Tibial Midshaft Research Articles

Sex estimation by discriminant function analysis of long bones in prehistoric Southeast Asian populations

AbstractBiological sex estimation is an integral part of reconstructing the biological profile of an individual in forensic anthropological and bioarchaeological contexts. Formulating population specific discriminant function equations for metric variables is vital for reconstructing biological sex of fragmentary skeletal remains. This study aimed to develop multivariable and univariable sectioning point sex estimation equations from long bones of prehistoric Thailand and Cambodia people dated from 4700 to 1450 BP. A total of 481 individuals (236 females and 245 males) with 997 long bone measurements were analyzed. Discriminant function analysis was used to analyze sexually dimorphic measurements from long bones of humeri (177 females and 183 males), femora (169 females and 178 males), and tibiae (139 females and 151 males). Stepwise and direct multivariable functions offered the highest accuracies of 97.3% for humeri, 97% for femora, and 96.7% for tibiae. Univariable functions indicated that the recommended measurements for use in sex estimations with high cross‐validation accuracies are the humeral epicondylar breadth (89.1%), femoral maximum head diameter (87.1%), and tibial midshaft circumference (88.3%). These equations are applicable for use in sex estimation for the specific prehistoric Southeast Asian populations to improve our understanding of the prehistoric demography. Further evaluation and validation of the equations are required to test whether these equations can also be applied to estimate biological sex of contemporary Southeast Asian populations.

A novel framework for elucidating the effect of mechanical loading on the geometry of ovariectomized mouse tibiae using principal component analysis.

Murine models are used to test the effect of anti-osteoporosis treatments as they replicate some of the bone phenotypes observed in osteoporotic (OP) patients. The effect of disease and treatment is typically described as changes in bone geometry and microstructure over time. Conventional assessment of geometric changes relies on morphometric scalar parameters. However, being correlated with each other, these parameters do not describe separate fractions of variations and offer only a moderate insight into temporal changes. The current study proposes a novel image-based framework that employs deformable image registration on in vivo longitudinal images of bones and Principal Component Analysis (PCA) for improved quantification of geometric effects of OP treatments. This PCA-based model and a novel post-processing of score changes provide orthogonal modes of shape variations temporally induced by a course of treatment (specifically in vivo mechanical loading). Errors associated with the proposed framework are rigorously quantified and it is shown that the accuracy of deformable image registration in capturing the bone shapes (∼1 voxel = 10.4μm) is of the same order of magnitude as the relevant state-of-the-art evaluation studies. Applying the framework to longitudinal image data from the midshaft section of ovariectomized mouse tibia, two mutually orthogonal mode shapes are reliably identified to be an effect of treatment. The mode shapes captured changes of the tibia geometry due to the treatment at the anterior crest (maximum of 0.103mm) and across the tibia midshaft section and the posterior (0.030mm) and medial (0.024mm) aspects. These changes agree with those reported previously but are now described in a compact fashion, as a vector field of displacements on the bone surface. The proposed framework enables a more detailed investigation of the effect of disease and treatment on bones in preclinical studies and boosts the precision of such assessments.

A rare case of Anti-Jk3 Alloimmunization

Abstract Introduction/Objective The Kidd blood group system was discovered in 1951 and consists of two antithetical antigens, Jka and Jkb, in addition to a third high-incidence antigen, Jk3. Jk null, also known as Jk(a-b-), is an extremely rare blood group in which all Kidd antigens are absent. Jk is a urea transporter found in the renal medulla, and Jk-deficient individuals are unable to concentrate urine to its maximum concentration. If these individuals are exposed to the Jk antigen via transfusion or pregnancy, they are able to produce antibodies against the Jk3 antigen with a high incidence. Jk3 is expressed in over 99.9% of the blood donor pool, which has severe clinical implications and complicates transfusion. Methods/Case Report CASE PRESENTATION: A 68-year-old male was admitted to the Stanford Medical Center with chronic right midshaft tibia osteomyelitis and a sinus drainage tract for a right tibial diaphysectomy. His test for antibodies was positive. Plasma from the patient is reactive with all tested cells except auto control, AHG in PEG, and solid phase. Phenotyping yielded negative results for Jka and Jkb, suggesting that the antibody is Jk3. Anti-Jk3 was eliminated by adsorption and rendered nonreactive. Results (if a Case Study enter NA) NA Conclusion Anti-Jk3 should be suspected in a previously pregnant or transfused patient during antibody screening and identification if it demonstrates the pattern of an antibody reacting to all cells in the panel, i.e., reacting to a high- frequency antigen with negative autocontrol. Awareness on the part of blood bank personnel regarding the variability of the blood group phenotype and the capricious nature of Kidd antibodies may aid in the improved management of these patients. It is recommended that patients with rare antibodies carry an antibody ID card indicating the rare antibody they have to prevent further exposure. A patient may be advised to undergo an autologous transfusion. Fortunately, the patient’s procedures were uncomplicated, so a blood transfusion was unnecessary. Awareness on the part of blood bank staff regarding the variability of the blood group phenotype and the unpredictability of Anti-Jk3 may aid in improving patient care. To prevent further exposure, it is recommended that patients with rare antibodies carry an Antibody ID card indicating the rare antibody they possess.Jk3 antigen blood donors are underrepresented in the general donor pool. It is recommended to develop a systematic recruitment for Jk3 antigen donors.

Effectiveness of Soleus Muscle Flap for The Coverage of Wound in Open Tibia Fracture in The Mid Shaft

Introduction: An open fracture of the tibia has been one of the most common long bone injuries. Soleus muscle flap supply can be a remedy for this kind of soft tissue difficulties. The soleus muscle flap’s blood supply may help in the construction of a longer, safer, and more functional flap. When the incision is clinically fit for covering, the flaps from the same leg are elevated between 0 and 14 days following the damage. In the majority of these cases, the flaps are covered with a split-thickness skin graft taken from the anterior aspect of the thigh in the same sitting. This can be a great solution. Aim of the study: The study aimed to assess the effectiveness of soleus muscle flap for the coverage of wound in open tibia fracture in the mid shaft. Methods: This prospective interventional study aimed to evaluate the outcomes of early coverage using the soleus muscle flap in the management of Gustilo type-IIIB fractures of the mid-shaft tibia. The study followed a quasi-experimental design and was conducted over an 18-month period from January 1, 2010, to June 30, 2011. The research took place in the Department of Orthopaedics and Traumatology at Dhaka Medical College Hospital (DMCH) and the National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR) in Dhaka. The study population included all 15 patients admitted to the hospitals with clinical and radiological evidence of open Gustilo type-IIIB fractures of the mid-shaft tibia followed by the inclusion and exclusion criteria. Informed written consent was taken before data collection and confidentiality was maintained. The analysis was done by SPSS version 15. Result: Among 15 patients most (12) were male, 3 were female. Mean age was 38 ± 12 years. Majority were in 31-45 years. Male female ratio was 4:1. The selected study subjects were predominantly motor driver (26.66%), followed by day labor, housewife, service holder, farmer, and businessman (each was-13.33%), and student was 6.66%. ...

The effects of endurance trainability phenotype, sex, and interval running training on bone collagen synthesis in adult rats

Bone is influenced by many factors such as genetics and mechanical loading, but the short-term physiological effects of these factors on bone (re)modelling are not well characterised. This study investigated the effects of endurance trainability phenotype, sex, and interval running training (7-week intervention) on bone collagen formation in rats using a deuterium oxide stable isotope tracer method. Bone samples of the femur diaphysis, proximal tibia, mid-shaft tibia, and distal tibia were collected after necropsy from forty-six 9 ± 3-month male and female rats selectively bred for yielding low (LRT) or high (HRT) responses to endurance training. Bone collagen proteins were isolated and hydrolysed, and fractional synthetic rates (FSRs) were determined by the incorporation of deuterium into protein-bound alanine via GC-pyrolysis-IRMS. There was a significant large main effect of phenotype at the femur site (p < 0.001; η2g = 0.473) with HRT rats showing greater bone collagen FSRs than LRT rats. There was a significant large main effect of phenotype (p = 0.008; η2g = 0.178) and a significant large main effect of sex (p = 0.005; η2g = 0.196) at the proximal site of the tibia with HRT rats showing greater bone collagen FSRs than LRT rats, and male rats showing greater bone collagen FSRs compared to female rats. There was a significant large main effect of training at the mid-shaft site of the tibia (p = 0.012; η2g = 0.159), with rats that underwent interval running training having greater bone collagen FSRs than control rats. Similarly, there was a significant large main effect of training at the distal site of the tibia (p = 0.050; η2g = 0.156), with rats in the interval running training group having greater bone collagen FSRs compared to rats in the control group. Collectively, this evidence highlights that bone responses to physiological effects are site-specific, indicating that interval running training has positive effects on bone collagen synthesis at the tibial mid-shaft and distal sites, whilst genetic factors affect bone collagen synthesis at the femur diaphysis (phenotype) and proximal tibia (phenotype and sex) in rats.

Evaluation of Radiological and Functional Outcomes of Closed Complex Mid-shaft Tibia Fractures Treated with Primary Definitive All Wire Ilizarov Ring Fixator: A Prospective Study at Tertiary Care Centre of Nepal.

Introduction: Closed complex tibial shaft fractures are frequently encountered fractures in lower limb injuries. Various surgical methods for these fractures include primary or delayed fixation with intramedullary nails, minimal invasive plates, and primary definitive external stabilization using ring fixators. We conducted this study to evaluate the radiological and functional outcomes of primary definitive fixation of these fractures using an all-wire Ilizarov circular fixator. Objectives: The objectives of this study were to evaluate the radiological and functional outcomes of primary definitive fixation of closed complex tibial mid-shaft fractures in patients with compromised soft tissue status. Methodology: We defined Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) 42-B1 to AO/OTA 43-C3 fractures as complex tibial shaft fractures for this prospective observational study, and evaluated all 26 patients for the functional and radiographical progression according to ASAMI classification. Results: Twenty-six patients were stabilized with an all-wire circular ring fixator. The union time on average was 27.61 weeks. Among all patients, 7 (37.5%) cases had minor pin tract infections, and one (2.7%) patient landed a non-union, which required bone graft. Conclusion: With the use of an all-wire Ilizarov circular frame, there is a good mean time to union, fewer chances of re-operations, and good functional outcomes without any major complications.

A delay in flap coverage of open midshaft tibia fractures increases complications: A retrospective study

Background: This retrospective study aimed to assess whether delaying flap coverage in open midshaft tibia fractures leads to higher infection rates. Methods: Patients were recruited retrospectively from a tertiary trauma database between 2012 and 2020. Patients included were over 18-years old and had an open tibia fracture that required flap coverage with at least 6 months follow-up. The collected complications were deep infections, aseptic non-union, flap failure and revision surgery. Results: Group-A ( n = 18) and Group-B ( n = 37) were analysed. Deep infections rate was 6% in Group-A and 38% in Group-B which was significantly different, χ2(1, N = 55) = 6.4, p = 0.01. The rate of revision surgery was 17% in Group-A and 54% in Group-B and was significant, χ2(1, N = 55) = 7, p = 0.008. Binary logistic regression showed that Group-B were 10 times more likely to develop a deep infection (95% confidence interval 1.2–83, p = 0.034). Conclusion: Delaying soft tissue coverage of open tibia fractures for over a week increases the risk of deep infection and revision surgery.

Association of secondhand smoke with fracture risk in community-dwelling nonsmoking adults in Korea.

Although the detrimental effects of active smoking on bone health have been widely recognized, the impact of secondhand smoke exposure on fracture risk in non-smokers remains less understood. A total of 4843 nonsmokers aged 40-69yr, who participated in the Korean Genome and Epidemiology Study from 2001 to 2018, were analyzed. The participants were categorized into two groups based on their exposure status to secondhand smoke: currently exposed and unexposed. The exposure group was subsequently divided into two subgroups based on the median weekly exposure time (high vs low). The incidence of new fractures was determined using self-reported questionnaires. The identified fractures were categorized according to the fracture site: overall, vertebral, hip, non-vertebral, and non-vertebral non-hip fractures. The mean age of the participants was 52.4yr (84.1% women). Exposure to secondhand smoke was associated with an increased risk of fracture (adjusted hazard ratio [aHR]: 1.27, P =0.028) after adjusting for multiple covariates including age, sex, BMI, household income, bone density of mid-shaft tibia, C-reactive protein, alcohol consumption, and fracture history. Secondhand smoke remained as a significant risk factor for fracture, independent of the major osteoporotic fracture probabilities estimated using a fracture risk assessment tool (aHR: 1.24, P =0.038). The high exposure group had higher risk of fracture than that of the unexposed group (aHR: 1.33, P =0.025), whereas the fracture risk did not differ significantly between low exposure and unexposed groups (aHR: 1.18, P =0.253), suggesting a potential dose-response relationship. Secondhand smoke showed robust association with increased risk of non-vertebral (aHR: 1.37, P =0.008) or non-vertebral non-hip fractures (aHR: 1.36, P =0.013), while its association with vertebral fracture was attenuated (aHR: 1.03, P =0.908). Secondhand smoke was associated with an elevated risk of fracture in nonsmokers, independent of clinical risk factors.

Toward the use of MRI measurements of bound and pore water in fracture risk assessment.

The current clinical assessment of fracture risk lacks information about the inherent quality of a person's bone tissue. Working toward an imaging-based approach to quantify both a bone tissue quality marker (tissue hydration as water bound to the matrix) and a bone microstructure marker (porosity as water in pores), we hypothesized that the concentrations of bound water (Cbw) are lower and concentrations of pore water (Cpw) are higher in patients with osteoporosis (OP) than in age- and sex-matched adults without the disease. Using recent developments in ultrashort echo time (UTE) magnetic resonance imaging (MRI), maps of Cbw and Cpw were acquired from the uninjured distal third radius (Study 1) of 20 patients who experienced a fragility fracture of the distal radius (Fx) and 20 healthy controls (Non-Fx) and from the tibia mid-diaphysis (Study 2) of 30 women with clinical OP (low T-scores) and 15 women without OP (normal T-scores). In Study 1, Cbw was significantly lower (p=0.0018) and Cpw was higher (p=0.0022) in the Fx than in the Non-Fx group. In forward stepwise, logistic regression models using Bayesian Information Criterion for selecting the best set of predictors (from imaging parameters, age, BMI, and DXA scanner type), the area-under-the-receiver operator characteristics-curve (AUC with 95% confidence intervals) was 0.73 (0.56, 0.86) for hip aBMD (best predictors without MRI) and 0.86 (0.70, 0.95) for the combination of Cbw and Cpw (best predictors overall). In Study 2, Cbw was significantly lower (p=0.0005) in women with OP (23.8±4.3 1H mol/L) than in women without OP (29.9±6.4 1H mol/L); Cpw was significantly higher by estimate of 2.9 1H mol/L (p=0.0298) with clinical OP, but only when accounting for the type of UTE-MRI scan with 3D providing higher values than 2D (p<0.0001). Lastly, Cbw, but not Cpw, was sensitive to bone forming osteoporosis medications over 12-months. UTE-MRI-derived measurements of bound and pore water concentrations are potential, aBMD-independent predictors of fracture risk.

Mini approaches fasciotomy combined with vacuum sealing drainage for acute compartment syndrome caused by fractures in children.

Acute compartment syndrome (ACS) is an urgent, critical condition that requires immediate fasciotomy once diagnosed. Traditionally, fasciotomy of the forearms and lower leg involves one or two long approaches. Our previous study demonstrated that mini approaches fasciotomy was an effective method to treat ACS. This study is aimed at further evaluating the limb functions and complications of mini approaches combined with vacuum sealing drainage (VSD) for treating ACS caused by fractures in the forearms and lower legs. This was a retrospective cross-sectional study, and after applying the inclusion and exclusion criteria, we reviewed 126 children who underwent mini treatment approaches for ACS from Jan 2008 to Jan 2022. The selected patients were divided into two groups: group A (ACS group; 58 patients aged 7.77±3.45 years) and group B (ACS combined with VSD; 68 patients aged 7.17±3.55 years). Patients' clinical data were collected. The patients were followed up, and muscle function in the forearms and lower legs was evaluated. The overall incidence of lower legs and forearmsACS was 126/29642 (0.425%). The most common mechanisms of injury were fractures of the forearm (39/74, 52.7%), supracondylar humerus (31/74 41.9%), and elbow (4/74, 5.4%), while those for the lower legs were fractures of the proximal tibia (19/52, 36.5%), midshaft of tibia (25/52, 48.1%), and distal tibia (7/52, 13.5%). According to Flynn's assessment, no significant difference was observed between the two groups (p=0.151). However, the two groups showed significant differences in the hospitalization time (p=0.002) and incision infection rate (0.043). Mini approaches fasciotomy combined with VSD is an effective and safe method to treat ACS of the forearms and lower legs caused by fractures in children. This method involves a single-stage surgery and is associated with shorter hospitalization time and incision infection.

#6641 BONE MATERIAL STRENGTH INDEX AND DUAL ENERGY X-RAY ABSORPTIOMETRY IN EVALUATION OF BONE HEALTH IN AUTOSOMAL POLYCYSTIC KIDNEY DISEASE

Abstract Background and Aims Bone material strength measured with the use of impact microindentation technique (OsteoProbe®) has emerged recently as potentially beneficial tool in evaluating bone quality in metabolic bone disorders. Patients with autosomal polycystic kidney disease (ADPKD) carry an increased risk of skeletal complications, both due to deficiency of polycystins and development of chronic kidney disease-mineral bone disorder (CKD-MBD). In our preliminary study, we found that bone material strength index (BMSi) associated with bone mineral density (BMD) measured with the use of dual energy X-ray absorptiometry (DXA) in chronic kidney disese patients (CKD). The aim of the present study was to find if the same applies to patients with ADPKD. We evaluated bone health by measuring BMSi and performing DXA in patients with ADPKD. Method BMSi was measured (OsteoProbe®, Active Life Scientific, USA) in 64 adult patients (37 men, mean age 43 years) with ADPKD in CKD stages G1-4. The measurement of BMSi compared the resistance to impact of microindentation in bone and reference material. After applying local anaesthesia, we impacted the cortical bone in the midshaft tibia in 10 different points. BMD was measured using Hologic Discovery Wi densitometer in multiple sites: lumbar spine, hip, 1/3 distal non-dominant forearm and whole-body. Trabecular bone score (TBS) was calculated using Medimaps TBS iNsight software. Results Mean values of BMSi, TBS and BMD are presented in the Table 1. BMSi in ADPKD patients was lower than average value observed in healthy individuals (85 men and 80 women). A positive linear relationship between BMSi and BMD was found in all of the examined sites with the highest standardized regression coefficient for 1/3 distal forearm (R2 = 0.315, beta = 0.57, p &amp;lt; 0.001) and weakest for lumbar spine (R2 = 0.003, beta = 0.33, p = 0.003). There was no association between BMSi and TBS. Conclusion This is the first report on BMSi in ADPKD patients. In agreement with the notion of a distinct bone phenotype in ADPKD, we observed a median bone material strength index in patients with ADPKD that was lower than the reference value. BMSi associated with BMD, but not with TBS. However, the association with BMD overall is weak, with BMD explaining only 3 to 31% of the variability of BMSi. This observation suggests complementarity and warrants additional studies investigating whether BMSi associates with hard bone endpoints, independent of BMD.

Alone in a cave: Examination of a 5200 BCE skeleton from the Judean Desert, Israel

The remains of a &gt;50-years-old male, thus far representing the only complete skeleton dated to the Early Chalcolithic (Wadi Rabah) period in Israel, were recovered in a cave in the Judaean desert (Nahal Mishmar, F1-003). The old male suffered abscesses in the maxilla following tooth caries, and a well-healed trauma in the left tibial midshaft. Skull and mandibular morphology were described using plain measurements, indices and angles, and compared with similarly taken Chalcolithic data. In addition, mandibular morphology was captured using a landmark-based geometric morphometrics method and compared to Natufian hunter-gatherers, Pre-Pottery Neolithic early farmers, and Late Chalcolithic populations. The results, although cautionary, reveal similarity to the succeeding Ghassulian Chalcolithic period populations and suggest population continuity from the Early to the Late (Ghassulian) Chalcolithic period. Future ancient DNA study may clarify this hypothesis and further reveal population affinity in this period in Israel.

Bone lead variability in bone repository skeletal samples measured with portable x-ray fluorescence

Bone lead serves as a better, more accessible biomarker to many communities experiencing chronic exposure to lead. A new method using low energy x-ray fluorescence in a handheld device (portable XRF) allows us to measure this chronic biomarker in only a few minutes. However, many unknowns remain about this biomarker measured using a new low energy x-ray technique. The low energy of the new method was theorized to measure a slightly different portion of the bone than previous techniques, which could influence measurements at different bone sites and types. We tested how bone measurements varied across five bone sites: mid-tibial shaft, proximal tibia, distal tibia (ankle), ilium, and cranium. We found bone lead measurements are not significantly different between skeletal elements when measured using a portable XRF. On average, bone lead in the repository samples was measured to be 21.6 ± 21.3 μg/g with an XRF detection limit of 2.1 ± 0.5 μg/g. Cumulative lead exposure can be effectively measured using the portable XRF on a variety of bone types, but the tibia should be preferentially measured to compare between studies and individuals.

Hindlimb Skeletal Morphology of the Helmeted Guinea Fowl (Numida meleagridis)

Abstract The Guinea fowl (Numida meleagridis) is a semi-domestic bird whose commercial popularity is on the increase. The gross anatomy of the hindlimbs of 8 helmeted Guinea fowls of equal sexes were studied. The pubic shafts were free, thus they did not fuse ventrally to form a symphysis. The ilium had a quadrilateral and roughly triangular pre and post acetabular wings, respectively. A conspicuous renal fossa was observed in the post acetabular wing. An incomplete concentric obturator foramen, lacking a caudal margin, was formed by the ventral border of the ischium and dorsal border of the cranial pubic shaft, while a prominent ischiopubic fissure was formed by the same bones, caudally. The incomplete concentric nature of the obturator foramen created a common space between it and the ischiopubic fissure. The femoral major trochanter was more proximal than the head, while the minor tro-chanter and the head were on the same horizontal level. The femur lacked a visible pneumatic foramen. The tibiotarsus had a prominent cranial cnemial crest. The fibular spine terminated at the tibia mid-shaft, leaving one interosseous space. An intertarsal sesamoid bone was identified, indicative of an adult skeleton. Crests and channels depicted the hypotarsus. Vascular foramen was identified in the distal extremity of the tibiotarsus. Digit I was oriented to the planter direction. These results, and others, were compared with those of other birds in the available literature, and some morpho-functional paradigm of the Guinea fowl hindlimb skeleton was established.

Application of 3D printed patient-specific instruments in the treatment of large tibial bone defects by the Ilizarov technique of distraction osteogenesis.

The Ilizarov technique of distraction osteogenesis is an effective treatment for tibia defect. However, repeated attempts to reduce due to the complexity of the bone defect during the operation will increase the operation time and iatrogenic injury, and excessive radiation exposure. Three-dimensional (3D)-printed patient-specific instrument (PSI) for preoperative 3D planning and intraoperative navigation have the advantages of accuracy and visualization. The purpose of this study is to investigate whether 3D-printed PSI is helpful to correct tibial bone defects accurately and effectively. From May 2019 to September 2022, 19 patients with tibial bone defects were treated, including 9 males and 10 females, aged 37 to 64 years. There were 4 cases in proximal tibia, 9 in midshaft tibia and 6 in distal tibia. All were treated with Ilizarov technique of distraction osteogenesis. 3D-printed PSI was used in 9 cases, while traditional surgery was used in 10 cases. All patients underwent computed tomography before surgery. Computer software was used to analyze the measurement results, design and print PSI. During the operation, PSI was used to assist in reduction of tibia. Operation times were recorded in all cases, the number of fluoroscopy during the operation, and the varus/valgus, anteversion/reversion angle after the operation were measured. All measurement data were expressed by means ± SD, and Student's t test was used to examine differences between groups. The chi square test or Fisher's precise test was used to compare the counting data of the two groups. All PSI matched well with the corresponding tibia bone defect, and were consistent with the preoperative plan and intraoperative operation. The affected limb had a good reduction effect. The operation time from the beginning of PSI installation to the completion of Ilizarov ring fixator installation was 31.33 ± 3.20 min, while that in the traditional operation group was 64.10 ± 6.14 min (p < 0.001). The times of fluoroscopy in the PSI group during operation was 10.11 ± 1.83, and that in the traditional operation group was 27.60 ± 5.82. The reduction effect of tibia in PSI group was better than that in traditional operation group, with the average angle of PSI group is 1.21 ± 0.24°, and that of traditional operation group is 2.36 ± 0.33° (p < 0.001). The PSI simplifies procedures, reduces the difficulty of the operation, improves the accuracy of the operation, and provides a good initial position when used in distraction osteogenesis to treat the tibial defects.

Zip Line To Fracture Line: An Unusual Cause Of Pediatric Fracture

HISTORY: An 8-year-old male presented to the orthopedic clinic for follow up of a nondisplaced pathologic fracture. He was initially seen at an urgent care center with his mother, presenting with left lower leg pain after falling off a zip line at school. He was diagnosed with a pathologic fracture through an undifferentiated tibial diaphyseal lesion. He was placed in a splint followed by a long leg cast. He was sent for MRI and referred to orthopedic oncology for further diagnostic workup of his bone lesion. PHYSICAL EXAMINATION: Left lower leg: Positive for ecchymosis, swelling, and tenderness to palpation over the middle third of the tibia shaft. There are no gross deformities, skin breakdown, or tense compartments. DIFFERENTIAL DIAGNOSIS: 1.Nonossifying fibroma 2. Bone cyst 3.Osteofibrous dysplasia4. Adamantinoma TESTS AND RESULTS: X-Ray Left tibia/fibula: -“pathologic nondisplaced fracture of the tibia shaft. There is a discrete lesion of the tibia shaft with expansion of the cortex. No obvious periosteal reaction.”MRI Left tibia/fibula-“Distal tibial diaphysis expansile T2 hyperintense/T1 hypointense intramedullary lesion with associated cortical thinning”Follow up X-Ray Left tib/fib (16 weeks after fracture): -“Redemonstrated asymmetrically located lucency in the mid shaft tibia with scalloping.”FINAL/WORKING DIAGNOSIS:Osteofibrous dysplasia TREATMENT AND OUTCOMES:1.Treated with immobilization of the fracture 2.Returned to normal activities without pain at 11 weeks3.MRI showed findings concerning for osteofibrous dysplasia versus adamantinoma4. He had follow-up with the orthopedic oncologist and serial x-rays following the completion of his MRI5. After discussion at tumor board and little change on sequential x-rays, he was treated for presumed osteofibrous dysplasia6.He has since sustained a second pathologic fracture which is currently being treated with immobilization7.The surgery team discussed deferring surgical intervention due to his age

Sex-differences In Bone Density, Geometry, And Estimated Strength Adaptations To 10-weeks Of Military Officer Training

Mechanical loading (e.g. physical activity) is associated with changes in bone density and structure; however, few investigations have examined the adaptive bone response to arduous military training in men and women. PURPOSE Investigate the effects of military training on volumetric bone density (vBMD), geometry, and strength in men and women who complete Marine Corps Officer Candidates School (OCS). METHODS Male and female candidates (n=267) completed a tibial peripheral quantitative computed tomography (pQCT) scan before and after a 10-week physically intensive military training course. Three-dimensional vBMD, geometry, and estimated bone strength were assessed at the 4%, 38%, and 66% sites. Wilcoxon signed-rank tests assessed changes across training. Data are mean±SEM, α=0.05. RESULTS Subjects were aged 19-35 (25.3±0.2 yrs) with a BMI 25.5±0.1 kg/m2. At the distal (4%) tibia, increases in total vBMD (pre: 354.5±2.7, post: 356.3±2.7 mg/cm3), trabecular vBMD (294.3±2.2, 295.6±2.2 mg/cm3), and estimated compression strength (BSI; 154.7±2.2, 156.2±2.1 mg2/mm4) were observed in men (n=222, p<0.001). In women (n=39), total vBMD (324.2±5.1, 326.5±5.2 mg/cm3 p=0.03), trabecular vBMD (262.7±4.8, 264.4±4.9 mg/cm3 p=0.01), and BSI (105.9±3.3, 107.4±3.4 mm3 p<0.01) also increased. At the midshaft (38%) tibia, total vBMD (938.1±3.7, 938.9±3.7 mg/cm3 p=0.03), cortical thickness (6.8±0.1, 6.8±0.1 mm, p<0.01), periosteal circumference (77.0±0.3, 77.1±0.3 mm p<0.01) and estimated bending strength (SSI; 2182.7±25.9, 2193.8±25.1 mm3 p=0.02) increased in men (n=208). In women (n=40), only periosteal circumference increased (70.0±0.6, 70.1±0.6 mm p=0.05). At the proximal (66%) tibia, no significant changes (p>0.05) were observed in men (n=200). In women (n=38), total vBMD decreased (735.9±9.0, 732.7±8.8 mg/cm3 p=0.04) and periosteal circumference increased (82.5±0.9, 82.8±0.9 mm p<0.01) following training. CONCLUSION Bone adaptations in response to 10 weeks of military training are slight (≤1.5%), but statistically significant and may be sufficient to improve estimates of bone strength. Changes are further dependent on biological sex and anatomical location.

Experimental and numerical investigation on ZnP coated Mg-Mn based composite materials for internal fixation of tibia midshaft fracture: A comprehensive study

The study is aimed to assess the role of Ca10(PO4)6(OH)2 (HAp) and Zn3(PO4)2 (ZnP) bioceramics respectively as powder reinforcement and coating agent for magnesium alloys. The nano-sized HAp powder was synthesised and Mg-2Mn-1.5Zn (MZ21) and Mg-2Mn-1.5Zn/1HAp (MZ21/HAp) metal matrix nanocomposites were developed using vacuum-assisted stir casting process in Ar-SF6 protected environment. The chemical conversion coatings of ZnP were prepared on fabricated composites using Teflon lined stainless steel with zinc phosphate-based reaction solution. X-ray diffraction was used to assess the interaction of Mn and Zn on Mg crystal lattice. Microstructural observations were made using optical and scanning electron microscopy with energy dispersive X-ray spectroscopy. Mechanical properties were determined using tensile, hardness and dynamic mechanical analysis. Tensile yield and ultimate strengths of the MZ21 (60.31 ± 0.24 MPa, 142.83 ± 18.40 MPa) and MZ21/HAp (73.41 ± 2.24 MPa, 139.65 ± 16.16 MPa) showed a two-fold increase compared to pure Mg (30.36 ± 2.66 MPa, 73 ± 5.74 MPa). In-vitro studies indicated 10 % and 59 % improvement in cell viability, and 60 % and 33 % reduction in hemolysis rate respectively for MZ21 and MZ21/HAp by employing ZnP, and its bioactivity resulted in increased cell attachment. The effectiveness of the material was biomechanically evaluated and analysed using finite element approach. The results indicated that the developed composites reduced the mechanically shielded region and could provide enhanced healing in transverse tibial shaft fracture.

Intraoperative fluoroscopic protocol to avoid rotational malalignment after nailing of tibia shaft fractures: introduction of the ‘C-Arm Rotational View (CARV)’

PurposeRotational malalignment (≥ 10°) is a frequent pitfall of intramedullary-nailing of tibial shaft fractures. This study aimed to develop an intraoperative fluoroscopy protocol, coined ‘C-Arm Rotational View (CARV)’, to significantly reduce the risk for rotational malalignment and to test its clinical feasibility.MethodsA cadaver and clinical feasibility study was conducted to develop the CARV-technique, that included a standardized intraoperative fluoroscopy sequence of predefined landmarks on the uninjured and injured leg in which the rotation of the C-arm was used to verify for rotational alignment. A mid-shaft tibia fracture was simulated in a cadaver and an unlocked intramedullary-nail was inserted. Random degrees of rotational malalignment were applied using a hand-held goniometer via reference wires at the fracture site. Ten surgeons, blinded for the applied rotation, performed rotational corrections according to (1) current clinical practice after single-leg and dual-leg draping, and (2) according to the CARV-protocol. The primary outcome measure was the accuracy of the corrections relative to neutral tibial alignment. The CARV-protocol was tested in a small clinical cohort.ResultsIn total, 180 rotational corrections were performed by 10 surgeons. Correction according to clinical practice using single-leg and dual-leg draping resulted in a median difference of, respectively, 10.0° (IQR 5.0°) and 10.0° (IQR 5.0°) relative to neutral alignment. Single-leg and dual-leg draping resulted in malalignment (≥10°) in, respectively, 67% and 58% of the corrections. Standardized correction using the CARV resulted in a median difference of 5.0° (IQR 5.0°) relative to neutral alignment, with only 12% categorized as malalignment (≥10°). The incidence of rotational malalignment after application of the CARV decreased from 67% and 58% to 12% (p = <0.001). Both consultants and residents successfully applied the CARV-protocol. Finally, three clinical patients with a tibial shaft fracture were treated according to the CARV-protocol, resulting all in acceptable alignment (<10°) based on postoperative CT-measurements.ConclusionThis study introduces an easy-to-use and clinically feasible standardized intraoperative fluoroscopy protocol coined ‘C-arm rotational view (CARV)’ to minimize the risk for rotational malalignment following intramedullary-nailing of tibial shaft fractures.

Short term outcome of Gustilo Anderson open type 3A mid shaft tibia fractures using intramedullary interlocking nail and external fixator

Aim: The purpose of the present study is to assess the outcome of treating Gustilo Anderson open Type 3A mid shaft tibia fracture with intramedullary interlocking nail as well as external fixator. Methodology: In this prospective cohort study, adult patients (≥18 years-old) with Gustilo 3A open tibia shaft fractures treated by either intramedullary nail or external fixation (EF) were involved. This study was directed for a period of twelve months from March 2021 to February 2022. After registration, patients were followed-up at 2, 6, 10, 14, and 18 weeks postoperatively. At these appointments, degree of callus formation at fracture site and surgical problems (e.g. infection, limb length discrepancy, malalignment) were assessed. Results: Out of 50 patients registered in the study, 26 were treated by IM nail and 24 by external fixation. Twenty-four patients (92.3%) in the IM nail group and 6 (25%) in the external fixation group had callus formation by the 10th week. The mean times to callus formation in the IM nail group and external fixation group were 8.2±2.6 weeks and 14.7±3.3 weeks, individually (p=0.000). Two (7.7%) patients in the IM nail group and 3 (12.5%) in the external fixation group developed infection (p=0.661).