Bone structure and geometry in young men: The influence of smoking,alcohol intake and physical activity

BackgroundThe development of osteoporosis is influenced by peak bone mass attained in youth — the influence of lifestyle factors upon which is poorly described, especially amongst males. We sought to address this issue in a large scale study.MethodsHip bone mineral density (dual X-ray absorptiometry, DXA), bone microarchitecture (calcaneal quantitative ultrasound, QUS) and femoral geometry (magnetic resonance imaging, MRI) were characterised in 723 healthy male military recruits (mean ± S.E. age 19.92 ± 0.09 years [range 16–18 years], height 177.67 ± 0.24 cm, weight 73.17 ± 0.37 kg) on entry to UK Army training. Association was sought with prior physical activity, smoking status and alcohol intake.ResultsDXA measures were made in 651, MRI measures in 650, and QUS measures in 572 recruits. Increasing levels of weight-bearing physical activity enhanced periostial bone apposition, increases in both total hip and femoral neck bone mineral density (BMD; p ≤ 0.0001 in both cases), and cortical [p < 0.0001] and periostial bone volumes [p = 0.016]. Smoking habit was associated with preserved bone geometry, but worse BMD [p = 0.0001] and QUS characteristics [p ≤ 0.0005]. Moderate alcohol consumption was associated with greater BMD [p ≤ 0.015].ConclusionsWhilst exercise (and perhaps moderate alcohol intake) is beneficial to bone morphometry, smoking is detrimental to bone mineral density in young males notable for the likely short duration of smoking to influence skeletal properties. However, differences in socio-economic status, lifestyle and related environmental factors may to some extent confound our results.     

Plate fixation in periprosthetic femur fractures Vancouver type B1—Trochanteric hook plate or subtrochanterical bicortical locking?

IntroductionProximal plate fixation in periprosthetic femur fractures can be improved by plate anchorage in the greater trochanter (lateral tension band principle) or bicortical locking screw placement beside the prosthesis stem in an embracement configuration. Both concepts were compared in a biomechanical test using a femoral hook plate (hook) or a locking attachment plate (LAP).MethodsAfter bone mineral density (BMD) measurement in the greater trochanter, six pairs of fresh frozen human femora were assigned to two groups and instrumented with cemented hip endoprostheses. A transverse osteotomy was set distal to the tip of the prosthesis, simulating a Vancouver B1 fracture. Each pair was instrumented using a plate tensioner with either hook or LAP construct. Cyclic testing (2 Hz) with physiologic profile and monotonically increasing load was performed until catastrophic failure. Plate stiffness was compared in a four-point-bending-test. Paired student’s-t-test was used for statistical evaluation (p < 0.05).ResultsMean BMD was 250 mgHA/ccm ± 47. The hook construct exhibited a significantly (p = 0.015) lower number of cycles and load to failure (26′177 cycles ± 2777; 3′118N ± 778) correlating significantly with BMD (R² = 0.83; p = 0.04) compared to the LAP construct (37′423 cycles ± 5′299; 4′242N ± 1′030) (R² = 0.71;p = 0.11). BMD was a significant covariate (p = 0.01). Plate stiffness was in a comparable range (hook Plate 468 N/mm ± 7; LCP 445 N/mm ± 6).ConclusionSubtrochanterically placed LAP provides an increased fixation strength under repetitive loading compared to hook plate fixation in the greater trochanter. Trochanteric fixation is highly BMD dependent and may be restricted to major greater trochanteric involvement requiring stabilization.     

Radiological determination of stone density and skin-to-stone distance—Can it predict the success of extracorporeal shock wave lithotripsy?

ObjectivesTo determine the role of stone density and skin-to-stone distance (SSD) by non-contrast computed tomography of the kidneys, ureters and bladder (CT-KUB) in predicting the success of extracorporeal shock wave lithotripsy (ESWL).MethodsWe evaluated 89 patients who received ESWL for renal and upper ureteric calculi measuring 5–20 mm, over a 12 month period. Mean stone density in Hounsfield units (HU) and mean SSD in millimetres (mm) was determined on pre-treatment CT-KUB at the CT workstation. ESWL was successful if post-treatment residual stone fragments were ≤3 mm.ResultsESWL success was observed in 68.5% of the patients. Mean stone densities were 505 ± 153 and 803 ± 93 HU in ESWL successful and failure groups, respectively; this was statistically significant (p < 0.001, student's t-test). Mean SSD were 10.6 ± 2.0 and 11.2 ± 2.6 cm in ESWL successful and failure groups, respectively, this was not statistically significant.ConclusionsThis study shows that stone density can help in predicting the outcome of ESWL. We propose that stone densities <500 HU are highly likely to result in successful ESWL. Conversely, stone densities ≥800 HU are less likely to do so. This should be accounted for when considering ESWL.     

Doctor,when can I drive? — Range of functional ankle motion during driving

BackgroundDriving a motor vehicle needs a specific joint mobility and yet only limited knowledge exists regarding the necessary ankle range of motion. The goal of this study is to characterize the sequence and range of ankle motion.MethodsThe arc of plantarflexion/dorsiflexion and supination/pronation was recorded in the right and left ankle using electrogoniometers while thirty laps were driven by fifteen healthy participants around a course in a manual transmission car with a left sided steering wheel. The driver was required to perform the following maneuvers during each lap: (I) Vehicle acceleration and gear change, (II) Sudden evasion, (III) Routine turning, (IV) Rapid turning, (V) Vehicle acceleration followed by emergency braking.ResultsDriving required the right ankle to plantarflex 13 ± 9 and dorsiflex 22 ± 7 while supinating 15 ± 7 degrees and pronating minimally. The left ankle plantarflexed 19 ± 10and dorsiflexed 17 ± 10 while supinating 15 ± 7 degrees and pronating minimally. The right ankle dorsiflexed significantly more (p = 0.00), and yet the left ankle had a significantly higher maximum plantarflexion and range of plantarflexion/dorsiflexion (p = 0.00). Emergency braking resulted in a significantly higher maximum plantarflexion as well as plantarflexion/dorsiflexion range when compared to other maneuvers.ConclusionThis study describes the range of ankle motion identified to drive a car with a manual transmission and a left-sided steering wheel. The right and left ankle exhibit different arcs of motion during driving. This knowledge may assist when evaluating a patient’s driving capability. Further studies are needed to investigate whether movement restrictions impair driving.Level of evidenceBasic science study.     

Combined subtalar distraction arthrodesis with peroneus brevis tenotomy for posttraumatic subtalar arthritis

BackgroundSubtalar distraction arthrodesis is advocated as a salvage procedure for isolated posttraumatic subtalar arthritis. This study aimed at evaluating combined subtalar distraction arthrodesis with peroneus brevis tenotomy for such cases.MethodsTwenty patients with isolated posttraumatic subtalar arthritis managed by combined subtalar distraction arthrodesis and peroneus brevis tenotomy were reviewed for a retrospective study. The American orthopaedic foot and ankle society [AOFAS] hindfoot scoring, talocalcaneal height [TCH], talocalcaneal angle [TCA] and heel valgus angle [HVA] were used for both pre and postoperative assessments.ResultsThe mean postoperative [TCH] [70.3 ± 1.9 mm] was statistically better than the preoperative value [64.7 ± 2.2 mm] [p < 0.001]. There was a statistically significant decrease in [HVA] [p < 0.001]. On the contrary, there was a statistically significant increase in both [AOFAS] hindfoot scoring and the [TCA] [p < 0.001].ConclusionsApplying this technique for isolated posttraumatic subtalar arthritis with peroneal tendinitis improved both lateral retromalleolar swelling and deformity correction.     

Biomechanical comparison of conventional versus modified technique in distal chevron osteotomies of the first metatarsal: A cadaver study

BackgroundDistal chevron osteotomy can be performed using a conventional or a modified technique. The aim of this biomechanical study was to compare the stability of the two techniques.MethodsEighteen first metatarsals from nine pairs of fresh frozen human cadaver feet were used. A distal chevron osteotomy was performed using the conventional technique in group 1 (n = 9) and using the modified technique in group 2 (n = 9). The head of the first metatarsals was loaded in two different configurations (cantilever and physiological), using a materials testing machine.ResultsIn the cantilever configuration, the relative stiffness of the osteosynthesis in comparison with intact bone was 60% (±21%) in group 1 and 65% (±25%) in group 2 (p = 0.61). In the physiological configuration, it was 47% (±29%) in group 1 and 47% (±21%) in group 2 (p = 0.98). The failure strength in the cantilever configuration was 235 N (±128 N) in group 1 and 210 N (±107 N) in group 2 (p = 0.47).ConclusionsThe conventional and the modified technique for distal chevron osteotomy in the treatment of hallux valgus show a comparable biomechanical loading capacity in this cadaver study.     

Tibial torsion correlates with talar morphology

BackgroundThere is limited literature on axial rotation of the ankle or variations in anatomy of the talus. We aim to evaluate the rotational profile of the distal tibia and its relationship to talus morphology, radiographic foot-type, and tibiotalar tilt in arthritic ankles.MethodsPreoperative imaging was reviewed in 173 consecutive patients with ankle arthritis. CT measurements were used to calculate tibial torsion and the talar neck-body angle (TNBA). Tibiotalar tilt and foot-type were measured on weightbearing plain radiographs.ResultsMeasurements indicated mean external tibial torsion of 29.2 ± 9.1? and TNBA of 35.2 ± 7.5? medial. Tibiotalar tilt ranged from 48? varus to 23.5? valgus. A moderate association between increasing external tibial torsion and decreasing TNBA was found (ρ = ?0.576, p < .0001). Weak relationships were found between external tibial torsion and varus tibiotalar tilt (ρ = ?0.239, p = .014) and plantarflexion of the talo-first metatarsal angle (ρ = ?0.218, p < .025).ConclusionWe observed a statistically significant correlation between tibial torsion and morphology of the talus, tibiotalar tilt, and first ray plantarflexion. This previously unreported association may provide information regarding the development of foot and ankle deformity and pathology.Level of evidenceLevel III.     

Early Endothelial Dysfunction in Young Type 1 Diabetics

ObjectivesEndothelial dysfunction is a known precursor of atherosclerosis and can be assessed by measuring the brachial artery flow-mediated dilatation (FMD) via ultrasonography. This study investigated endothelial function in young type 1 diabetics without cardiovascular morbidity or diabetes-related pathology.MethodsYoung diabetics and healthy controls were recruited, both meeting strict inclusion and exclusion criteria. To prove absence of subclinical atherosclerosis, intima-media thickness (IMT) measurements at the carotid bifurcation were done in all of them. FMD was measured at the brachial artery. The results were compared using the t-test and the influences of different variables on FMD were assessed using multiple linear regression.ResultsTwenty-six diabetics (23.4 ± 5.8 years) and 36 healthy volunteers (23.1 ± 2.8 years) were recruited. The duration of diabetes was 9.2 ± 5.3 years; metabolic control was moderate (HbA1c 7.6 ± 1.0%) and IMT was normal in both groups.FMD was significantly impaired in type 1 diabetics (7.13 ± 0.43 vs. 8.77 ± 0.43%; p = 0.002). The FMD grade was associated with diabetes and age. Patients with a good metabolic control (HbA1c ≤ 7.0%) had a better FMD.ConclusionsIn type 1 diabetics, even without preclinical or clinical atherosclerosis, endothelial function is already disturbed and can be detected using ultrasonography.     

Increased cortical area and thickness in the distal radius in subjects with SHOX-gene mutation

IntroductionShort-stature homeobox (SHOX) gene haploinsufficiency may cause skeletal dysplasia including Léri–Weill Dyschondrosteosis (LWD), a clinical entity characterised by the triad of low height, mesomelic disproportion and Madelung's deformity of the wrist. Bone microarchitecture and estimated strength in adult SHOX mutation carriers have not been examined.MethodsTwenty-two subjects with a SHOX mutation including 7 males and 15 females with a median age of 38.8 [21.1–52.2] years were recruited from five unrelated families. The control group consisted of 22 healthy subjects matched on age and sex. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. Bone geometry, volumetric density, microarchitecture and finite element estimated (FEA) bone strength were measured using high-resolution peripheral quantitative computed tomography (HR-pQCT). A full region of interest (ROI) image analysis and height-matched ROI analyses adjusting for differences in body height between the two groups were performed.ResultsAreal BMD and T-scores showed no significant differences between cases and controls. Total radius area was smaller in cases than controls (207 [176–263] vs. 273 [226–298] mm, p < 0.01). Radius cortical bone area (74 ± 20 vs. 58 ± 17 mm², p = 0.01) and thickness (1.16 ± 0.30 vs. 0.84 ± 0.26 mm, p < 0.01) as well as total density (428 ± 99 vs. 328 ± 72 mg/cm³, p < 0.01) were higher in SHOX mutation carriers compared to controls. Radius trabecular bone area (119 [103–192] vs. 202 [168–247] mm², p < 0.01) and trabecular number (1.61 [1.46–2.07] vs. 1.89 [1.73–2.08] mm^− 1, p = 0.01) were smaller in SHOX mutation carriers. Tibia trabecular thickness was lower in cases (0.067 ± 0.012 vs. 0.076 ± 0.012 mm, p = 0.01). These results remained significant after adjustment for differences in body height and when restricting analyses to females. There were no differences in BMD, radius and tibia cortical porosity or FEA failure load between groups. A segment of cortical bone defect was identified in the distal radius adjacent to ulna in five unrelated SHOX mutation carriers.ConclusionSubjects with a SHOX mutation presented with a different bone geometry in radius and tibia while there were no differences in BMD or failure load compared to controls, suggesting that mutations in SHOX gene may have an impact on bone microarchitecture albeit not bone strength.     

Biomechanical comparison of plate and screw fixation in anterior pelvic ring fractures with low bone mineral density

IntroductionOsteosynthesis of anterior pubic ramus fractures can be challenging, especially in poor bone quality. The aim of the present study was to compare plate and retrograde endomedullary screw fixation of the superior pubic ramus with low bone mineral density (BMD).Materials and methodsTwelve human cadaveric hemi-pelvises were analyzed in a matched pair study design. BMD of the specimens was 35 ± 30 mgHA/cm³, as measured in the fifth lumbar vertebra. A simulated two-fragment superior pubic ramus fracture model was fixed with either a 7.3-mm cannulated retrograde screw (Group 1) or a 10-hole 3.5-mm reconstruction plate (Group 2). Cyclic progressively increasing axial loading was applied through the acetabulum. Relative interfragmentary movements were captured using an optical motion tracking system.ResultsInitial axial construct stiffness was 424 ± 116.1 N/mm in Group 1 and 464 ± 69.7 N/mm in Group 2, with no significant difference (p = 0.345). Displacement and gap angle at the fracture site during cyclic loading were significantly higher in Group 1 compared to Group 2. Cycles to failure, based on clinically relevant criteria, were significantly lower in Group 1 (3469 ± 1837) compared to Group 2 (10,226 ± 3295) (p = 0.028). Failure mode in Group 1 was characterized by screw cutting through the cancellous bone. In Group 2 the specimens exclusively failed by plate bending.ConclusionsFrom biomechanical point of view, pubic ramus stabilization with plate osteosynthesis is superior compared to a single retrograde screw fixation in osteoporotic bone. However, the extensive surgical approach needed for plating must be considered.     

Duration of breastfeeding as a risk factor for vertebral fractures

PurposeAmong the risk factors for osteoporosis and fractures, gynecological history (fertile period, parity and breastfeeding) play an important part. Changes in calcium metabolism to enable an adequate mineral transfer to the milk have a prominent role in bone loss during breastfeeding. Data on the influence of breastfeeding in postmenopausal osteoporosis are inconsistent. The aim of the present study was to identify any association between duration of breastfeeding and vertebral fractures in postmenopausal women.MethodsAll patients underwent the following tests: bone mineral density measurements of the lumbar spine (L1–L4) and the total and femoral neck using dual-energy X-ray absorptiometry and antero-posterior and lateral radiography of the thoracic and lumbar spine to identify vertebral fractures.ResultsThe study involved 752 women with a mean age of 64.5 ± 9.3; 23% of them reported vertebral osteoporotic fractures. The women with vertebral fractures had breastfed for longer periods (11.8 ± 12.9 vs. 9.3 ± 11.2 months, p = 0.03) and had more pregnancies (2.6 ± 2.2 vs. 2.2 ± 1.3, p = 0.002). Breastfeeding for more than 18 months was associated with a two-fold risk of developing vertebral fractures (OR 2.12, 95% CI 1.14–5.38, p = 0.04), particularly in those without current or past use of drugs positively affecting bone.ConclusionsOur study showed an association between long periods of breastfeeding and vertebral fractures, supporting a role for lengthy lactation as a risk factor for osteoporotic fractures after menopause. Bearing in mind all the benefits of breastfeeding, this finding suggests the importance of an adequate calcium and vitamin D intake during pregnancy and breastfeeding, with the aid of dietary supplements if necessary.     

Clinical outcomes comparing arthroscopic vs open ankle arthrodesis

BackgroundOver the last twenty years, minimally invasive ankle arthrodesis has evolved into a well-tolerated and safe procedure. It has grown in favor to open ankle arthrodesis due to shorter length of stay and fewer complications recorded. This paper aims to compare the clinical outcomes of arthroscopic vs open ankle arthrodesis at 24-months followup.MethodsFrom 2004 to 2015, we reviewed a prospectively collected database in a tertiary hospital foot and ankle registry. 28 feet that underwent arthroscopic ankle arthrodesis were matched to 56 feet that underwent open ankle arthrodesis for age, sex and body mass index (BMI). Visual analogue scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-hindfoot Scores and Short Form Health Survey (SF-36) were obtained to assess clinical outcomes. These parameters were collected before surgery, at 6 months and 24 months after surgery.ResultsThe arthroscopic group demonstrated significant less pain in the perioperative period (arthroscopic: 1.9 ± 1.2, open: 3.8 ± 1.1, p < 0.001) and shorter length of hospitalization stay (arthroscopic: 2.1 ± 0.7 open: 3.5 ± 1.7, p < 0.001). Patients who underwent arthroscopic ankle arthrodesis also reported a higher SF-36 score on physical functioning at 6 months (arthroscopic: 58.4 ± 27.1, open: 47.1 ± 24.0, p < 0.05) and higher AOFAS Ankle-hindfoot Scale score at 24-months (arthroscopic: 78.9 ± 18.9, open: 68.9 ± 24.7, p < 0.05). There were no postoperative complications in the arthroscopic group but 11 in the open group, including 9 which required followup operations. There was no significant difference in length of operative procedure between both groups.ConclusionsWe conclude that the arthroscopic group displayed better clinical outcomes compared to the open group at the 24 months followup. The advantages of arthroscopic ankle arthrodesis include significantly less perioperative pain, higher AOFAS Ankle-hindfoot scores at 24 months, shorter length of stay, fewer postoperative complications and followup operations.Level of evidenceLevel III, retrospective comparative series.     

Kinematic analysis of ankle stiffness in subjects with and without flat foot

BackgroundAlthough the magnitude of ankle motion is influenced by joint congruence and ligament elasticity, there is a lack of understanding on ankle stiffness between subjects with and without flat foot.ObjectiveThis study investigated a quantified ankle stiffness difference between subjects with and without flat foot.MethodsThere were forty-five age- and gender-matched subjects who participated in the study. Each subject was seated upright with the tested foot held firmly onto a footplate that was attached to a torque sensor by the joint-driving device.ResultsThe flat foot group (mean ± standard deviation) demonstrated increased stiffness during ankle dorsiflexion (0.37 ± 0.16 for flat foot group, 0.28 ± 0.10 for control group; t = −2.11, p = 0.04). However, there was no significant group difference during plantar flexion (0.35 ± 0.15 for flat foot group, 0.33 ± 0.07 for control group; t = 0.64, p = 0.06).ConclusionThe results of this study indicated that the flat foot group demonstrated increased ankle stiffness during dorsiflexion regardless of demographic factors. This study highlights the need for kinematic analyses and joint stiffness measures during ankle dorsiflexion in subjects with flat foot.     

Cost-Minimization Study Comparing Annual Infusion of Zoledronic Acid or Weekly Oral Alendronate in Women With Low Bone Mineral Density

Cost-minimization study to assess the annual direct costs of 2 antiresorptive strategies in postmenopausal women with low bone mineral densities (BMDs). Patients were randomly assigned to receive 70 mg of oral weekly alendronate or a 1-time 5 mg of intravenous zoledronic acid. All medical and nonmedical direct costs were recorded for 1 yr. Student's t-test or the Chi-squared test was used. A total of 101 postmenopausal women were enrolled with a mean age of 58.3 ± 7.6 yr and a postmenopausal period of 13.5 ± 8.3 yr. A total of 50 patients completed 1 yr of alendronate and 51 patients received zoledronic acid. At baseline, no differences were seen between the 2 groups in anthropometric measures, comorbidities, and bone mineral density. The costs for medical attention for low bone mass were $81,532 (US Dollars) for the alendronate group and $69,251 for the zoledronic acid group; the cost per patient was $1631 in the alendronate group vs $1358 in the zoledronic acid group (p < 0.0001). Therefore, zoledronic acid treatment provided an annual savings of 15% of the direct costs compared with oral alendronate treatment. Moreover, there was a significant increase in lumbar spine T-scores in the zoledronic acid group when compared with the alendronate group. Annual zoledronic acid infusion as an antiresorptive treatment in women with low BMD provides significant monetary savings when compared with weekly alendronate therapy for 1 yr. Zoledronic acid infusion is also linked to higher increase in BMD and compliance.     

Intra-operative fluoroscopy time and radiation dose during suprapatellar tibial nailing versus infrapatellar tibial nailing

BackgroundFractures of the tibial shaft are routinely managed with intramedullary nailing. An increasingly accepted technique is the suprapatellar extended leg method. The aim of this study was to investigate whether the suprapatellar tibial nailing technique offers shorter intraoperative fluoroscopy times and lower radiation doses when compared to the traditional infrapatellar technique.Study design and methodsData from 200 consecutive intramedullary tibial nailing operations in our level 1 Major Trauma Centre were retrospectively collected from a prospective database (January 2014–December 2017). Only acute diaphyseal nailing procedures were included. The operations were performed by seven senior trauma consultants experienced in both suprapatellar and infrapatellar tibial nailing. The operations were divided into two groups: infrapatellar and suprapatellar. Intraoperative radiation time and dose data were collected.ResultsA total of 90 cases were included and analysed. The majority of the patients were male (82%). 37 operations were infrapatellar and 53 were suprapatellar. Independent samples t-test revealed lower radiation time and dose for the suprapatellar group. The infrapatellar group had a mean radiation time of 129.7 ± 56.6 s versus 94.4 ± 47.9 s for the suprapatellar group. The infrapatellar group had a mean radiation dose (Dose Area Product) 53.6 ± 34.2 cGY cm² versus 38.2 ± 26.7 cGY cm² for the suprapatellar group. The difference in mean radiation time and mean radiation dose were both significant (p = 0.002 and p = 0.02 respectively).ConclusionsSuprapatellar tibial nailing is an increasingly accepted technique in the management of tibial fractures. It is shown here that amongst surgeons experienced in both suprapatellar and infrapatellar nailing techniques, the suprapatellar approach trends towards lower use of intra-operative fluoroscopy as measured by time and dose and thus potentially lower radiation exposure to the operating surgeon, assistants and patient.     

External versus internal fixation for arthrodesis of chronic ankle joint infections — A comparative retrospective study

BackgroundArthrodesis of the ankle is a salvage procedure in case of chronic ankle joint infection. External fixation still is the gold standard.We compared the outcome of external fixator versus intramedullary nailing for arthrodesis of the infected ankle joint.MethodsAll patients with ankle joint infection who received arthrodesis with either external fixator or intramedullary nail between 08/2009 and 09/2017 were retrospectively analyzed. Endpoints were the successful control of infection, osseous fusion, and mobilization with full weightbearing.ResultsSeventy-one patients were included. Nineteen patients (27%) suffered reinfection. Patients with intramedullary nailing showed significantly fewer reinfections (p = 0.019), achieved full weightbearing significantly more often (p = 0.042) and faster and developed significantly fewer complications (p < 0.001). Forty-three patients showed bone fusion without significant differences between the groups.ConclusionsAnkle arthrodesis with intramedullary nailing appears to be a successful alternative to the established procedure of external fixation in cases of chronic ankle joint infection.     

The effect of bone marrow mononuclear cells on vascularization and bone regeneration in steroid-induced osteonecrosis of the femoral head

ObjectiveWe examined whether implantation of autologous bone marrow mononuclear cells (BM-MNC) can augment neovascularization and bone regeneration in steroid-induced osteonecrosis of the femoral head.MethodsSixty-five 28-week-old male New Zealand white rabbits were divided into group I (left untreated, N = 20), group II (core decompression, N = 20) and group III (core decompression + autologous bone marrow cells implantation, N = 25) after receiving an established inductive protocol for inducing steroid-associated ON. Four weeks later, these rabbits were euthanized, bilateral femora were dissected for micro-CT-based microangiography to assess vascularization, and then the osteonecrotic changes and repair processes were examined histopathologically.ResultsQuantitative analysis showed that new vessel formation in group III was significantly greater compared with other groups at 4 weeks after treatment. Penetrating capillary vessels number vessels number in group III (44.5 ± 5.11) was significantly larger than that of group II (11.4 ± 2.46) and group I (3.10 ± 0.33) (p < 0.01). The histologic and histomorphometric analysis revealed that the new bone volume was significantly higher in the group III than in the group I and II, 4 weeks after treatment.ConclusionIn this animal model, a combination of bone marrow mononuclear cells and core decompression enhance the neovascularization and the osteoinductive ability, resulting in bone regeneration. These findings confirm the preliminary clinical results obtained in humans that the implantation of bone marrow mononuclear cells is an effective and feasible method for treating early osteonecrosis.     

Characterization of bone mineral density in male-to-female transsexuals receiving treatment for reassignment surgery: 15 years of follow-up

BackgroundCross-sex hormone treatment in male-to-female (M2F) transsexuals appears reasonably safe. Little is known about its long-term use. The aim of our study was to evaluate the effect of long-term high dose estrogens, plus the antiandrogen cyproterone acetate, on bone composition and on biochemical/hormonal parameters in M2F transsexuals.MethodsA retrospective analysis was performed on 45 young M2Fs (mean age 39.5 years; body mass index (BMI) = 22) receiving estrogens (previously 100 μg ethinyl estradiol, now 2–4 mg oral estradiol valerate/day or 100 μg transdermal estradiol/day) plus the antiandrogen cyproterone acetate 100 mg/day. Data were retrieved from 20 subjects after reassignment surgery (mean hormonal treatment duration 15.6 years). A complete hormonal and biochemical assessment, as well as bone biochemical markers (parathyroid hormone (PTH), calcium, phosphorus, alkaline phosphatase and plasma pyridinoline crosslinks), were evaluated. Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (DEXA).ResultsAll subjects had suppressed serum testosterone levels (mean = 0.57 nmol/l), whereas serum estradiol levels were within the supraphysiological range (mean = 880 pmol/l). A mild osteopenia at both lumbar spine and femoral neck was observed in 15 out of the 20 (75%) M2Fs (BMD = 0.89 ± 0.14 (mean ± standard deviation (SD)) g/cm² versus 1.1 ± 0.09, p < 0.001; lumbar T-score = −1.39 ± 0.84 versus 0.5 ± 1.10, p < 0.0005; femoral T-score = −1.12 ± 0.76 versus 0.08 ± 1.00, p < 0.05, respectively). No differences in plasma crosslink levels or in hormonal and biochemical parameters were found between subjects.ConclusionsOur results indicate that cross-sex hormone treatment of M2Fs, independently of serum testosterone levels, seems acceptably safe over a median treatment period of 15 years in a consistent population of subjects. A protective role for estrogens on bone seems to be present in a minority of subjects.     

Bone Mineral Density in Premenopausal Arab Women With Type 2 Diabetes Mellitus

IntroductionThis study compares an ethnically uniform group of premenopausal type 2 diabetic (T2DM) Arab women with a matched control group of nondiabetic subjects, in terms of their bone mineral density (BMD) and anthropometric measurements.MethodsThe study included 252 premenopausal Arab women. Their age ranged from 26 to 50 yr with a mean ± SD of 43.65 ± 8.97 yr. One hundred and twenty-two women were T2DM patients and 130 women were nondiabetic controls. The controls matched the subjects in gender, age, and body mass index (BMI). BMD was measured at total lumbar spine (L1–L4) and total left hip, using dual-energy X-ray absorptiometry (DXA; HOLOGIC, QRS SERIES, Europe, Belgium). Difference in BMD and its relationship to the anthropometric measurements in T2DM and control groups were assessed.ResultsSignificant difference was found between T2DM patients and nondiabetic patients in their mean hip BMD (0.92 ± 0.16 vs. 0.87 ± 0.14, p < 0.05) and spine BMD (0.93 ± 0.15 vs. 0.88 ± 0.14, p < 0.01). No significant difference was found in age, height, weight, and BMI (p > 0.05). The increase in hip BMD in T2DM patients normalized and the increase in spine BMD persisted after controlling for the confounding effect of age and anthropometric measurements.ConclusionPremenopausal Arab women with T2DM have higher BMD at the spine than women without T2DM. The underlying mechanism causing this increase does not seem to be related to ethnicity, gender, hormonal status, or anthropometric measurements.     

Development and evaluation of a low-cost part-task trainer for laparoscopic repair of inguinal hernia in boys and the acquisition of basic laparoscopy skills

PurposeTo examine the fidelity of our model of laparoscopic inguinal hernia repair (LIHR) in boys and evaluate its value in resident training programs and the learning of basic laparoscopy skills.MethodsWe created a simulation model with inexpensive, easy-to-obtain equipment. Study participants from 34 university hospital departments received a user manual and an evaluation questionnaire (11 items rated on a 5-point Likert scale). We considered that the evaluation was positive when the median overall score was 4 or over. We compared the results for residents (n = 26) vs. expert surgeons (n = 29) (t tests).ResultsThe duration of the procedure was significantly longer among the residents (30.0 ± 16.8 min) than among the expert surgeons (20.5 ± 11.7 min; p = 0.01). In both groups, the participants rated the model favorably with regard to the overall impression (median score: 4.0 ± 1.0), realism (4.0 ± 0.9), ease of access to the required equipment (5.0 ± 0.6), the quality of the user manual (5.0 ± 0.6), ease of assembly (5.0 ± 0.8), ease of the procedure (5.0 ± 0.8), value in resident training programs (4.0 ± 0.9), and value in learning basic laparoscopy skills (5.0 ± 0.8)). The evaluation was positive (4.0 ± 0.9).ConclusionOur low-cost model was an effective teaching and training tool for LIHR and basic laparoscopy skills.Level of EvidenceLevel IV.