Trochanteric Area Research Articles

Pedicled ALT-flap for soft tissue reconstruction in the trochanteric area.

Coverage of soft tissue defects following surgery at the trochanteric area is challenging. Revision surgery in case of compromised wound healing may lead to soft tissue defects requiring reconstruction with pedicled or free flaps. Previous access to the hip joint may jeopardize neurovascular structures relevant to the flap. In this study, we evaluated if the use of a pedicled anterior lateral thigh (ALT) flap is a valuable option for soft tissue reconstruction. In this retrospective study, seven patients were included. Defect etiology was tumor resection in one case, screw osteosynthesis in another case and total hip arthroplasty in three cases. All patients underwent reconstruction by proximal pedicled anterior lateral thigh (ALT) flap. Pedicled ALT flap was a safe procedure in all cases. One patient showed delayed wound healing with need for additional surgery. No further complications were observed. Pedicled ALT flap transfer represents a reliable option for soft tissue coverage in the trochanteric area after primary surgery such as hip arthroplasty, osteosynthesis or tumor resection.

EVALUATION OF SURGICAL TREATMENT RESULTS FOR FRACTURES IN THE TROCHANTERIC AREA USING LOCKING PLATES AT HA DONG GENERAL HOSPITAL

Objectives: To evaluate the results of surgery to treat adult fractures in the trochanteric area using locking plates at Ha Dong General Hospital. Methods: A retrospective, cross-sectional descriptive study on 30 patients with fractures in the trochanteric area who underwent surgery with locking plates, followed up, and re-examined at Ha Dong General Hospital from January 2018 to February 2022. Results: The main cause of injury was daily life accidents (63.3%). Classification according to AO: Type A1 fractures accounted for 13.3%, type A2 fractures were 56.7%, and type A3 fractures were 30%. The average hospital stay was 12.3 days. The anatomical correction results were 90% good and 10% not good. Bone healing results: Good bone healing was 96.7%; poor bone healing was 3.3%, with no cases of osteoarthritis or pseudoarthritis. The results of good and very good walking function were 86.7%, and poor walking function was 3.3%. Overall results: Very good and good accounted for 86.7%, average was 10%, and poor results was 3.3%. Conclusion: Fractures in the femoral trochanter area are mainly caused by daily life accidents. Bone union with locking plates is a good treatment method for patients with fractures in the trochanteric area helping to firmly fix fractures, allowing patients to exercise and practice early rehabilitation. It is convenient for patients to return to daily life, reducing the rate of complications encountered, thereby improving the quality of life for patients and reducing the burden on families and society.

Low Molecular Weight Hyaluronic Acid Added to Six Specific Amino Acids in the Treatment of Striae Alba (SA): An Observational Study

Striae distensae or stretch marks are a common complaint among women and can be distressing. The present study aimed to assess the efficacy of a mixture of low molecular weight hyaluronic acid and six amino acids when applied with a specific intradermal injection technique known as intra-mural fluid technique. A clinical study was carried out in 32 patients (with a dropout rate by 9.4%) with striae distensae alba (SA) in one or more of the following anatomical areas: breast, abdomen, inner thigh, trochanteric area, gluteal area, posterior supra-iliac area, and lumbar area. Product efficacy was assessed by the investigator using the Global Aesthetic Improvement Scale, while a Likert scale was used to evaluate to score the treatment tolerability and a QoL stretch marks questionnaire was used to investigate the patients’ self-body image. The treatment was effective in improving the appearance of SA fifteen days after the second treatment and 6 months after the first treatment (and after a total of 4 treatments). The product efficacy and tolerability were also perceived by the patients during each treatment session. Our results suggest that the test treatment is a valid treatment option to decrease the appearance of SA.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266

Usefulness of fat-containing agents: an initial study on estimating fat content for magnetic resonance imaging.

This initial study aimed at testing whether fat-containing agents can be used for the fat mass estimation methods using magnetic resonance imaging (MRI). As an example for clinical application, fat-containing agents (based on soybean oil, 10% and 20%), 100% soybean oil, and saline as reference substances were placed outside the proximal femurs obtained from 14 participants and analyzed by 0.3T MRI. Fat content was the estimated fat fraction (FF) based on signal intensity (SIeFF, %). The SIeFF values of the femoral bone marrow, including the femoral head, neck, shaft, and trochanter area, were measured. MRI data were compared in terms of bone mineral content (BMC) and bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA) in the proximal femur. Twelve pig femurs were also used to confirm the correlation between FF by the DIXON method and SIeFF. According to Pearson's correlation coefficient, the SIeFF and total BMC and BMD data revealed strong and moderate negative correlations in the femoral head (r < - 0.74) and other sites (r = - 0.66 to - 0.45). FF and SIeFF showed a strong correlation (r = 0.96). This study was an initial investigation of a method for estimating fat mass with fat-containing agents and showed the potential for use in MRI. SIeFF and FF showed a strong correlation, and SIeFF and BMD and BMC showed correlation; however, further studies are needed to use SIeFF as a substitute for DXA.

Tuberculous trochanteric bursitis in an immunocompetent patient

Musculoskeletal Tuberculosis occurs in 1%–3% of patients with tuberculosis, and Tuberculous trochanteric bursitis (TTB) is responsible for 1%, assuming it as a rare clinical condition, especially if it occurs in immunocompetent patients. This is a case report about a 51 years old man, with pain in right trochanteric area, without swelling or inflammatory signs, 1 year of evolution. About 20 years ago, he suffered an infected traumatic local hematoma. Ultrasound revealed trochanteric bursitis. He was then submitted to a bursectomy. Histological study revealed chronic necrotizing granulomatous bursitis, with negative Acid-Fast Bacillus (AFB) Tests. After 6 mouths the patient suffer relapse of his complains. The MRI revealed intraosseous edema of the great right trochanter, inflammation of adjacent soft tissues and small infratrochanteric collection. Analytically, CRP of 1.24 mg/dl and positive interferon Gamma. A new bursectomy and curettage were performed with sequestrectomy. Lowestein culture was positive for AFB, it was identified protein MPT64, and a positive DNA Mycobacterium tuberculosis complex research. It was associated medical treatment with antibiotics (12 months). Currently with clinical and imaging improvement, without relapse, after 1 and a half years of follow-up. Usually, TTB arises from the reactivation of an unknown primary infection, whose clinical presentation is often vague, characterized by chronic symptoms. This condition should be considered in the diagnostic discussion whenever a case of recurrent bursitis arises despite the treatment instituted. With the decline in the incidence of tuberculosis, the number of clinical cases of TTB described in the recent literature has decreased considerably, with special attention being given to the reporting and sharing of these cases, with the goal of keeping this diagnosis in perspective in the discussion and orientation of cases of trochanteric bursitis.

Traumatic hip luxation in an orange‐spined hairy dwarf porcupine (Sphiggurus villosus)

AbstractA free‐ranging adult, 1.59‐kg, female orange‐spined hairy dwarf porcupine (Sphiggurus villosus) was presented due to inability to locomotion. Ventrodorsal and lateral radiographs of the pelvis showed craniodorsal luxation of the right hip joint, and ischial fracture on the left side. Femoral head and neck ostectomy was performed, but the lesser trochanter was preserved. At the final evaluation, 2 months after the surgery, the porcupine showed full weight‐bearing on the right hindlimb, with no signs of lameness. Range of motion of the hip joints showed a decrease in the right hip joint, but crepitation was not observed in palpation. On radiographs, no bony proliferation was seen along the osteotomy line or in the area of the lesser trochanter, and the right and left trochanter were on the same level. The animal was released back into its natural habitat.

Alteration in Microcirculation With Osteonecrosis of the Femoral Head: A Study of Dynamic Contrast-Enhanced MRI.

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is commonly used in clinical practice to detect tumor blood supply, and it has recently been applied to assess skeletal vasculature. In this study, we retrospectively analyzed DCE-MRI data from 37 patients with osteonecrosis of the femoral head to evaluate alterations in microvascular circulation of the femoral head. Time-intensity curves (TICs) in the region of interest were classified into different lesion stages. In the greater trochanter area, extracellular space volume per unit volume of tissue was significantly higher in Association Research Circulation Osseous (ARCO) stage III than in ARCO stage II (P<.05 and power ≥ 0.8), while other parameters showed no statistical difference (P>.05 and/or power < 0.8). In the necrotic area, contrast enhancement ratio and maximum slope of increase were significantly lower in ARCO stage III than in ARCO stage II (P<.05 and power ≥ 0.8), while other parameters showed no statistical difference (P>.05 and/or power < 0.8). In the repair reaction area, all parameters were significantly higher in ARCO stage III than in ARCO stage II (P<.05 and power ≥ 0.8). TIC classification showed that the greater trochanter area mainly exhibited type C (plateau type), the necrotic area mainly exhibited type B (out-flow type), and the repair reaction area mainly exhibited type A (inflow type). We believe that the exchange capacity of the vessels has a much greater impact on femoral head necrosis than the number of vessels, while the generation of the repair area greatly affects the prognosis of femoral head necrosis. These findings suggest that DCE-MRI can provide a good assessment of osteonecrosis of the femoral head perfusion and can serve as a new reference for clinical treatment decisions. [Orthopedics. 2024;47(2):e73-e78.].

The association between dietary inflammation index and bone mineral density: results from the United States National Health and nutrition examination surveys

Objective To investigate the associations of dietary inflammation index (DII) with bone density and osteoporosis in different femoral areas. Methods The study population was selected from the National Health and Nutrition Examination Survey (NHANES) with the exclusion criteria of age 18, pregnancy, or missing information on DII, femoral bone marrow density (BMD), estimated glomerular filtration rate (eGFR), and urine albumin-to-creatinine ratio (UACR), or had diseases which may influence systemic inflammation. DII was calculated based on the questionnaire interview of dietary recall within 24 h. Subjects’ baseline characteristics were collected. The associations between DII and different femoral areas were analyzed. Results After applying exclusion criteria, 10,312 participants were included in the study. Significant differences among DII tertiles were found in BMD or T scores (p < .001) of the femoral neck, the trochanter, the intertrochanter, and the total femur. High DII was associated with low BMDs and T scores in all the femoral areas (all p < .01). Compared to low DII (tertile1, DII < 0.380 as reference), in the femoral neck, the intertrochanter, and the total femur, increased DII is independently associated with increased the possibility of the presence of osteoporosis (OR, 95% CI: 1.88, 1.11–3.20; 2.10, 1.05–4.20; 1.94, 1.02–3.69, respectively). However, this positive association was only observed in the trochanteric area of the non-Hispanic White population after full adjustment (OR, 95% CI: 3.22 (1.18, 8.79)). No significant difference in the association of DII and the presence of osteoporosis were found in subjects with or without impaired kidney function (eGFR < 60 ml/min/1.73 m2). Conclusion High DII is independently related to declined femoral BMD of femoral areas.

Surface profile analysis of laminated transfemoral prosthetic socket fabricated with different ratios of epoxy resin and acrylic resin

Acrylic and epoxy are common types of resin used in fabricating sockets. Different types of resin will affect the internal surface of a laminated socket. This paper is to determine the best combination of ratio for epoxy and acrylic resin for a laminated prosthesis socket and to evaluate the surface profile analysis of different combinations of laminated prosthetic sockets for surface roughness. Transfemoral sockets were created using various resin-to-hardener ratios of 2:1, 3:1, 3:2, 2:3, and 1:3 for epoxy resin and 100:1, 100:2, 100:3, 100:4, and 100:5 for acrylic resin. Eight layers of stockinette consisting of four elastic stockinette and four Perlon stockinette were used. A sample with a size of 4 cm × 6 cm was cut out from the socket on the lateral side below the Greater Trochanter area. The Mitutoyo Sj-210 Surface Tester stylus was run through the sample and gave the Average Surface Roughness value (Ra), Root Mean Square Roughness value (Rq), and Ten-Point Mean Roughness value (Rz). Epoxy resin shows a smoother surface compared to acrylic resin with Ra values of is 0.766 µm, 0.9716 µm, 0.9847 µm and 1.5461 µm with 3:2, 3:1, 2:1 and 2:3 ratio respectively. However, for epoxy resin with ratio 1:3, the resin does not cure with the hardener. As for acrylic resin the Ra values are 1.0086 µm, 2.362 µm, 3.372 µm, 4.762 µm and 6.074 µm with 100: 1, 100:2, 100:5, 100:4 and 100:3 ratios, respectively. Epoxy resin is a better choice in fabricating a laminated socket considering the surface produced is smoother.

Pedicled anterolateral thigh flap: A versatile flap for complex regional defect reconstruction.

Soft-tissue defects of the lower abdomen, perineum, groin, and trochanteric area often involve the loss of composite tissue components and are technically challenging to reconstruct. The goals of reconstruction should include the replacement of the defect with a suitable soft-tissue flap that provides stable coverage while protecting important exposed structures. However, there are limited locations in this region for the creation of pedicled flaps for complex defect reconstruction. The pedicled anterolateral thigh (ALT) flap is considered superior to other comparable flaps due to its varying soft-tissue components and long pedicle with consistent anatomy that allow the reconstruction of locations that are difficult to reach without significant flap donor site morbidity. Herein, we present a case series of our experience of using a pedicled ALT flap to reconstruct regional defects over a range of locations. The present study comprised ten patients who underwent surgical reconstruction of soft-tissue defects of the lower abdomen, groin, trochanteric, scrotal, and penoscrotal defects using a pedicled ALT flap over a two-year period. The flap was customized according to the defect when required. In our case series, flap loss was not observed with only a few minor complications. All patients accepted the aesthetic appearance of the flap recipient site area without requesting revision surgery. The donor site was closed primarily in half of all cases, with split skin grafting applied in the remaining patients. Graft take at the flap donor site was satisfactory in all cases. A pedicled ALT flap is a reliable and suitable option for complex soft-tissue reconstruction for regional soft-tissue defects of the lower abdomen and perineum.

Comparison of the Right and Left Femur Bone Mineral Densities in Postmenopausal Women.

Bone mineral density (BMD) is measured in the hip and posteroanterior spine; moreover, according to the 2019 International Society for Clinical Densitometry guidelines, unilateral hip can be used. This study aimed to determine whether there is a difference between the BMD of both the femurs in postmenopausal women. A total of 343 postmenopausal women were enrolled in this study from January 1, 2010, to December 31, 2019 at a single tertiary hospital. By using the Hologic® Horizon W DXA System, the femur and spine BMD was measured; BMD was recorded in g/cm². Following regions were analyzed in both the femurs: the femur neck, the trochanter area, and total femur. Mean age at imaging was 62 ± 9.7 years, and significant difference in the total BMD of both the femurs (P = 0.003) was observed. In secondary analysis, patients with osteoporosis showed significant contralateral BMD discrepancies in trochanter and total proximal femur BMD (P = 0.041 and P = 0.011, respectively). However, in women with normal BMD, no significant difference between the right and left femur BMD was observed. Furthermore, measurement of solely the unilateral hip can lead to a 16.9% of underdiagnosis in postmenopausal women. In conclusion, it is necessary to check BMD in both hips, particularly in patients suspected of osteoporosis.

Clinical and Ultrasonographic evaluation of patients with Trochanteric Bursitis

Background: Trochanteric bursitis is an inflammation of the greater trochanteric bursa which is a recurrent source of lateral hip pain. Objective: To assess the diagnostic value of 6 clinical tests that can be used to diagnose trochanteric bursitis and utilize ultrasound as an imaging modality to confirm the diagnosis. Patients and Methods: This Cross-sectional study included 85 consecutive patients who had been experienced lateral hip pain in the greater trochanteric area for at least 6 weeks with at least one of the following features: pain on lying on the affected side, pain while climbing stairs or when sitting. Six clinical tests on examination that elicit pressure on the greater trochanteric region were performed to evaluate their value to diagnose trochanteric bursitis and then ultrasound was utilized to confirm the diagnosis. Results: A total of 85 participants were enrolled in the study. Tenderness to deep palpation was the most accurate sign in predicting the diagnosis, with a sensitivity of 100% and specificity of 81.8%. There were no significant differences between its results and the ultra-sonographic findings (p=0.500). Regarding the other tests, there were significant differences between their results and the results of ultrasound (p&lt; 0.001). Conclusion: Tenderness to deep palpation of the greater trochanter, combined with ultrasound imaging modality, is likely to have the best diagnostic value for evaluation of trochanteric bursitis in patients complaining of lateral hip pain around the greater trochanter region. Keywords: Trochanteric Bursitis, evaluation, clinical tests, ultrasound

Clinical and Ultrasonographic evaluation of patients with Trochanteric Bursitis

Background: Trochanteric bursitis is an inflammation of the greater trochanteric bursa which is a recurrent source of lateral hip pain.&#x0D; Objective: To assess the diagnostic value of 6 clinical tests that can be used to diagnose trochanteric bursitis and utilize ultrasound as an imaging modality to confirm the diagnosis.&#x0D; Patients and Methods: This Cross-sectional study included 85 consecutive patients who had been experienced lateral hip pain in the greater trochanteric area for at least 6 weeks with at least one of the following features: pain on lying on the affected side, pain while climbing stairs or when sitting. Six clinical tests on examination that elicit pressure on the greater trochanteric region were performed to evaluate their value to diagnose trochanteric bursitis and then ultrasound was utilized to confirm the diagnosis.&#x0D; Results: A total of 85 participants were enrolled in the study. Tenderness to deep palpation was the most accurate sign in predicting the diagnosis, with a sensitivity of 100% and specificity of 81.8%. There were no significant differences between its results and the ultra-sonographic findings (p=0.500). Regarding the other tests, there were significant differences between their results and the results of ultrasound (p&lt; 0.001).&#x0D; Conclusion: Tenderness to deep palpation of the greater trochanter, combined with ultrasound imaging modality, is likely to have the best diagnostic value for evaluation of trochanteric bursitis in patients complaining of lateral hip pain around the greater trochanter region.

Complications Patients Faces while Fixation, in Terms of Pain Relief, Walking, Sitting

Background: The fracture of the trochanteric area of the femur is one of the most frequent and challenging complications orthopedic surgeons deal daily. In virtually all instances, fractures develop through the highly vascular cancellous bone and heal within 8 to 12 weeks, independent of therapy. Malunion and varus angulations are prevalent. Due to the demands placed on the patient, nursing staff, and length of hospitalization, conservative therapy is no longer acceptable. Seventy percent of intertrochanteric fractures are considered unstable. During regular exercises, the proximal femoral loading has been calculated to reach up to three times the body weight. Muscle attachments apply force vectors in several directions, hence contributing to a trend for fracture displacement. This fracture is typically accompanied by severe comminution and osteopenia. Objective: The main objective of this study is to find thecomplications patients faces while fixation, in terms of pain relief, walking, witting. Materials and Methods: Descriptive study conducted at Department of Orthopedic Surgery, Chittagong Medical College Hospital, Chittagong, with the sample size of 36 patients aged above 50 years admitted to the Chittagong Medical College Hospital with closed trochanteric fracture. The aim of the study is to find out the Effectiveness of dynamic hip screw in fixation of trochanteric fractures of femur in elderly patients. Results: The patients' ages ranged from 52 to 95 years. The majority of patients were 70-79 years old (36.1 percent), followed by 80-89 years (25 percent), 60-69 years (22.2 percent), 50-59 years (11.1 percent), and 90-99 years (5.6 percent). The mean (±SD) age of the total study patients (n=36) was 72.± 1.20 years, male (n=21) was 75.05±12.62 years and female (n=15) were 68.07±7.46 years. There are considerable disparities between the age groups of 70-79 and 90-99.Males made up the majority of patients (58.3 percent), while females made up 41.7 percent. ....

Relationship between Characteristics of the Wound and Healing Duration among Patients Treated during Home-Visits.

In humans, wound healing is a vital but complex process governed by chronological yet overlapping stages, such as hemostasis, inflammation, proliferation, and remodeling. Because of the complexities of wound healing, it is prone to pausing at multiple levels. Wound healing can potentially be influenced by factors that affect cellular functions and physiologic responses. This research aimed to investigate the relationship between wound healing duration and demographic properties and characteristics of wounds among patients treated during home visits in Erbil, Iraq. To this end, a longitudinal correlational quantitative design was employed in the current study. A random sample of about 101 chronic wounds was found in 77 patients of both genders selected from all ages during home visits for around four years in Erbil. The professional nurse applied nursing management according to the nursing plan during home visits until the wound recovered. The total duration of wound healing was calculated and documented for each wound. Seventy-seven patients participated in the current study, with their mean±SD age being 58.02±16.29 years, ranging from 19 to 89. The median age was 60. More than half of the sample (54.5%) were ≥60 years, and 62.3% were males. Less than one-third of patients (31.2%) were of normal weight, 93.5% were married, 37.7% were housewives, and 35.1% were illiterate. Regarding the duration of wound healing, in more than one quarter (26.7%), it was delayed (took more than three months for healing). The longest mean healing time (20.06 weeks) was for pressure ulcers (P<0.001), which was significantly higher than all the mean healing times of other types of wounds. The study showed a significant (P=0.011) association between the mean healing time and the anatomic location of wounds, revealing that the highest mean healing time was for wounds located in the trochanteric area (21.10 weeks) or the sacrum (18.25 weeks). A significant association (P=0.002) was also detected between the mean healing time and the edge of the wound, with the highest mean healing time (18.64 weeks) found in wounds with undermined edges. Furthermore, the mean healing time was significantly higher among those with infected wounds (14.59 weeks) than the mean (6.50 weeks) among those with no infection (P<0.001). In conclusion, wound healing progression is an important but complicated process that healthcare providers use for patients during home visits. It is divided into phases, including hemostasis, inflammation, proliferation, and remodeling. The current study revealed that the healing time was affected by the anatomical site of the wound and took longer in pressure ulcers, undermined edge wounds, and infected wounds.

Risk factors for osteoporosis in patients with rheumatoid arthritis

Aim of the study was to investigate risk factors for osteoporosis (OP) in patients with rheumatoid arthritis (RA). Material and methods. We observed 110 patients with a verified diagnosis of RA. RA was diagnosed based on the 2010 EULAR/ACR clinical classification. All patients with RA were divided into 2 groups: with ОP (53 patients) and without ОP signs (57 patients). Bone mineral density (BMD) was assessed by dual-energy X-ray densitometry (DEXA), the diagnosis was made on the basis of WHO recommendations. All patients underwent a standard clinical and laboratory examination, in addition the following parameters were studied: 25-OH vitamin D, C-terminal telopeptide of type I collagen (CTX-1), N-terminal propeptide of procollagen I (P1NP) content in the blood, the ratio of calcium to urine creatinine. Results. We found a statistically significant relationship between the presence of ОP and the following clinical signs: patient weight (р = 0.014), duration of RA course (р = 0.024), and the presence of erosive changes (р = 0.014). In addition, a relationship was found between the presence of OP and lower BMD in the Ward area (Ward) and the greater trochanter area (Troch) (р &lt; 0.0001). It was also shown that taking glucocorticosteroid drugs for more than 3 months significantly increases the risk of developing ОP (р &lt; 0.0001). Conclusions. Identification of risk groups for patients at risk for the development of OP is of great practical importance. The factors given in the article can be adjusted towards normalization in order to reduce the degree of possible risk, which is quite feasible in practice.

Both indirect maternal and direct fetal genetic effects reflect the observational relationship between higher birth weight and lower adult bone mass

BackgroundBirth weight is considered not only to undermine future growth, but also to induce lifelong diseases; the aim of this study is to explore the relationship between birth weight and adult bone mass.MethodsWe performed multivariable regression analyses to assess the association of birth weight with bone parameters measured by dual-energy X-ray absorptiometry (DXA) and by quantitative ultrasound (QUS), independently. We also implemented a systemic Mendelian randomization (MR) analysis to explore the causal association between them with both fetal-specific and maternal-specific instrumental variables.ResultsIn the observational analyses, we found that higher birth weight could increase the adult bone area (lumbar spine, β-coefficient= 0.17, P < 2.00 × 10−16; lateral spine, β-coefficient = 0.02, P = 0.04), decrease bone mineral content-adjusted bone area (BMCadjArea) (lumbar spine, β-coefficient= − 0.01, P = 2.27 × 10−14; lateral spine, β-coefficient = − 0.05, P = 0.001), and decrease adult bone mineral density (BMD) (lumbar spine, β-coefficient = − 0.04, P = 0.007; lateral spine; β-coefficient = − 0.03, P = 0.02; heel, β-coefficient = − 0.06, P < 2.00 × 10−16), and we observed that the effect of birth weight on bone size was larger than that on BMC. In MR analyses, the higher fetal-specific genetically determined birth weight was identified to be associated with higher bone area (lumbar spine; β-coefficient = 0.15, P = 1.26 × 10−6, total hip, β-coefficient = 0.15, P = 0.005; intertrochanteric area, β-coefficient = 0.13, P = 0.0009; trochanter area, β-coefficient = 0.11, P = 0.03) but lower BMD (lumbar spine, β-coefficient = − 0.10, P = 0.01; lateral spine, β-coefficient = − 0.12, P = 0.0003, and heel β-coefficient = − 0.11, P = 3.33 × 10−13). In addition, we found that the higher maternal-specific genetically determined offspring birth weight was associated with lower offspring adult heel BMD (β-coefficient = − 0.001, P = 0.04).ConclusionsThe observational analyses suggested that higher birth weight was associated with the increased adult bone area but decreased BMD. By leveraging the genetic instrumental variables with maternal- and fetal-specific effects on birth weight, the observed relationship could be reflected by both the direct fetal and indirect maternal genetic effects.

Evaluation of Clinical Outcome of Subtrochanteric &amp; Proximal Femur Fracture treated by Interlocking Intramedullary Nail with Side plate

Fractures of the subtrochanteric region and proximal femur can be especially challenging to manage, and they warrant special consideration to obtain consistently satisfactory results. The subtrochanteric zone of the femur is generally considered to include the area extending 5 cm distally from the inferior border of the lesser trochanter, or the junction of the proximal one third and middle third of the femoral shaft. Fractures that have their major displacement in this area are considered subtrochanteric fractures despite the possibility that some of them may extend into the trochanteric area proximally or the distal femoral shaft. The management of fractures of the subtrochanteric region and proximal femur has always held a particular interest for orthopedic surgeons. Biomechanically, the subtrochanteric area of the proximal femur is an area of high stress concentration, which has led to high rates of implant failures in the treatment of these fractures. Current evidence suggested that interlocking intramedullary nail with side plate offer better outcome.&#x0D; Objectives: To evaluate the operative efficacy and clinical outcome of interlocking intramedullary nail with side plate in the treatment of subtrochanteric &amp; proximal femur fracture.&#x0D; Methods: This prospective cross sectional study was conducted in Cumilla General Hospital and private Clinics, Cumilla, from April 2018 to November 2019 among the 62 cases of subtrochanteric femur fractures. Objective of this study was to find out a safe, effective management of fracture, early mobility of patient, functional joint motion and short stay in hospital. All patients were treated by interlocking intramedullary nail with side plate. Routine follow up was carried out and outcomes were assessed. Radiographic examination was used to evaluate callus formation and fracture healing in postoperative 1, 3, 6 and 12 months follow-up. Functional recovery was evaluated by Harris Hip Scoring (HHS) system.&#x0D; Result: In this study, the mean age was 49.3±8.5 years. Among 62 cases 52 cases (83.9%) were male and 10 cases (16.1%) were female. The male and female ratio was 5.2:1. Regarding the causes of injury, out of 62 patients 50 (81%) had a history of fall from height. In 12 (19%) cases, motor vehicle accident was the cause of fracture. Average time of healing was 18 weeks. According to Harris hip score findings, 46 cases were considered as excellent in functional recovery, 11 good, 4 fair and 1 poor. The proportion of the patients with excellent and good recovery was 91.8%.&#x0D; Conclusion: Study showed interlocking intramedullary nail with side plate provides better functional outcome with early mobility of patients, and fracture unites without joint stiffness and less complication.&#x0D; Central Medical College Journal Vol 5 No 2 Jul 2021 PP 88-93

Effect of drilling and bone substitute on revascularization of an avascular femoral head

Introduction: Avascular Necrosis (AVN) is pathology in which femoral head undergoes degenerative changes due to reduced blood supply. Osteotomy is surgical procedure that involves cutting bone to reshape or realign your bones. It acts by multiple mechanisms. Newer mechanisms include increased blood flow, Osteoinduction due to new fracture (Osteotomy), Change of shear force into compression force. Novel concept for AVN treatment is blocking of femoral canal near lesser trochanter area by Osteotomy/Drilling and insertion of synthetic absorbable Bone substitute (hydroxyapatite cement). Thereby blocking the trabecular canal system at junction so Blood supply get diverted towards femoral head. Methods and Materials: Study was carried out in New Civil Hospital, Surat in September 2021. The prospective study comprised of 62 year old male having C/o Pain, limp while walking and restriction of Adduction and Internal rotation of Left Hip. Xray, MRI of both hip showed Left Avascular Necrosis Femoral Head (Ficat Arlet Grade 2B). Via Lateral incision of Hip, Drilling and Scooping done at level of Lesser Trochanter. Drilled site was inserted with 10-12 gm of synthetic absorbable Bone substitute (hydroxyapatite cement). Full weight bearing started after 1 week. All patients were followed up immediately, 3rd month, 6th month, 1 year. Follow up X-ray were taken to assess radiological outcome and Harris Hip score for functional outcome. Results: Xray at 3rd, 6th month, 1 year showed No further progression of Grade 2B AVN Femoral head. Improvement in Harris Hip Score with values 38, 67, 81, 89 at Immediate, 3rd, 6th month, 1 year postop respectively. Improvement in Left Hip range of motion. Conclusion: Drilling creates disturbance in trabecular canal system (Creating haematoma callus) so that proximal shaft femoral blood supply is cut off (partially) and that blood supply which was destined for the upper shaft is now directed more proximally Towards femoral head.

Abstract #1183932: Management Challenge in Hyperphosphatemic Tumoral Calcinosis

Tumoral calcinosis (TC) is a rare metabolic disorder causing abnormal calcium salt deposition in different peri-articular soft tissue regions. The most common site is lateral hips. TC can be primary normo-phosphatemic or primary hyperphosphatemic. It can be secondary also, seen commonly in chronic renal failure. We describe a case report of 14 years old girl who presented with primary hyperphosphatemic tumoral calcinosis with recurrent swellings even after surgery and medical therapy. A 14-year-old girl presented to us with recurrent soft tissue mass and persistent hyperphosphtemia associated with pain and decreased movements. She was operated twice for this soft tissue. Her medical record stated that patient had undergone 6 surgeries till date for these periarticular swellings at multiple sites (right elbow, left hip, right hip and left knee) but it recurs after 3-4 months of surgery and progressively enlarges in size. Physical examination revealed firm tender 9 X 4 cm oval shaped swelling in the left greater trochanteric area with restriction in abduction, internal rotation and rotator movements at hip joint and 4 X 4 cm circular hard, non-sessile mass over medial aspect of left knee joint with slight difficulty in complete flexion of knee. Biochemical work up showed hyperphosphatemia with normal serum calcium and low iPTH levels, low serum 25 hydroxyvitamin-D and slightly high 1,25 vitamin D with calculated TmP/GfR of 5.7 mg/dl. C-terminal FGF23 level was grossly elevated to 1200 RU/ml. Histological evaluation of previously surgically excised soft tissue mass revealed fibrocollagenous stroma with clusters of crystalline and amorphous calcium enclosed by band of histiocytes and lymphocytes compatible with findings seen in tumoral calcinosis. Presently the patient is maintaining the near normal phosphate level with oral phosphate restricted diet and multiple phosphate binder and acetazolamide. Hyperphosphatemic Tumoral calcinosis is a disorder of dysregulated phosphate metabolism characterized by hyperphosphatemia and deposition of calcium salts in soft tissue regions of the body usually in the periarticular sites. FGF23 is a 251-amino acid peptide secreted by osteoblasts, osteocytes and erythroid precursor cells of the bone marrow that plays a critical role in phosphate regulation. In the proximal tubule of the kidney, FGF23 binds to the FGF receptor 1 (FGFR1) and its co-receptor KLOTHO, downregulating expression of the sodium-phosphate cotransporters NPT2a and NPT2c, which leads to phosphaturia. Additionally, FGF23 inhibits 1-alpha-hydroxylase and stimulates 25-vitamin D-24 hydroxylase, resulting in decreased 1,25-(OH)2-vitamin D (1,25D), the active form of vitamin D. Recently an entitity named autoimmune hyperphosphataemic tumoral calcinosis has been reported in which pathogenetic autoantibodies mediate FGF23 resistance.Treatment is to lower serum phosphorus by blocking dietary phosphate absorption and increasing renal phosphate excretion. Surgery is usually reserved for patients with significant pain or restricted movements of joint.