Trochanteric Area Research Articles

Effectiveness of treatment of patients affected by trochanter major enthesitis

Introduction: Enthesitis of the trochanter major is characterized by pain and often by limping when walking, then pain, tension, swelling, increased warmth and redness in the area of trochanter, and hip weaknessespecially when performing exercises with resistance. Research goals: Determine the effectiveness of treatment of major trochanter enthesitis, and analyze the representation of it in patients of both gender, different ages and professions.Methods: Retrospective analysis of data from the clinic "Praxis" in the period from 01.01.2001. to 31.12.2011. year because of the major trochanter enthesitis 30 patients were treated. Criteria for inclusion in the study were those people with symptoms and diagnosis of of the trochanter major enthesitis who have accessed treatment, while the criteria for exclusion were inadequate diagnosis, treatment abandonment and lack ofpatient data. The process of therapy included the evaluation of the functional status of patients graded 0-5, then conducted physical therapy that included: bed rest, manual massage and local instillation of depot corticosteroids, and assessment of treatment success ranging from 0 to 5.Research results: The mean score for condition of respondents was 3.27 before therapy, while after treatment it was 4.33. The mean score for status of respondents was 3.13 before treatment, and after therapy itwas 4.33.Conslusion: Based on these data we can conclude that treatment in the clinic "Praxis" leads to the improvement in patients suffering from the enthesitis of trochanter major.

The treatment of intertrochanteric fractures of the femur with Endovis nail

The incidence of fractures in the trochanteric area has risen with the increasing numbers of elderly persons with osteoporosis. The imperative goals of treatment are early mobilization by means of stable fixation using as minimally invasive a procedure as possible. Nowadays, there is an increasing interest in intramedullary nailing, especially for unstable intertrochanteric fractures. The aim of the present paper is to assess the efficacy of closed intramedullary osteosynthesis with the Endovis® proximal femoral nail in the treatment of peritrochanteric fractures to solve the problems associated with the use of intramedullary fixation devices. The authors describe their experience with 87 stable and unstable proximal extra-capsular femoral fractures treated with the Endovis femoral nail from July 2007 to March 2009. The results were evaluated clinically, functionally and radiographically during the 1st, 3th, 6th and 12th months post-op. Pre-injury activity and functional levels were recorded using the modified Harris hip score and V.A.S. score. Postoperative radiographs showed a near-anatomical fracture reduction in 85% of patients. Three were the cases of cut-out, one case of valgus and two cases of shortening of the operated leg (<1 cm). The Harris Hip Score increased between the thirtieth and ninetieth postoperative day, accompanied by a significant decrease in pain symptoms and functional limitation. 1. The application of an intramedullary nail provides primary stability of the fracture. 2. The Endovis nail constitutes a powerful synthesis for stable and unstable fractures of the trochanteric region, in which is difficult to reconstruct appropriate continuity between the medial and posterior cortical layers. 3.The good mechanical stability of the nail allows rapid mobilization and early functional recovery. 4. The presence of an additional anti-rotational screw and the free sliding mechanism of the lag screw may increase rotational stability of cervico-cephalic fragments and decrease overload on the femoral head.

Five-Year Outcome of Surgical Treatment of Migraine Headaches

Sir:FigureWe particularly appreciated the article entitled “Five-Year Outcome of Surgical Treatment of Migraine Headaches” by Drs. Guyuron, Kriegler, Davis, and Amini (Plast Reconstr Surg. 2011;127:603–608). We read with interest about different techniques used in treatment of migraine headaches. The authors discussed the role of surgery in the amelioration of this disabling condition and attempted to determine pathophysiologic reasons for the surgical success their patients have been enjoying, affirming that many questions are still unanswered. We agree with the consideration that an accurate identification of trigger sites is of critical importance, and we focused our attention particularly on reading about surgical techniques used by the authors for occipital trigger point. We would like to report our experience in treating chronic headaches related to occipital neuralgia and explain what, in our opinion, is the pathophysiologic reason for the success of our technique. Occipital neuralgia is frequently resistant to pharmacologic and surgical approaches. Often, important anatomical variations related to occipital neuralgia can be found, compromising the effectiveness of procedures such as surgical decompression or nerve block.1,2 Encouraged by our experience in using autologous fat graft in scar outcomes,3,4 we decided to use this technique in a case of severe unresponsive posttraumatic occipital neuralgia with cicatricial entrapment of the greater occipital nerve. Autologous fat graft, harvested from trochanteric areas and centrifuged at 3000 rpm for 3 minutes, was injected at the clinical trigger point (indicated by the patient with manual palpation) and the point of anatomical scar entrapment. The stable, long-term success of this procedure has been documented by asking the patient to indicate the pain level using a visual analogue scale (preoperative level, 8; 1-month postoperative level, 3), and by performing magnetic resonance imaging. Preoperative examination showed a thinning of subcutaneous adipose tissue and the presence of cicatricial fibrous tissue, whereas examination at 3 months postoperatively showed restored appearance of subcutaneous adipose tissue in the treated area. Considering the results obtained, we used this technique in other cases of occipital neuralgia not related to posttraumatic scars, and always obtained a reduction of frequency, duration, and intensity of headache episodes. We are now conducting an important clinical study with long-term follow-up in all treated patients. Our hypothesis is that, in many cases of chronic headache related to occipital neuralgia, a pathologic thinning of the subcutaneous fat layer in this area is involved, making possible the contact between occipital nerves and other anatomical structures—such as occipital arteries—and thus conditioning development of pain. The autologous fat graft procedure allows the subcutaneous adipose tissue layer to be thickened, possibly acting as a “decompression neurolysis.” Furthermore, as shown in our other studies,3–5 adipose tissue has regenerative properties and, first of all, an analgesic effect. The biological reasons of these properties are still unclear but appear to be related to the therapeutic success we achieve in treatment of chronic headaches. Considering also the simplicity of the procedure, the absence of residual scars, and the virtual lack of complications, we believe that autologous fat graft is an excellent option for the treatment of migraine headaches. Fabio Caviggioli, M.D. Università degli Studi di Milano, U.O. Chirurgia Plastica, IRCCS Multimedica Group Milano, Sesto San Giovanni, Milan, Italy Silvia Giannasi, M.D. Valeriano Vinci, M.D. Guido Cornegliani, M.D. Università degli Studi di Milano, U.O. Chirurgia Plastica 2, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy Daniel Levi, M.D. Paolo Gaetani, M.D. Università degli Studi di Milano, U.O. Neurochirurgia, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy

Long-term result after femoral head substitution in postinfectious aplasia of the femoral head

This case report presents a new and unique surgical greater trochanter split procedure for reconstructing a hip joint after an infantile hip sepsis with consequent aplasia of the femoral head. One patient underwent the new trochanter split osteotomy for postinfectious aplasia of the femoral head at the age of 4years. A follow-up of 17years is presented. The remaining proximal femur is sagittally split and the medial part is shifted into the acetabulum, preserving the lateral part of the greater trochanter. The osteotomy is fixed by an osseous wedge and K-wires. In contrast to the techniques known so far, it does not harm the vastogluteal muscle sling, thus, significantly reducing abductor lurch. Furthermore, through placing juvenile growth cartilage from the greater trochanter area into the acetabulum, there is, by far, more potential for the regeneration of a femoral head than by the procedures known so far. The presented surgical technique is able to improve the biomechanics of a hip joint with postinfectious aplasia of the femoral head. The growth of a new femoral head and the development of a well-shaped acetabulum is enabled. A clinical outcome with a stable joint and very good clinical function can be achieved.

Contouring of the Gluteal Region in Women

Techniques for improving the appearance of the gluteal region are important elements in body contouring. In all cultures and communities, this aspect of the physique holds a special place among the elements comprising the ideals of physical beauty. Recent studies described the aesthetics of the gluteal region in terms of shape, volume, and projection. Accumulation of fat at the supragluteal, lower paralumbar, infragluteal, and/or trochanteric areas often disturbs the natural shape of the buttocks. The problem is accentuated by the lack of lateral projection. This study was designed to find a method for contouring of the gluteal region. This method is based on the enhancement of the shape by liposculpture of the areas around the buttocks, and lipoinjection to achieve the volume and projection. Between July 2008 and December 2009, the study included 40 female patients complaining of disfigurement of the gluteal region. With 1 year follow-up period, 36 patients showed high satisfaction with the results. Pre- and postoperative perimeters of the gluteal regions showed good improvement in proportion and projection. The study concluded that liposuction of the areas around the buttocks could enhance the shape of the gluteal region. Lipoinjection could add a balanced shape, size, and projection. A pleasing gluteal appearance could be achieved by the combination of enhancement and augmentation.

Large Diameter Femoral Heads Impose Significant Alterations on the Strains Developed on Femoral Component and Bone: A Finite Element Analysis

Total Hip Arthroplasty aims at fully recreating a functional hip joint. Over the past years modular implant systems have become common practice and are widely used, due to the surgical options they provide. In addition Big Femoral Heads have also been implemented in the process, providing more flexibility for the surgeon. The current study aims at investigating the effects that femoral heads of bigger diameter may impose on the mechanical behavior of the bone-implant assembly. Using data acquired by Computed Tomographies and a Coordinate Measurement Machine, a cadaveric femur and a Profemur-E modular stem were fully digitized, leading to a three dimensional finite element model in ANSYS Workbench. Strains and stresses were then calculated, focusing on areas of clinical interest, based on Gruen zones: the calcar and the corresponding below the greater trochanter area in the proximal femur, the stem tip region and a profile line along linea aspera. The performed finite elements analysis revealed that the use of large diameter heads produces significant changes in strain development within the bone volume, especially in the lateral side. The application of Frost’s law in bone remodeling, validated the hypothesis that for all diameters normal bone growth occurs. However, in the calcar area lower strain values were recorded, when comparing with the reference model featuring a 28mm femoral head. Along line aspera and for the stem tip area, higher values were recorded. Finally, stresses calculated on the modular neck revealed increased values, but without reaching the yield strength of the titanium alloy used.

Prevalence and Impact of Pain at the Greater Trochanter After Open Surgery for the Treatment of Femoro-Acetabular Impingement

Femoro-acetabular impingement can cause pain and degenerative changes of the hip joint. Traditionally, surgical dislocation of the hip joint has been performed for correction of pathologic abnormalities in the proximal part of the femur and the acetabulum. Failures of surgical treatment are often related to postoperative pain in the groin or in the area of the greater trochanter, associated with this surgical approach. The aim of our study was to determine the prevalence and functional impact of pain at the greater trochanter after surgical dislocation of the hip. Fifty consecutive patients in whom femoro-acetabular impingement had been treated with surgical dislocation of the hip at our institution were seen for clinical and radiographic follow-up at one year. The Merle d'Aubigné score was calculated preoperatively and at the time of follow-up. Pain in the groin or at the greater trochanter during activity and at rest was recorded. The mean Merle d'Aubigné score significantly improved from 14.4 points preoperatively to 17 points postoperatively. Preoperatively, eight patients (16%) had pain over the greater trochanter. At one year after surgery, twenty-three (46%) had such pain; these patients were primarily female (seventeen of the twenty-three). The mean Merle d'Aubigné score was 17.4 points for the patients without groin pain and 16.1 points for those with groin pain. The presence or absence of pain at the greater trochanter had no significant influence on the outcome, but groin pain was associated with inferior results. Tenderness or pain over the greater trochanter is frequent after osteotomy of the greater trochanter and has a distinct female predominance. However, it has no significant negative influence on outcome. This is in contrast to groin pain, which is associated with inferior results.

Distance from the growth plate and Its relation to the outcome of unicameral bone cyst treatment

Interventions to treat unicameral bone cysts vary. Nonetheless, regardless of the intervention modality, the outcome is not certain. The purpose of this study was to determine if the distance between the growth plate and the cyst can be used to predict the outcome of the treatment. Retrospectively, we assessed the outcome of 39 interventions in nineteen children that were performed between 1994 and 2003. Seventeen different modalities of treatment were employed. There were three female and sixteen male patients. The average age was 8years. Nine cysts were in the greater trochanter area, three were in the femoral capital area and seven were in the proximal humerus. According to the cyst's distance from the growth plate, at the intervention time, there were 18 cases within less than 2cm and 21 cases of more than 2cm. Complete healing was achieved in 10 children (employing seven different modalities). In nine of them, the cysts were more than 2cm away from the growth plate. In one child, the cyst was within less than 2cm of the growth plate, however, treatment here involved epiphyseodesis. This study confirmed that, regardless of intervention modality, complete healing was not achievable in those cysts that are within less than 2cm of an active growth plate. Complete healing was possible in those cysts that are more than 2cm away from the growth plate. The 2-cm distance from the growth plate could be used as a predictor of treatment outcome of unicameral bone cysts.

Isolated lesser trochanter fracture in adults: An early indicator of tumor infiltration

We report on a case of isolated lesser trochanter fracture, without associated trauma, secondary to pulmonary adenocarcinoma metastasis. Treatment consisted in resection-reconstruction by megaprosthesis. This form of isolated fracture is rare, and results from infiltration of the trochanteric area by a malignant tumoral process, which is usually metastatic.

A Decline in Renal Function is Associated With Loss of Bone Mass in Korean Postmenopausal Women With Mild Renal Dysfunction

This study was conducted to assess the relationship between estimated glomerular filtration rate (eGFR) and bone mineral density (BMD) in Korean postmenopausal women with mild renal dysfunction. A total of 328 postmenopausal women who underwent BMD measurement during health check-up was investigated. BMD was measured in lumbar spine (L1-L4), femoral neck, total proximal femur and femoral trochanteric areas by dual energy radiography absorptiometry and renal function was estimated by eGFR using Cockcroft-Gault equation. Of the 328 subjects, 317 (96.6%) had an eGFR ≥60 mL/min/1.73 m2. By using simple linear regression analysis, age, height, weight and eGFR were significantly associated with BMD for the 4 aforementioned anatomic sites, while serum levels of creatinine and blood urea nitrogen did not influence BMD. When multiple regression analyses were applied, age and body weight still had significant associations with BMD at 4 different anatomic sites (P < 0.001). A significant association of eGFR with BMD remained in the lumbar spine, femoral neck and proximal total femur (P < 0.05) but not in the trochanteric area (P = 0.300). Our study suggests that a decline of renal function is associated with lower BMD in the lumbar spine, femoral neck and total proximal femur areas in Korean menopausal women with mild renal dysfunction.

Femoral Neck Anteversion Measured Using a 3D CT Scan Perpendicular to the Mechanical Axis of the Femur

Purpose: We wanted to measure the femoral neck anteversion (FNA) angles using a 3D CT scan that perpendicularly cut the mechanical axis of the femur and to assess the accuracy and reproducibility of different measuring methods. Materials and Methods: We obtained 95 cases of 3D CT images of the cross-section perpendicular to the mechanical axis of the femur. The methods used to measure the FNA angles included a method using the CT image of the area where the femoral neck is confluent to the greater trochanter (method 1), a method using the CT image taken from the neck base immediately prior to the beginning of the area of the lesser trochanter (method 2) and a method by which measurements are made after putting 3D bone models on a horizontal plane in virtual space (method 3). The reference axes of the distal femur we used were the anatomical transepicondylar axis, the surgical transepicondylar axis and the real posterior condylar axis. Results: The FNA angles measured by method 1 were 4.79±6.41。to the anatomical transepicondylar axis (ATEA), 6.09±6.58。to the surgical transepicondylar axis (STEA) and 7.96±6.81。to the real posterior condylar axis (rPCA). The FNA angles measured by method 2 were 16.01±8.31。to the ATEA, 19.52±8.38。to the STEA and 21.79± 8.52。to the rPCA. The FNA angles measured by method 3 were 20.15±12.89。to the rPCA. Conclusion: The measurement of the FNA angle using a 3D CT scan perpendicular to the mechanical axis is reproducible. The measurement method on the neck base level is more reliable than the one on the proximal neck confluence, and more similar to the measurement method by classic definition.

Total hip replacement of recurrent monostotic fibrous dysplasia of proximal hip

Correspondence: Dr. Ajay Pal Singh, Department of Joint Replacement Surgery, Inderprastha Apollo Hospital, Sarita Vihar, Delhi. E-mail: docajaypal@boneandspine.com and lytic lesions of the neck of the femur and trochanteric area extending distally along with secondary osteoarthritis (Figure 1). We planned a biopsy to rule out malignancy. A biopsy was taken from three sites under fluoroscopic control. Histology revealed delicate trabeculae of immature bone with no osteoblastic rimming, enmeshed within a bland fibrous stroma of dysplastic spindle shaped cells without any cellular features of malignancy (Figure 2). We planned eradication of the diseased tissue and total hip replacement with customized implants. First, bone graft was harvested from the contralateral iliac crest and then the patient was repositioned and lateral approach was used utilizing the previous incision. Removal of plate and screws were done. Thorough curettage of the lesion was performed using the help of fiber-optic light cable, dental mirror, and high speed burr to remove all the pathological tissue. Femoral head and acetabulum had osteoarthritic changes. Corrective closed wedge valgus osteotomy of proximal femur was made and impaction bone grafting using femoral head bone & harvested grafts was done. We used Total hip replacement of recurrent monostotic fibrous dysplasia of proximal hip

Subcutaneous adipose tissue classification

The developments in the technologies based on the use of autologous adipose tissue attracted attention to minor depots as possible sampling areas. Some of those depots have never been studied in detail. The present study was performed on subcutaneous adipose depots sampled in different areas with the aim of explaining their morphology, particularly as far as regards stem niches. The results demonstrated that three different types of white adipose tissue (WAT) can be differentiated on the basis of structural and ultrastructural features: deposit WAT (dWAT), structural WAT (sWAT) and fibrous WAT (fWAT). dWAT can be found essentially in large fatty depots in the abdominal area (periumbilical). In the dWAT, cells are tightly packed and linked by a weak net of isolated collagen fibers. Collagenic components are very poor, cells are large and few blood vessels are present. The deep portion appears more fibrous then the superficial one. The microcirculation is formed by thin walled capillaries with rare stem niches. Reinforcement pericyte elements are rarely evident. The sWAT is more stromal; it is located in some areas in the limbs and in the hips. The stroma is fairly well represented, with a good vascularity and adequate staminality. Cells are wrapped by a basket of collagen fibers. The fatty depots of the knees and of the trochanteric areas have quite loose meshes. The fWAT has a noteworthy fibrous component and can be found in areas where a severe mechanic stress occurs. Adipocytes have an individual thick fibrous shell. In conclusion, the present study demonstrates evident differences among subcutaneous WAT deposits, thus suggesting that in regenerative procedures based on autologous adipose tissues the sampling area should not be randomly chosen, but it should be oriented by evidence based evaluations. The structural peculiarities of the sWAT, and particularly of its microcirculation, suggest that it could represent a privileged source for regenerative procedures based on autologous adipose tissues.

Three-Dimensional Arterial Anatomy of the Gluteus Maximus and the Proper Method of Muscle Splitting

Sir: The gluteus maximus muscle is a large muscle that is sometimes used as a split muscle flap in reconstructive surgery. Although several methods have been reported for splitting the gluteus maximus muscle,1–4 the proper method based on three-dimensional arterial anatomy has never been described. Using fresh cadavers, we performed systemic angiography. After dissecting the gluteus maximus muscle from the surrounding tissue, stereoscopic images were taken, and the three-dimensional arterial anatomy was reviewed (Fig. 1). Cadaveric studies demonstrated that the peripheral arteries inside the muscle are oriented in the direction of the muscle fibers, and the lower gluteal artery and the first perforating artery are strongly connected. From these observations, three methods can be used. The first is a superior gluteal artery pedicled flap using the superficial half of the gluteus maximus muscle where the skin is situated in the distal portion. The second is an inferior gluteal artery pedicled flap using the superficial half of the gluteus maximus muscle where the skin is situated in the distal portion. The third is a first perforating artery pedicled flap using the superficial half of the gluteus maximus muscle where the skin is situated medially. In all cases, the deeper part of the gluteus maximus muscle is preserved. Because the perforating branches in the muscle are difficult to identify, dissection of the muscle for the splitting should be performed with one-fifth of the muscle length around the pedicle untouched. Six patients with a total of seven skin defects underwent reconstruction with a split gluteus maximus musculocutaneous flap. In all cases, the flaps took well without any evidence of necrosis. The profiles of patients and results are listed in Table 1. A representative case (case 4) is shown in Figures 2 and 3. The application of the type of split gluteus maximus musculocutaneous flap depends on the sites of the skin defect. From our experience, the superior gluteal artery–based split gluteus maximus musculocutaneous flap is suitable for reconstructing the sacral and sciatic areas, the inferior gluteal artery–based split gluteus maximus musculocutaneous flap sciatic area, and the first perforating artery–based split gluteus maximus musculocutaneous flap greater trochanter area. The merits of using a split gluteus maximus muscle flap are as follows: (1) it is easy to perform; (2) there is less dead space and serous discharge from the drain becomes less after surgery; (3) the part of the function of the gluteus maximus is preserved; and (4) compared with the “perforator flap,” the surgeon does not need to worry about disturbing important perforating arteries. In contrast, the limits on how thin the muscle can be or how small the pedicle can be have not been delineated from the anatomical data. From our clinical cases, construction of a gluteus maximus musculocutaneous flap using half of the gluteus maximus muscle thickness with four-fifths of the muscle being dissected free was performed safely.Fig. 1.: A stereoscopic view of the gluteus maximus muscle demonstrates that the upper half of the gluteus maximus muscle is nourished by the superior gluteal artery (yellow arrow), and the lower half is nourished by the inferior gluteal artery (red arrow). The lateral portion is nourished by the first perforating artery of the deep femoral artery (blue arrow). Peripheral branches are inclined to the direction of the muscle fiber. The peripheral areas of the inferior gluteal artery and the first perforating artery communicate with one another (dotted line).Table 1: Profiles of the Patients and Clinical Results of the Split Gluteus Maximus Musculocutaneous FlapFig. 2.: A 40-year-old man with hidradenitis suppurativa on the right buttock underwent a split gluteus maximus musculocutaneous flap reconstruction based on the distribution of the superior gluteal artery (left). The dissection was performed at 50 percent thickness of the gluteus maximus, and three-fourths of the full length of the muscle was used (right).Fig. 3.: The patient immediately postoperatively.In conclusion, the gluteus maximus muscle can be safely split along the superficial and deep layers of its muscle fibers based on its blood supply. This technique represents an easier and safer method for reconstructing defects found in the gluteal region. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Kazuo Kishi, M.D., Ph.D. Hideo Nakajima, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Nobuaki Imanishi, M.D., Ph.D. Department of Anatomy Tatsuo Nakajima, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Keio University School of Medicine Tokyo, Japan

압박의류 착용에 의한 신체변화 연구

The purpose of this study was to determine the effect of compression clothing on the body shape of the human subjects. Thirty seven healthy females being overweighted with local adiposity on the buttocks and legs between the ages of 20's to 50's were used as the human subjects for the study. The selected subjects wore the compression clothing during 60 days by 8 hours a day. At the start(T0), after 30(T30) and after 60 days of treatment(T60), a cutaneous echography was measured on the right trochanter area of each volunteer in order to assess the thickness of the subcutaneous fatty tissue. At the start(T0), after 30(T30) and after 60 days of treatment(T60), the body weight of each volunteer was taken and the instrumental variations of skinfold measurements of the abdominal fold and inner thigh circumference of the waist, hips and thigh were conducted. The results show that the echography and weight loss of subjects were reduced to 8.34% and 2.08% after 60 days, respectively. Moreover, the skinfold of subjects was also reduced. Finally, skin elastometry of subjects increased.

Leisure time physical activity in adulthood is positively associated with bone mineral density 22 years later. The Tromsø study

Although the positive association between physical activity and bone mineral density (BMD) is well established, few epidemiological studies have investigated the long-term associations between physical activity during adulthood and BMD later in life. The aim of this prospective, population-based study was to examine the association between leisure time physical activity in adulthood and areal BMD (aBMD) later in life. We examined 1,766 women and 1,451 men aged 20-54 years at baseline who were followed up 22 years later, as part of a population-based study in Norway. Leisure time physical activity was assessed by questionnaire at baseline and follow-up. aBMD was measured at the hip and forearm at follow-up, using X-ray absorptiometry. The association between aBMD and physical activity was analyzed using general linear models. We observed a positive linear trend in aBMD across physical activity levels in both women and men, after adjustments for baseline age, height, weight, and smoking status (P < 0.05). The relationship between aBMD and leisure time physical activity was consistent over different sites of the hip (total hip, femoral neck and trochanter area) and forearm (distal and ultradistal area). In a subsample of 2,436 men and women under 70 years of age, those who where sedentary at both baseline and follow-up (6%) had lower aBMD than those who were moderately active or active at both baseline and follow-up (71%) (P <or= 0.01). This study suggests that leisure time physical activity in adulthood is associated with higher aBMD and reduced risk of osteoporosis later in life.

Mechanical Evaluation of Polymer Composite Hip Protectors

Hip fractures often result in serious health implications, particularly in the geriatric population, and have been related to long-term morbidity and death. In most cases, these fractures are caused by impact loads in the area of the greater trochanter, which are produced in a fall. This work is aimed at developing hip protectors using composite materials and evaluating their effectiveness in preventing hip fractures under high impact energy (120 J). The hip protectors were developed with an inner layer of energy absorbing soft material and an outer rigid shell of fiberglass-reinforced polymer composite. According to the experimental results, all tested configurations proved to be effective at reducing the impact load to below the average fracture threshold of proximal femur. Furthermore, an addition of Ethylene Vinyl Acetate (EVA) to the impacted area of the composite shell proved to be beneficial to increase impact strength of the hip protectors. Thus, composite hip protectors proved to be a viable alternative for a mechanically efficient and cost-effective solution to prevent hip fractures.

A New Technique for Gluteal Lifting Using Deepithelialized Dermal Flaps

In this article, Handschin et al. [1] promote several modifications to the inferior buttock lift techniques previously described by Gonzalez [2] and Huemer et al. [3]. The main modifications include the division of the deepithelialized infragluteal crescent into upper and lower segments. The other adjustment is the subsequent anchoring of the deepithelialized flaps into the gluteal fascia instead of the ischial periosteum in order to recreate the inferior gluteal fold and provide the buttock lift. The authors describe the procedure in a series of eight patients with very good aesthetic results by postoperative analysis and patient satisfaction report and no recorded complications after a 2month follow-up. The inferior gluteal lift is a very powerful and effective tool in the appropriate candidate. It improves the inferior gluteal fold and the skin and subcutaneous tissue of the superior posterior thigh. The procedure is indicated in patients with mild buttock ptosis with excess skin and subcutaneous tissue in the inferior gluteal fold or ‘‘banana fold.’’ It can also be used to improve a double infragluteal fold, to correct infragluteal fold asymmetry, or to shorten a long buttock when combining it with an upper buttock lift. It is indicated when the maximum point of buttock fullness is at the mid to upper portion of the buttocks, which should coincide with the level of the pubic symphysis [4]. If the maximum point of fullness falls below this line, then a superior approach and/or augmentation should be contemplated [5]. Furthermore, the inferior gluteal lift technique is contraindicated when the excess skin and subcutaneous tissue extends laterally toward the trochanteric area because this would force the incision to extend laterally, resulting in a long infragluteal fold. It has been widely accepted that one of the features of aesthetically pleasing buttocks is a short infragluteal fold that does not extend past the union of the semitendinous muscle with the biceps femoris, which is medial to the midaxial line of the thigh [4]. The postoperative results depicted in the article demonstrate a successful creation of an inferior gluteal fold and improvement in the contour of the inferior buttock and posterior thigh skin. Yet, the resulting inferior gluteal fold is long and extends into the trochanteric area. Unfortunately, only one patient was depicted in the postoperative images. We agree that avoidance of anchoring the dermal flaps to the periosteum of the ischial tuberosity would result in less postoperative pain as described by the authors. We routinely extend horizontal medial thigh lifts posteriorly into the inferior gluteal crease to create an improved infragluteal fold and lift the skin and subcutaneous tissue of the medial posterior thigh. In our experience with inferior gluteal lifts and horizontal thigh lifts, we have avoided scar migration and recurrence of ptosis by anchoring the superficial fascial system of the lower skin flap to the ischial periosteum with satisfactory long-term results [6]. We are concerned with the ability of the gluteal fascia to withstand the gravitational and muscle pull over a period of time. In their study, the patients were followed postoperatively for 2 months. It would be interesting to know whether the authors have experienced sustained long-term results without scar migration or ptosis recurrence. S. O. Sozer (&) F. J. Agullo Department of General Surgey, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, TX 79905, USA e-mail: doctor@elpasoplasticsurgery.com

Double Negative Pressure for Seroma Treatment in Trocanteric Area

We report the use of topic negative pressure for seromas resulting from mobilization of tensor fascia lata miocutaneous flap in the trochanteric areas for pressure sores. In 5 consecutive patients we successfully treated seroma with the use of external and internal topic subatmospheric pressure.

The analysis of the results of the surgical treatment of trans- and intertrochanteric fractures in the femoral bone of elderly and senile patients

Results of the surgical treatment of 62 patients with trans- and intertrochanteric femoral fractures, who underwent osteosynthesis of fractures in the trochanteric area with angular plates, EN8 fixing device or intraosseal blocking nails, were analysed. The patients (35 women and 27 men) were randomized into 3 groups depending on the way of their fracture fixing. The mean age of the patients was 74, ranging from 60 to 97. The received results essentially do not differ from those obtained by foreign researchers: 61 % of complications, the survival rate during the first year following fracture up to 77 %. The results of the treatment of trans- and intertrochanteric fractures of the femoral bone depend upon the supporting ability of the extremity and the patient’s activity during the early postoperative period and after his discharge from the hospital.