled microstructure. This means that the outer surface of a bone lesion may not give a complete picture of the tissues response (Fig. 2 A-B). In spite of the good preservation of some bone samples, massive diagenetic changes due to the action of bacteria and fungi were observed at microscopic level. This clearly suggests that gross inspection is not a good measure of the bone tissue quality. In contrast, microscopy is essential to differentiate between pseudopathology and physiological or pathological signs.Microscopy revealed surprising results that reinforce the pertinence of applying histological techniques in the description and diagnosis of bone changes in human remains.This research was supported by Fundação para a Ciência e Tecnologia, Portugal [SFRH/BD/36739/2007, Sandra Assis].

Imaging features of hemangioma in the long bone

Objective To explore the imaing features of hemangioma in the long bone and improve the diagnostic level of this disease. Methods The X-ray(14 cases), CT(9 cases) and MRI(6 cases)findings of 18 patientswith histologically proven hemangioma in the long bone after surgery were retrospectively reviewed. Results Ten tumors occurred in medullary cavity or bone end(medullary type),6 on the surface of bone (periosteal type) and 3 in cortex (intracortical type). X-ray findings: among 8 cases of medullary type, 3 showed honeycomb appearance, 3 lytic areas with sclerotic borders, one purely osteolyticchanges, and 1 frosted glass; 3 cases of periosteal type showed sclerosis and thickening of the underlying cortex; 3 cases of intracortical type showed well-defined osteolytic foci. CT findings: among 6 cases of medullary type, 5 appeared as expansile lytic lesion with uneven selerotic rim (3 cases)orhoneycomb appearance (2 cases), 1 cribriform appearance in the cortical bone, 2 periostealnew bone formation in vertical radiation pattern; 1 ground-glass appearance; among 2 cases of periosteal typeone showed regular cortical thickening, and the other irregular periosteal proliferation with marrowing of medullarycavity; 1 case of intracorticaltype showed density similar to that of soft tissue, with cortical thickening and expansion . MRI findings: 2 apeared as well-defined lesions with low signal intensity on T1WI and high signal intensity on T2WI; 1 appeared as ill-defined lesion with low to intermediate signal intensity on T1 WI and T2 WI. One showed breakthrogh of cortex and formation of soft tissue mass with low signal intensity on T1 WI and high signal on T2WI. Two showed thickening of periosteumwith intermediate signal intensity in one of them and very low signal intensity in the other. Two showed abnormal signal intensity in surrounding muscles, which was high on T2 WI and intermediate on T1 WI. Conclusions The soap-bubble or honeycomb appearance is the typical radiographic finding of hemangioma in long bone. CT and MRI can provide useful information for the diagnosis of hemangioma in long bone. Key words: Hemangioma; Diaphyses; Diagnostic imaging

A Comprehensive Clinicopathologic Analysis Suggests that Vascular Endothelial Growth Factor (VEGF) is the Most Likely Mediator of Periosteal New Bone Formation (PNBF) Associated with Diverse Etiologies

Periosteal new bone formation (PNBF) is the means by which appositional bone growth normally takes place on the surfaces of compact bone. Alterations in the periosteal microenvironment trigger complex interactions between osteoblasts and endothelial cells to promote PNBF. Physiologic processes like mechanical stress result in normal PNBF; but, a variety of pathologic processes result in excessive PNBF. The production of sufficient bone to be detectable by conventional radiography is a common feature of diverse etiologies, including infection; inflammation; prostaglandin E2 administration for ductal-dependent congenital heart disease; metabolic and hormonal abnormalities; neoplasms; fracture repair; systemic hypoxia; and hypertrophic osteoarthropathy. While the clinical settings and distribution of affected bone sites in these conditions are different, the histopathology of the PNBF is essentially identical; so, it seems logical that a common pathway might mediate them all. By combining the observations and insights gained from osseous research and studying the clinical pathology of these diverse conditions, we constructed a comprehensive pathway to explain PNBF. In doing so, it seems likely that Vascular Endothelial Growth Factor (VEGF) is the most likely common mediator of the pathways that lead to PNBF.

EWING SARCOMA IN AN OCTOGENARIAN

Ewing sarcoma is a round‐cell bone tumor that most often affects older children and adolescents1. Although less common, Ewing sarcoma in adults has been documented in clinical reports; the tumor primarily occurs in patients less than forty years of age, and the oldest patient in whom it was previously reported was sixty-one years of age1. The prognosis in adults and their response to current treatment modalities have been topics of discussion in recent studies. Diagnosis is crucial, since lymphoma has a similar cytologic appearance and is more common in the elderly, but it differs in terms of both treatment and prognosis. We present a case of Ewing sarcoma in an octogenarian, in whom the findings on cytologic, histochemical, and cytogenetic examination facilitated accurate diagnosis and directed treatment. An eighty‐one-year-old man presented with a six‐month history of a painless mass of increasing size in the distal aspect of the right thigh. He had not had fever, chills, or weight loss, and he reported no previous malignant lesions in himself or his family. Examination revealed a 15 20-cm soft-tissue mass on the posterolateral aspect of the distal part of the thigh; the mass was firm, nontender, and fixed to the adjacent tissue. The overlying skin was intact and not erythematous. The range of motion of the knee was from full extension to 100 of flexion. The findings on the neurovascular examination were normal, and no inguinal or popliteal adenopathy was present. Radiographs of the right femur revealed a permeative lesion in the lateral aspects of the diaphysis and metaphysis with abundant periosteal new-bone formation. An associated soft-tissue mass was also noted (Figs. 1-A and 1-B). Magnetic resonance imaging revealed …

Treatment of sequestra, pseudarthroses, and defects in the long bones of children who have chronic hematogenous osteomyelitis.

We reviewed the results, after follow-up ranging from twenty-three months to six years, in thirty-four patients who were treated during childhood for hematogenous osteomyelitis of a major long bone complicated by sequestration of a portion of the diaphysis and by pseudarthrosis or segmental bone loss, or both. Of the thirty-four lesions, twenty-four were in the tibia, eight were in the femur, and two were in the humerus. In twenty-three patients (Group I), the infection was still active, while in the other eleven (Group II), it was quiescent at the time of admission to the hospital. In nine of the patients in Group I (four tibial and five femoral lesions), an involucrum bridged the osseous defect, indicating that the periosteal tube had not been destroyed. In these nine patients, sequestrectomy and débridement, appropriate antibiotic therapy, and prolonged immobilization in a plaster cast resulted in healing of the defect without recurrence of the infection. In the remaining fourteen patients (twelve tibial and two femoral lesions), there was no periosteal new-bone formation, and operative treatment consisted of two stages: the first, to resolve the infection, and the second, to heal the osseous defect with corticocancellous iliac grafts. In the eleven patients in Group II (eight tibial, one femoral, and two humeral lesions), there were no involucra. All of these patients were treated with cancellous bone grafts and prolonged immobilization. In twenty-two of the thirty-four patients (thirteen in Group I and nine in Group II), there were varying degrees of angular deformity at the pseudarthrosis, necessitating correction by manipulation when the plaster cast was applied postoperatively (ten patients), by fibular transposition (six patients), or by fibular osteotomy in addition to manipulation (six patients). Excluding complications specific to the fibular transfer procedure, the complications in the Group-I patients (six recurrent postoperative infections, one fracture of the graft, and one non-union of a fibular strut graft) were approximately as frequent as those in the Group-II patients (one failure of fusion and two fractures of the graft). Operative treatment resulted in healing of all but one tibial lesion, in a patient who nonetheless had good function at follow-up. Of the seven limb-length discrepancies of 2.8 centimeters or more, by the latest follow-up two had been treated uneventfully: one by femoral and the other by tibial lengthening.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of irradiation on cortical bone and their time-related changes. A biomechanical and histomorphological study.

The effects of high-dose irradiation on the biomechanical and morphological properties of cortical bone and their time-related changes were studied in male Sprague-Dawley rats. A single fraction of 3500 rads was applied to the middle part of the right thigh. Age and sex-matched control rats that did not receive radiation were used for comparison. Two weeks after irradiation, the animals had lost weight and disappearance of bone cells, shrunken osteocytes, and significantly decreased bone-turnover activities were noted. The bone marrow showed reduced hematopoietic elements and sinusoids with increased fat. No change in the torsional strength and geometric properties of bone was noted at this time. Six to ten weeks after irradiation, histopathological abnormalities of the bone persisted, and there was an accelerated resorption process. However, significant increases in the strength and cortical area of bone appeared only in the non-irradiated, contralateral femur. On the irradiated side, decreased cortical area and increased porosity of bone were found at fourteen to eighteen weeks when compared with the control rats. Other histomorphological properties, such as bone porosity, osteocyte count, and periosteal new-bone formation, appeared to recover eighteen weeks after irradiation, as they became similar to the values for the age-matched normal control rats.

External skeletal fixation of canine tibial osteotomies. Compression compared with no compression.

In this study we compared the effects of compression on the maturity and pattern of osseous healing in canine tibial osteotomies that were fixed with an external fixation system at a single time-period, ninety days after osteotomy. The in vitro model demonstrated that compression increased rigidity of fixation. Relative to the rigidity of the intact tibia, this increase was small. Estimation of osteotomy-site bone blood flow at ninety days by 85Sr clearance and torsional testing to failure of the healed osteotomies were used to compare the maturity of bone union in each group. The pattern of healing of the osteotomy was evaluated by quantitative histological determination of new-bone formation and porosity. All of the osteotomies healed by the ninetieth day. We found no significant difference at that time in osteotomy-site bone blood flow or strength of healing of the osteotomy, although the compression-treated osteotomies healed with higher torsional stiffness. No differences were demonstrated between the two groups in the pattern of healing of the osteotomy. In both groups there was a significantly greater amount of periosteal new-bone formation in the relatively less rigidly fixed antero-posterior plane when compared with the mediolateral plane. Primary bone-healing of both the contact type and the gap type was seen in both groups. There were no significant complications and the pin-loosening rate was similar in both groups.

Growth and development of the acetabulum in the normal child. Anatomical, histological, and roentgenographic studies.

Postmortem studies of ten normal full-term infants and of three children, seven, nine, and fourteen years old, showed that the acetabular cartilage complex is a unit that is triradiate medially and cup-shaped laterally and is interposed between the ilium, ischium, and pubis. This complex is composed of epiphyseal growth-plate cartilage adjacent to these bones, of articular cartilage adjacent to these bones, of articular cartilage around the acetabular cavity, and, for the most part, of hyaline carilage. Interstitial growth within the triradiate part of the cartilage complex causes the hip socket to expand during growth. The concavity of the acetabulum develops in response to the presence of the spherical femoral head. The depth of the acetabulum increased during development as the result of interstitial growth in the acetabular cartilage, of appositional growth at the periphery of this cartilage, and of periosteal new-bone formation at the acetabular margin. At puberty, three secondary centers of ossification appear in the hyaline cartilage surrounding the acetabular cavity. These centers are homologous with other epiphyses in the skeleton. The os acetabuli, which is the epiphysis of the os pubis, forms the anterior wall of the acetabulum. The epiphysis of the ilium, which has been called the acetabular epiphysis, forms a good part of the superior wall of the acetabulum. A small epiphysis of the ischium was seen in the oldest patient, who was fourteen years old. The bone in these epiphyses expands toward the periphery of the acetabulum and thus contributes to its increase in depth.

Chronic sclerosing osteomyelitis of the mandible. Radiographic differential diagnosis from fibrous dysplasia.

Among 13 patients with chronic osteomyelitis of the lower jaw, clinical, radiologic and histologic difficulties were encountered in 5 cases, in the differential diagnosis from fibrous dysplasia. The radiologic, and in some measure the clinical and histologic features typical of the two diseases are described. Variations in the bone structure during the course of the disease, as well as periosteal new-bone formation, are characteristics of chronic osteomyelitis. When problems are encountered in differentiating between fibrous dysplasia with periodical pain and swelling, and osteomyelitis, repeated radiologic examinations are to be recommended.

Sickle-cell dactylitis

In order to define better the presentation, roentgenographic features, and clinical course of sickle-cell dactylitis, the records of nine children with sickle-cell anemia and acutely painful, swollen digits were reviewed. The average age of these children at the time of diagnosis was eighteen months, and in five instances the dactylitis occurred before the diagnosis of sickle-cell disease was established. The clinical signs, consisting of swelling, tenderness, fever, and leukocytosis, were self-limiting and resolved in five to thirty-one days. The roentgenographic features, characterized by periosteal new-bone formation or intramedullary densities, appeared in seven to fourteen days and resolved in two to three months. Incorrect diagnosis is frequent in this condition but can be avoided as familiarity with the syndrome increases.

The use of methylmethacrylate as an adjunct in the internal fixation of unstable comminuted intertrochanteric fractures in osteoporotic patients

Forty-two unstable, four-part intertrochanteric fractures in forty-one patients (seventy-one to 104 years old) with severe osteoporosis were treated by open reduction and internal fixation (Jewett nail or compression screw-plate) supplemented with methylmethacrylate packed into the curetted medullary space. One patient was lost to follow-up, one died of a myocardial infarction at six weeks, and one was excluded because of an unsuspected myeloma found at the fracture site. All patients were sitting up in a chair the day after operation. Full weight-bearing on the limb was started within three weeks by thirty patients and at an average of 118 days by six who had very comminuted fractures. Three patients, non-ambulatory preoperatively, did not walk after operation. Of the thirty-eight fractures followed for from nine to thirty-seven months, thirty-seven healed with no loss of position. One fracture which had been fixed with the nail and cement not extending far enough into the head and neck displaced, and the operation had to be repeated, this time with a successful result. The fractures healed by periosteal new-bone formation. There was no evidence of avascular necrosis or wound complications.

Adamantinoma of long bones. A clinicopathological study of fourteen cases with vascular origin suggested

Adamantinoma of long bones is a rare primary bone tumor. Approximately 100 cases have been reported in the literature. In the fourteen cases we studied in detail the ages of the patients ranged from thirteen to sixty-seven years and there were as many males as females. Twelve of the lesions were located in the tibia and two, in the humerus. The roentgenographic findings were sharply defined eccentric lobular lesions in the diaphysis. Some of the lesions were lytic and coarsely trabecular with a honeycomb appearance occasionally associated with periosteal new-bone formation. A sawtooth area of cortical-bone loss was found to be characteristic of this lesion. A microscopic finding is presented to support the theory of angioblastic origin of this tumor. The most successful treatment was amputation. Less often en bloc excision succeeded. Metastases to other bones, regional lymph nodes, and the lung were recorded.

Neonatal systemic candidiasis and arthritis.

A case of disseminated Candida albicans infection in a neonate is presented, consisting of meningitis, diffuse arthritis, and metaphyseal involvement. Radiographic findings include diffuse joint effusions, metaphyseal irregularities, and periosteal newboneformation. Amphotericin therapy resulted in complete remission of the clinical and roentgenographic manifestations. Differential diagnosis is discussed.

A comparative study of periosteal new-bone response in metastatic bone tumors (solitary) and primary sarcomas.

The radiographic appearance of a solitary metastatic focus in bone is frequently mistaken for a primary malignant bone tumor. As Lodwick pointed out, “the solitary metastatic lesion of bone is the one which usually offers the real challenge in differential diagnosis” (3). Often, the distinguishing feature of a primary sarcoma is the presence of an associated periosteal reaction which authors have stated to be absent or scant in metastatic bone lesions. This investigation was initiated to determine if periosteal new-bone formation is in fact rare in metastasis and, therefore, a roentgenographic finding of value in differentiating primary from secondary bone tumors. Clinical Material A. Metastatic Tumors: In a period of six years, 35 patients with solitary metastatic lesions in bone were studied. This study was a selective review as only patients with isolated metastatic foci in bone were included. These included primarily lesions involving the appendicular skeleton, those most difficult to differentiate from primary bone sarcomas. Histologic documentation of the lesion was available in most cases. The presence and type of periosteal reactions were recorded from the roentgenograms. The types of periosteal responses were classified into one of four categories: (a) the lamellated reaction (onion peel), (b) a perpendicular or spiculated sunburst appearance, (c) a dense periosteal reaction which is difficult to differentiate from thickened cortical bone and often associated with osteoblastic metastases, and (d) the Codman or reactive triangle at the margin of the lesion. Patients with callus formation at the site of pathologic fracture were excluded from the clinical study because it was difficult to decide from the radiographs what represented normal fracturehealing and what represented periosteal response to tumor. There were a variety of primary sites in the metastatic series; 13 in all. When periosteal reaction was present, however, the most frequent primary tumors noted were in the gastrointestinal tract, prostate, kidney, lung, and adrenal gland. In fact, the finding of a solitary metastasis to the femur from a latent primary focus in the lung masquerading as a reticulum-cell sarcoma stimulated this study (Fig. 1). Only after biopsy was the true nature of the lesion disclosed. Thirteen of 35 patients in this group showed radiographic evidence of one or more types of periosteal reaction. In most instances the new-bone responses were varied, but in patients with osteoblastic metastasis a dense periosteal reaction was frequently noted (Fig. 2). The most pronounced periosteal responses were in metastases from the colon, prostate, and adrenal glands (neuroblastoma) (7). The incidence of reaction was 37 per cent, and the distribution of cases is illustrated in Figure 3. B. Primary Bone Tumors: A comparative study of 41 patients with primary bone a periosteal reaction. Because osteosarcomas can produce tumor bone in the soft tissues, however, it is difficult to be certain if one is dealing with periosteal non-tumor bone or tumor bone o