Region Of Tibia Research Articles

Effect of bisphosphonates on periprosthetic bone loss after total knee arthroplasty: a meta-analysis of randomized controlled trials

BackgroundAseptic loosening and osteolysis are the most common indications after TKA for revision surgery. This meta-analysis which included high-quality randomized controlled trials (RCTs) aimed to analyze the effect of bisphosphonates (BPs) on maintaining periprosthetic bone mineral density (BMD) after total knee arthroplasty.MethodsPubMed, AMED, EMBASE, the Cochrane library, ISI Web of Science, and China National Knowledge Infrastructure were systematically searched, five RCTs were included and the total number of participants was 188. The weighted mean differences with 95% confidence interval were calculated to evaluate the efficacy of BPs on total BMD of knee and the BMD of different periprosthetic regions. A descriptive review was performed for BP-related adverse effects.ResultsThe BPs group presented significantly higher total BMD in proximal part of the tibia than the control group at 3 and 6 months (P < 0.05), but no significant difference at 12 months (P = 0.09). The BPs group presented significantly higher BMD in the distal aspect of the femur than that in the control group at 3, 6, 12 months. The BPs group presented significantly higher periprosthetic BMD than that in the control group at 3, 6 and 12 months in tibial medial and lateral metaphyseal region, and femoral anterior, central and posterior metaphyseal region (p < 0.05), but no significant difference for tibial diaphyseal region at 3, 6, and 12 months. None of the included studies described severe or fatal adverse effects related to BPs.ConclusionBPs have a short-term effect on reducing periprosthetic bone loss after total knee arthroplasty. Compared with diaphyseal region, BPs are more effective on the preservation of BMD in medial lateral metaphyseal regions of proximal tibia and in anterior, central, and posterior metaphyseal region of distal femur.

The relationship between accurate 3D measurements of cartilage thickness and radiographic joint space width: data from the osteoarthritis initiative

Purpose: Radiographic joint space width (rJSW) measurement has historically been the preferred measure of disease progression in OA structure modification trials. Magnetic resonance imaging (MRI) can visualise change in multiple tissues, and offers increased sensitivity to change, allowing for shorter trials with fewer patients. In order to compare changes measured using MRI biomarkers with previous studies using rJSW, it is important to understand (1) how well the new biomarkers agree with radiographic measures, and (2) the contribution made by different knee tissues to changes in rJSW. This is challenging, as MR images are normally obtained with the patient in a supine position, while radiographs are taken in a standing position, with the knee slightly flexed. We aimed to assess agreement between accurate 3D MRI measurements of cartilage thickness in the medial tibiofemoral joint and quantified rJSW, in a large dataset. Methods: Analyses were performed on all knees from the Osteoarthritis Initiative at baseline, which had a KL grade and a recorded quantitative measure of joint space width (5726 knees). Cartilage in the central medial regions of the femur and tibia were automatically segmented using a method based on active appearance models, a form of statistical shape model. This method produces highly accurate segmentations (mean accuracy = 0.05 mm, 95th percentile = 0.45, meaning that all errors are less than the average edge length of one voxel). Average thickness of the central medial femur and tibia regions were added to provide a measure of total cartilage thickness. Radiographic JSW measures were provided by the OAI, and were generated using the algorithm-based method of Duryea; for this comparison, we selected a position approximately in the middle of the tibial plateau, also found to be the most responsive in clinical studies (JSW 225). Agreement between the methods was assessed using Bland Altman plots. Results: For KL grades 0, 1 and 2, the systematic bias between rJSW and cartilage thickness was around 1mm, the 95% confidence limits were 1, 1.2 and 1.26 mm respectively (Figure 1). Figure 1 also shows typical examples of MR images for each KL grade within the region in which MR and radiographic measures are taken. For KL grades 0–2, the agreement between measures is close to theoretical agreement limits, which we estimate to be 0.74 mm based on the measurement errors for the methods. In KL3 knees, the bias reduces to 0.4 mm, and the 95% CL increases to 1.69. In KL4 knees, the bias is almost eliminated (0.14 mm). Conclusions: rJSW is composed of various pathologies that are not visualised in radiographs, which consolidate all changes into a single projection. These include cartilage loss, meniscal extrusion and synovial fluid. In healthy knees, and in the early stages of the disease (KL 2), agreement between cartilage thickness and rJSW is excellent – as close as realistically possible in measures of biological systems. The systematic bias of 1mm in KL grade 0–2 knees is most likely contributed by the posterior portion of the medial meniscus which is located within the field of measurement. The decrease in bias at KL3 is probably caused by the increasing damage seen in the menisci, which are less able to keep the bones separate when the patient is standing. At KL4, the meniscus is probably incapable of keeping the bones separate when loaded. The high value for the 95% confidence limits at KL4 are likely due to multiple factors within the knee, including meniscal damage and changes in bone shape, together with the inability of the rJSW method to discriminate the bone edges, once they are very close to each other. Additionally, it can be difficult to position the flexed knee in the radiograph both accurately and reproducibly when there is no clear joint space width, and bone shapes within the joint are altered. There may in fact be 2 groups within the KL4 Bland Altman plot - one group towards the right probably still maintains some joint space width, and perhaps a more competent meniscus, and retains the bias of KL0 to KL3 knees.

Functional outcome of distal third tibial fractures with intramedullary tibial locking nail and poller screws

Back Ground and Objectives: Tibia is the most commonly fractured long bone in the body with an annual incidence of Tibial shaft Fractures is 2 per 1000 individuals. Tibia is a large bone of the body and one of the principle load bearing bone in the lower extremity; Tibial fractures can cause a long morbidity and extensive disability unless treatment is appropriate. Various techniques are now available for the treatment of tibial fractures where the orthopedic surgeon must be aware of the advantages, disadvantages and limitation of each procedure to select the right choice of treatment for each particular patient. In case of tibial fractures the type; location; degree of comminution; age and patient’s social and economic demand may influence the method of treatment. In distal tibia fractures; malunion and stiffness of joint are commonly encountered problems, due to which the use of non-operative treatment of widely displaced distal tibia fractures may result in poor functional outcome. Hence the present study was undertaken to provide satisfactory functional outcome and to know the advantage and complications of the Tibial Interlocking nail with polar screws. Materials and Methods: The present study was conducted in Department of Orthopaedics at Sri Siddhartha medical college, hospital and Research Center Tumkur during the period from August 2015 and July 2017. A total of 30 patients attending the hospital during the study period with closed distal third diaphyseal fracture of Tibia aged more than 18 years who were medically fit for surgery were included in the study. Results: In this study, the mean age of patients with this fractures was 37.2 years and maximum patients were in the age group of 31-40 years. Males predominated in our study. Road traffic accidents are the main cause of fractures followed by fall. In our series most of the cases were transverse fractures 13 patients (43.37%) followed by oblique fractures 9 patients (30%) and 8 patients with spiral fractures (26.7%). All the fractures taken into the account occurred at the distal tibial region. Results were excellent in 93.3% of the patients, good in 6.67% with no fair and no poor cases as graded according to Klemm and Bornner criteria. Conclusion: The method has a long learning curve but with the excellent results, the advantages of rapid rehablitation and relatively few complications recommends this procedure and technique for wider use of distal tibia fractures.

Biological evaluation and finite-element modeling of porous poly(para-phenylene) for orthopaedic implants

Poly(para-phenylene) (PPP) is a novel aromatic polymer with higher strength and stiffness than polyetheretherketone (PEEK), the gold standard material for polymeric load-bearing orthopaedic implants. The amorphous structure of PPP makes it relatively straightforward to manufacture different architectures, while maintaining mechanical properties. PPP is promising as a potential orthopaedic material; however, the biocompatibility and osseointegration have not been well investigated. The objective of this study was to evaluate biological and mechanical behavior of PPP, with or without porosity, in comparison to PEEK. We examined four specific constructs: 1) solid PPP, 2) solid PEEK, 3) porous PPP and 4) porous PEEK. Pre-osteoblasts (MC3T3) exhibited similar cell proliferation among the materials. Osteogenic potential was significantly increased in the porous PPP scaffold as assessed by ALP activity and calcium mineralization. In vivo osseointegration was assessed by implanting the cylindrical materials into a defect in the metaphysis region of rat tibiae. Significantly more mineral ingrowth was observed in both porous scaffolds compared to the solid scaffolds, and porous PPP had a further increase compared to porous PEEK. Additionally, porous PPP implants showed bone formation throughout the porous structure when observed via histology. A computational simulation of mechanical push-out strength showed approximately 50% higher interfacial strength in the porous PPP implants compared to the porous PEEK implants and similar stress dissipation. These data demonstrate the potential utility of PPP for orthopaedic applications and show improved osseointegration when compared to the currently available polymeric material. Statement of significancePEEK has been widely used in orthopaedic surgery; however, the ability to utilize PEEK for advanced fabrication methods, such as 3D printing and tailored porosity, remain challenging. We present a promising new orthopaedic biomaterial, Poly(para-phenylene) (PPP), which is a novel class of aromatic polymers with higher strength and stiffness than polyetheretherketone (PEEK). PPP has exceptional mechanical strength and stiffness due to its repeating aromatic rings that provide strong anti-rotational biaryl bonds. Furthermore, PPP has an amorphous structure making it relatively easier to manufacture (via molding or solvent-casting techniques) into different geometries with and without porosity. This ability to manufacture different architectures and use different processes while maintaining mechanical properties makes PPP a very promising potential orthopaedic biomaterial which may allow for closer matching of mechanical properties between the host bone tissue while also allowing for enhanced osseointegration. In this manuscript, we look at the potential of porous and solid PPP in comparison to PEEK. We measured the mechanical properties of PPP and PEEK scaffolds, tested these scaffolds in vitro for osteocompatibility with MC3T3 cells, and then tested the osseointegration and subsequent functional integration in vivo in a metaphyseal drill hole model in rat tibia. We found that PPP permits cell adhesion, growth, and mineralization in vitro. In vivo it was found that porous PPP significantly enhanced mineralization into the construct and increased the mechanical strength required to push out the scaffold in comparison to PEEK. This is the first study to investigate the performance of PPP as an orthopaedic biomaterial in vivo. PPP is an attractive material for orthopaedic implants due to the ease of manufacturing and superior mechanical strength.

Predictive Validity of Radiographic Trabecular Bone Texture in Knee Osteoarthritis: The Osteoarthritis Research Society International/Foundation for the National Institutes of Health Osteoarthritis Biomarkers Consortium.

To evaluate radiographic subchondral trabecular bone texture (TBT) as a predictor of clinically relevant osteoarthritis (OA) progression (combination of symptom and structural worsening). The Foundation for the National Institutes of Health (FNIH) OA Biomarkers Consortium undertook a study of progressive knee OA cases (n = 194 knees with both radiographic and pain progression over 24-48 months) and comparators (n = 406 OA knees not meeting the case definition). TBT parameters were extracted from a medial subchondral tibial region of interest by fractal signature analysis of radiographs using validated semiautomated software. Baseline TBT and time-integrated values over 12 and 24 months were evaluated for association with case status and separately with radiographic and pain progression status, adjusted for age, sex, body mass index, race, baseline Kellgren/Lawrence grade, baseline joint space width, Western Ontario and McMaster Universities Osteoarthritis Index pain score, and pain medication use. C statistics were generated from receiver operating characteristic curves. Relative to comparators, cases were characterized by thinner vertical and thicker horizontal trabeculae. The summed composite of 3 TBT parameters at baseline and over 12 and 24 months best predicted case status (odds ratios 1.24-1.43). The C statistic for predicting case status using the TBT composite score (0.633-0.649) was improved modestly but statistically significantly over the use of covariates alone (0.608). One TBT parameter, reflecting thickened horizontal trabeculae in cases, at baseline and over 12 and 24 months, predicted risk of any progression (radiographic and/or pain progression). Although associations are modest, TBT could be an attractive means of enriching OA trials for progressors since it can be generated from screening knee radiographs already standard in knee OA clinical trials.

Possibility of quantitative T2-mapping MRI of cartilage near metal in high tibial osteotomy: A human cadaver study.

T2-mapping is a widely used quantitative MRI technique in osteoarthritis research. An important challenge for its application in the context of high tibial osteotomy (HTO) is the presence of metallic fixation devices. In this study, we evaluated the possibility of performing T2-mapping after a HTO, by assessing the extent of magnetic susceptibility artifacts and the influence on T2 relaxation times caused by two commonly used fixation devices. T2-mapping with a 3D fast spin-echo sequence at three Tesla was performed on 11 human cadaveric knee joints before and after implantation of a titanium plate and screws (n = 5) or cobalt chrome staples (n = 6). Mean T2 relaxation times were calculated in six cartilage regions, located in the distal and posterior cartilage of femoral condyles and the cartilage of tibial plateaus, both medially and laterally. T2 relaxation times before and after the implantation were compared with paired t-tests and Wilcoxon rank tests. Due to the extent of the magnetic susceptibility artifact, it was not possible to segment the knee cartilage and thus calculate T2 relaxation times in the lateral weight-bearing femoral and tibial cartilage regions only in the cobalt chrome group. In all cartilage regions of the titanium implanted knees and those unaffected by artifacts due to cobalt chrome implants, T2 relaxation times did not significantly differ between the two scans. Our results suggest that accurate T2-mapping after a HTO procedure is possible in all areas after implantation of a titanium fixation device and in most areas after implantation of a cobalt chrome fixation device. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1206-1212, 2018.

Bone replaces articular cartilage in the rat knee joint after prolonged immobilization

BackgroundLost joint range of motion (ROM) is common in chronic osteoarthritis, alters regional weight-bearing across the articular surfaces, and contributes to loss of cartilage and bone alterations. Limited data exist on the regional effects on joints subjected to chronic losses of ROM. ObjectiveTo characterize the regional replacement by bone as part of articular cartilage degeneration after prolonged immobilization. MethodsEleven rat knees were rigidly-immobilized in flexion for 32weeks with contralateral and sham-operated (n=6) knees as controls. Sagittal medial tibial epiphysis histological sections assessed the anterior (non-weight-bearing), middle and posterior (both weight-bearing) regions. We quantified the distribution of collagen I, collagen II, cartilage thickness, glycosaminoglycan (GAG) staining, Mankin scoring, and subchondral bone plate cross-sectional area. Using immunohistochemistry (IHC), we visualized blood vessels, osteoblasts, and mesenchymal stem cells (MSCs). ResultsImmobilized cartilage had increased collagen I content in the anterior tibial region with picrosirius red staining (immobilized=61±20%; contralateral=43±12%, p=0.033; sham=20±10%, p=0.028) and collagen I IHC (immobilized=40±10%; contralateral=11±4%, p=0.003; sham=5±3%, p=0.043). Articular cartilage was thinner anteriorly (18±30μm) in immobilized knees versus contralateral (124±40μm, p<0.001) and sham (125±43μm, p=0.043). GAG staining covered 2±4% of the anterior articular area in immobilized knees versus 28±12% contralaterally (p=0.003) and 26±7% in sham (p=0.043). Mankin scores in immobilized knees were 4.7±1.7 versus 0.2±0.4 and 0±0 for contralateral and sham (p=0.003, p=0.042), respectively. The trabecular bone plate area of anterior and posterior regions showed relative loss of cross-sectional area in immobilized knees compared to controls (immobilized/contralateral area ratios of 0.67 and 0.46 respectively, both p=0.003), while the area in the middle region was preserved. Movat's pentachrome stain and CD31 staining showed chondral vascular ingrowth from subchondral bone. Osteocalcin and CD90 MSC staining were decreased in immobilized knees versus contralateral (p=0.003, p=0.036 respectively). ConclusionsBony replacement characterizes articular cartilage degeneration of knees immobilized for 32weeks in the anterior, non-weight bearing region of the tibia. Replacement of cartilage by bone may have been mediated by chondral vascularization, suggesting irreversible changes. These findings stress the importance of weight-bearing and joint motion to maintain cartilage structure.

Evaluating the efficacy of functional electrical stimulation therapy assisted walking after chronic motor incomplete spinal cord injury: effects on bone biomarkers and bone strength

Objectives: To determine the efficacy of functional electrical stimulation therapy assisted walking (FES-T) compared to a conventional aerobic and resistance training (CONV) with respect to bone biomarkers and lower extremity bone strength outcomes among adults with chronic motor incomplete spinal cord injury (SCI). Design: Parallel group randomized controlled trial (www.clinicaltrials.gov - NCT0020196819). Site: Tertiary academic rehabilitation centre in Canada. Methods: Adults with chronic (≥18 months) motor incomplete SCI (C2-T12 AIS C-D) were consented and randomized to FES-T or CONV training for 45 minutes thrice-weekly for 4 months. Osteocalcin (OC), β-cross laps (CTX) and sclerostin were assessed at baseline, and 4 months. Similarly, total hip, distal femur and proximal tibia region bone mineral density (BMD) via DXA (4500A, Hologic Inc. Waltham, MA, USA) and tibia bone quality via pQCT (Stratec XCT-2000, Mezintecknik, Pforzheim, Germany) were assessed at baseline, 4, and 12 months. Between group differences were analyzed using repeated measures general linear models. Results: Thirty-four participants (17 FES-T, 17 CONV) consented and were randomized, 27 participants completed the 4-month intervention and 12-month outcome assessments. Participants in the FES-T arm had a decrease in CTX and a significant increase in OC at intervention completion (P<0.05). Significant biomarker changes were not observed in the CONV group. No within or between group differences from baseline were observed in sclerostin or bone strength. Conclusions: Four months of FES-T improved bone turnover (increase in OC and decrease in CTX) but not bone strength among individuals with chronic SCI. Future, long term FES-T may augment lower extremity bone strength.

Repeatability of gait pattern variables measured by use of extremity-mounted inertial measurement units in nonlame horses during trotting.

OBJECTIVE To determine repeatability of gait variables measured by use of extremity-mounted inertial measurement units (IMUs) in nonlame horses during trotting under controlled conditions of treadmill exercise. ANIMALS 10 horses. PROCEDURES Six IMUs were strapped to the metacarpal, metatarsal, and distal tibial regions of each horse. Data were collected in a standardized manner (3 measurements/d on 3 d/wk over a 3-week period) while each horse was trotted on a treadmill. Every measurement consisted of a minimum of 20 strides from which a minimum of 10 strides was selected for analysis. Spatial and temporal variables were derived from the IMUs. Repeatability coefficients based on the within-subject SD were computed for each gait analysis variable at each week. RESULTS Most of the temporal and spatial variables had high repeatability (repeatability coefficients < 10), and the repeatability coefficients were consistent among the 3 weeks of data collection. Some spatial variables, specifically the symmetry variables (which were calculated from other variables), had somewhat higher repeatability coefficients (ie, lower repeatability) only in the last week. CONCLUSIONS AND CLINICAL RELEVANCE With the exceptions of some symmetry variables, which may reflect individual variations during movement, the extremity-mounted IMUs provided data with high repeatability for nonlame horses trotting under controlled conditions of treadmill exercise. Repeatability was achieved for each instrumented limb segment with regard to the spatial relationship between 2 adjacent segments (joint angles) and the temporal relationship among all segments (limb phasing). Extremity-mounted IMUs could have the potential to become a method for gait analysis in horses.

Posterior plating of tibial shaft fractures: A functional outcome analysis

Tibial shaft fractures are the most common of long bone fractures. Tibial fractures are usually the result of trauma, both high energy and low energy. Increasing energy of injury leads on to both bone and soft tissue complications. Approximately 25 % of both bone fractures of leg are open fractures requiring external fixation or wound debridement with resultant problems in wound healing by secondary intention. A few often require secondary procedures for internal fixation which might get infected leading on to a vicious cycle implant exit, external fixation, wound debridement. Posterior tibial plating aims at avoiding the vicious cycle by providing primary internal fixation. We have reported a case series of patients who got operated for fracture tibia with posterior tibial plating, patients were followed up and functional outcome is reported in this study. Materials & Methods: Patients who had sustained lower limb fractures were examined and those patients with fracture at distal diametaphyseal region of tibia along with minor soft tissue injuries (Gustilo Anderson Type I and Type II) were chosen. Patients with fracture both bone leg with open physes were also included. We treated three patients with posterior plating of tibia. Results: Bone Union was achieved in all three patients with all of them bearing full weight at the end of four months. Conclusion: Posterior tibial plating adds another viable alternative in treating distal diametaphyseal fractures with soft tissue compromise or open physes.

Joint loading and proximal tibia subchondral trabecular bone microarchitecture differ with walking gait patterns in end-stage knee osteoarthritis.

To (1) stratify patient subgroups according to their distinct walking gait patterns in end-stage knee osteoarthritis (OA); (2) compare measures of joint loading and proximal tibia subchondral trabecular bone (STB) microarchitecture among these gait subgroups. Twenty-five knee OA patients undergoing total knee arthroplasty (TKA) had pre-operative gait analysis. Following surgery, excised tibial plateaus were micro-CT-scanned and STB microarchitecture analysed in four tibial condylar regions of interest. Peak knee moments were input to k-means cluster analysis, to identify subgroups with homogeneous gait patterns. Joint loading and STB microarchitecture parameters were compared among gait subgroups (Kruskal-Wallis, Bonferroni-corrected Mann-Whitney U tests). Three gait subgroups were revealed: biphasics (n=7), flexors (n=9), counter-rotators (n=9). Peak knee adduction moment (KAM) and KAM impulse were significantly higher (P<0.05) in biphasics than in flexors and counter-rotators (KAM=-0.65, -0.40 and -0.21Nm/kg, respectively), suggesting a higher medial-to-lateral tibiofemoral load ratio in biphasics. Interestingly, STB medial-to-lateral bone volume fraction (BV/TV) ratio was also significantly higher (more than double) in biphasics and flexors than in counter-rotators (2.24, 2.00 and 1.00, respectively), whereas in biphasics it was only 10% higher than in flexors and not significantly so. Within the confines of the limited sample size, data suggests that different mechanisms between the biphasic and flexor gait subroups may generate comparable loads upon the tibial plateau and corresponding bony responses, despite significantly lower KAM indices in flexors. Hence, in flexor gait OA patients, conservative treatments designed to reduce KAM, may not be appropriate. Understanding joint loading among walking gait patterns and relationships to bone microarchitecture may aid at identifying/improving management of persons at risk for developing knee OA.

Differences in tibial subchondral bone structure evaluated using plain radiographs between knees with and without cartilage damage or bone marrow lesions - the Oulu Knee Osteoarthritis study

ObjectivesTo investigate whether subchondral bone structure from plain radiographs is different between subjects with and without articular cartilage damage or bone marrow lesions (BMLs).MethodsRadiography-based bone structure was assessed from 80 subjects with different stages of knee osteoarthritis using entropy of Laplacian-based image (ELap) and local binary patterns (ELBP), homogeneity index of local angles (HIAngles,mean), and horizontal (FDHor) and vertical fractal dimensions (FDVer). Medial tibial articular cartilage damage and BMLs were scored using the magnetic resonance imaging osteoarthritis knee score. Level of statistical significance was set to p < 0.05.ResultsSubjects with medial tibial cartilage damage had significantly higher FDVer and ELBP as well as lower ELap and HIAngles,mean in the medial tibial subchondral bone region than subjects without damage. FDHor, FDVer, and ELBP were significantly higher, whereas ELap and HIAngles,mean were lower in the medial trabecular bone region. Subjects with medial tibial BMLs had significantly higher FDVer and ELBP as well as lower ELap and HIAngles,mean in medial tibial subchondral bone. FDHor, FDVer, and ELBP were higher, whereas ELap and HIAngles,mean were lower in medial trabecular bone.ConclusionsOur results support the use of bone structural analysis from radiographs when examining subjects with osteoarthritis or at risk of having it.Key points• Knee osteoarthritis causes changes in articular cartilage and subchondral bone• Magnetic resonance imaging is a comprehensive imaging modality for knee osteoarthritis• Radiography-based bone structure analysis can provide additional information of osteoarthritic subjects

Utilization of Whole-Exome Next-Generation Sequencing Variant Read Frequency for Detection of Lesion-Specific, Somatic Loss of Heterozygosity in a Neurofibromatosis Type 1 Cohort with Tibial Pseudarthrosis

A subset of neurofibromatosis type 1 patients develop tibial dysplasia, which can lead to pseudarthrosis. The tissue from the tibial pseudarthrosis region commonly has a somatic second hit in NF1: single-nucleotide variants, small deletions, or loss of heterozygosity (LOH). We used exome next-generation sequencing (NGS) variant frequency data (allelic imbalance analysis) to detect somatic LOH in pseudarthrosis tissue from three individuals with clinically and diagnostically confirmed neurofibromatosis type 1, and verified the results with microarray. The variant files were parsed and plotted using python scripts, and the NGS variant frequencies between the affected tissue and blood sample were compared. Individuals without somatic single-nucleotide variants or small insertions/deletions were tested for somatic LOH using the NGS variant allele frequencies. One individual's NGS data indicated no LOH in chromosome 17. The other two individuals demonstrated somatic LOH inclusive of NF1: one had an LOH region of approximately one million bases and Contra (NGS copy number program) indicated a somatic deletion and the other individual had LOH for most of chromosome 17q and Contra indicated no copy number change (microarray data verified this sample as copy neutral somatic LOH). Both LOH and copy number variation detected by NGS data correlated with microarray data, demonstrating the somatic LOH second hit can be detected directly from the NGS data.

MRI is not reliable in diagnosing of concomitant anterolateral ligament and anterior cruciate ligament injuries of the knee.

There has been a renewed interest in the anterolateral structures of the knee, including description of the anterolateral ligament (ALL) as a distinct structure. Recognizing injury to the ALL is challenging, particularly given the subjective nature of physical examination. Consequently, focus has turned to magnetic resonance imaging (MRI) to reach a preoperative diagnosis of this region. The aim of this study was to examine the ability of 3-Tesla (3T) MRI to identify the ALL in ACL-injured patients compared to a matched control group of ACL-intact patients. The hypothesis was that the ALL would be more difficult to identify in ACL-injured patients compared to ACL-intact patients. A prospective case control study was performed comparing 3T MRI scans of 63-patients with an ACL rupture with a control group of 64-patients without ACL injury. An experienced musculoskeletal radiologist and an orthopaedic surgeon evaluated the scans performed using standard knee protocols. The ALL was considered in three regions for analysis: femoral, meniscal, and tibial. The status of the ALL was determined as visualized or non-visualized, and the integrity was assessed as intact, attenuated, or focal discontinuity. The detection rate of at least a portion of the ALL was 41/64 (64%) in the control group and 45/63 (72%) in the ACL-injured cohort, respectively. The entire length of the ALL could only be identified in 15/64 (23%) of the control group and 13/63 (21%) of the ACL-injured cases. In both groups, the visibility of the ALL was poorest at the femoral region and greatest at the tibial regions. The ALL, when visualized, was deemed to be intact in 55/63 (87%) of cases. Although the inter-observer reliability was excellent for detection of the ALL in the control group (κ=0.86), this decreased to only moderate reliability in the ACL-injured group (κ=0.52). This study demonstrates that MRI alone should not be relied upon to make a diagnosis of ALL injury in the setting of concomitant ACL injury due to the inability to accurately visualize this structure consistently in its entirety. To make a diagnosis of ALL injury or anterolateral instability of the knee and clinical correlation remains essential. Case-control study, Level III.

Two cases of asymptomatic rib exostosis treated by prophylactic surgical excision

Abstract Exostosis is one of the most common benign bone lesions. It could be a solitary lesion or multiple lesions presented as part of HME. This condition often affects the metaphyseal region of long bones, including femur, tibia, humerus and ribs. Rib exostosis may cause severe complications such as pneumothorax, hemothorax, and diaphragmatic injury. We report two patients with asymptomatic rib exostosis who underwent surgical excision to prevent severe complications. The first patient was a 13-year-old male with HME. At the eight-year follow-up, the size of the exostosis at the left ninth rib was found to have increased to 5 cm in diameter and it compressed the diaphragm. Surgical excision was performed to prevent possible complications. The second patient was a 10-year-old male with HME. At the seven-year follow-up, the size of the exostosis at the right fourth rib was found to have increased to 5 cm in diameter and it protruded into the thoracic cavity. Surgical excision was performed to prevent possible complications. Both patients recovered uneventfully. The periodic evaluation of the size and shape of rib exostosis is important in HME patients, because we must judge the proper timing for surgical excision to prevent severe complications.

Ultra-short stem anchorage in the proximal tibial epiphysis after intercalary tumor resections: analysis of reconstruction survival in four patients at a mean follow-up of 56 months.

Tumors localized in the proximal tibial meta-diaphysis often lead to osteoarticular resections. In this study, we retrospectively reviewed four patients who underwent intercalary tumor resection and reconstruction using an ultra-short stem in the proximal tibial epiphysis, a procedure that to our knowledge has not been reported in literature so far. At the time of operation, the mean patient age was 26.2 years. Three patients were male and one was female. Patients were diagnosed with osteosarcoma in two cases, Ewing's sarcoma and malignant fibrous histiocytoma of bone in one case each. In all cases, wide tumor resections were achieved (osteotomy 3-3.5cm below the tibia plateau joint surface, mean resection length of tibial bone 18cm) at a mean time of operation of 198.8min. Two superficial wound-healing disorders occurred, leading to one surgical revision in each case. One local tumor recurrence occurred 12 months after operation in a patient who discontinued his adjuvant chemotherapy. This patient died of disease, 31 months after operation. Three patients are alive with no evidence of disease at a mean follow-up of 56 months. Walking is not impaired and light sports activities have been reported in all cases. The mean MSTS score is 28/30. Therefore, we report this reconstruction technique to be considered for special indications where the functional outcome can be improved by preservation of the knee joint in tumors of the proximal meta-diaphyseal tibial region.

Effects of Surgical Factors on Cartilage Can Be Detected Using Quantitative Magnetic Resonance Imaging After Anterior Cruciate Ligament Reconstruction

Background: Quantitative magnetic resonance (qMR) can be used to measure macromolecules in tissues and is a potential method of observing early cartilage changes in the development of posttraumatic osteoarthritis. Hypothesis/Purpose: We hypothesized that specific patient and surgical factors affecting cartilage matrix composition after anterior cruciate ligament (ACL) reconstruction (ACLR) can be detected using T1ρ and T2 relaxation times. Our purpose was to demonstrate this ability in a multicenter feasibility study. Study Design: Case series; Level of evidence, 4. Methods: A total of 54 patients who underwent ACLR underwent bilateral MRI at baseline before surgery and 6 months postoperatively. Operative findings were recorded. T1ρ and T2 relaxation times were calculated for 6 cartilage regions: the medial femur, lateral femur, medial tibia, lateral tibia, patella, and trochlea. A paired t test compared relaxation times at baseline and 6 months, univariate regression identified regions that influenced patient-reported outcome measures, and analysis of covariance was used to determine the surgical factors that resulted in elevated relaxation times at 6 months. Results: The injured knee had significantly prolonged T1ρ and T2 relaxation times in the tibiofemoral compartment at baseline and 6 months but had shorter values in the patellofemoral compartment compared with the uninjured knee. Prolonged T1ρ and T2 times at 6 months were noted for both the injured and uninjured knees. At 6 months, prolongation of T1ρ and T2 times in the tibial region was associated with lower patient-reported outcome measures. ACLR performed within 30 days of injury had significantly shorter T1ρ times in the tibial regions, and lateral meniscal tears treated with repair had significantly shorter T1ρ times than those treated with excision. Conclusion: Prolonged relaxation times in multiple regions demonstrate how the injury affects the entire joint after an ACL tear. Changes observed in the uninjured knee may be caused by increased loading during rehabilitation, especially in the patellofemoral articular cartilage and distal femur. Relaxation times in the tibial regions may be predictive of patient symptoms at 6 months. These same regions are affected by surgical timing as early as 30 days after injury, but this may partially be reflective of the severity of the preoperative injury and the choice of treatment of meniscal tears.

Surgical management of severe trauma involving group of muscles around the brisket of Dongola breed of horse:A case report

Equine wound management is challenging to the veterinarian in practice. This paper presents the successful management outcome of a large wound on the brisket of a seven and half years old Dangola Stallion horse sustained from a road traffic accident. There was traumatic shearing off of the skin including the dermis and fascia of the thoracic inlet beginning from the ventral caudal end of the neck to the cranial border of both shoulders and there were two open wounds on the medio-cranial aspect of the right tibial region just below the elbow joint. All physiological parameters were within normal range. Continuous suture and interrupted patterns were used during the surgical procedure until all the exposed muscles were apposed. The surgery was successful, with good post operative care, the wound healed properly.

Physiotherapy-related impacted proximal tibia metaphyseal fracture in a child with myelomeningocele

Pediatric cases with myelomeningocele are susceptible to fractures of lower extremities. Impacted proximal tibial metaphyseal fractures are uncommon injuries in pediatric age and peak around 3–6 years of age. Impacted fracture in proximal tibia region consists of periosteal buckling associated with compression load, particularly in metaphyseal area. Proximal tibial is an uncommon site for impacted fractures and the injury pattern in a child with paraplegia associated with myelomeningocele has been a rare report. As the displacement of the fracture is main concern, so a good splinting is the mainstay of treatment. Our report depicts a rare site of fracture in this subset of patients as well as treatment consideration in the form of short-term, light weight and fabricated bracing as the splints. Periodic supervised assessment for recurrence or de novo comorbidities as well as proper nutrition and therapy for osteomalacia is instrumental as part of the holistic management of such cases.

Tuberculosis of knee joint mimicking giant cell tumor – A case report

A 50-year-old woman presented with pain, swelling, and reduced range of motion of right knee joint since one year. Radiograph of knee joint revealed eccentric, expansile, geographic lytic lesion on the medial epiphyseal region of tibia mimicking giant cell tumor (GCT). She underwent minimally invasive biopsy, which was positive for acid-fast bacilli and revealed necrotizing chronic granulomatous lesion, diagnostic of tuberculosis (TB). This case emphasizes to consider tuberculosis arthritis as differential diagnosis when a case of destructive giant cell tumor is encountered.