The macroscopic and histomorphological properties of periosteal rib lesions and its relation with disease duration: evidence from the Luis Lopes Skeletal Collection (Lisbon,Portugal)

Periosteal new bone formation (PNBF) is a common finding in a large spectrum of diseases. In clinical practice, the morphology and location of periosteal lesions are frequently used to assist in the differential diagnosis of distinct bone conditions. Less commonly reported is the presence of PNBF on the ribs. This contrasts with the data retrieved from the study of skeletonized human remains that shows a high frequency of cases and a strong, albeit not specific, association between periosteal rib lesions and pulmonary conditions (e.g. tuberculosis). Despite that, an overall disagreement regarding the specificity and non‐specificity of periosteal reactions exists in the study of dry bone remains. The insufficient number of clinical models exploring the morphology and the pathophysiology of PNBF's and the lack of systematic studies of pathological samples with a known diagnosis are claimed as major reasons for the disagreements. This study aimed to describe and compare the macroscopic and the histomorphologic appearance of periosteal rib lesions and to discuss their usefulness as diagnostic indicators. To pursue this goal, an assemblage of 13 rib samples (males = 11, females = 2, mean age‐at‐death = 36.6 years old) was collected from the Luis Lopes Skeletal Collection (Museu Nacional de História Natural e da Ciência, Universidade de Lisboa, Portugal). The assemblage belongs to individuals who died from pulmonary‐TB (group 1), non‐TB pulmonary infections (group 2) and other conditions (group 3). Prior to sample preparation, the ribs were visually inspected and the PNBF described according to its thickness, the degree of cortical integration and the type of new bone formed (e.g. woven, lamellar or both). After sampling, each bone sample was prepared for histological analysis under plane and polarized light microscopy. Macroscopically, the results showed no differences in the new bone composition between cause‐of‐death groups. Only slight differences in the degree of cortical integration, which was most frequently classified as mild to high in the pulmonary‐TB group, were observed. Histologically, no distinguishing features were identified by pathological group. However, new bone microarchitectures were observed compatible with (1) acute, fast‐growing processes (e.g. spiculated reactions), (2) long‐standing processes with a rapid bone formation (e.g. appositional layering of bone) and/or (3) chronic, slow‐growing processes (e.g. layers of compact lamellae). To some extent, these distinct rates of disease progression resonate with the cause‐of‐death listed for some individuals. Despite the small sample size, the results of this investigation are in agreement with previous studies, according to which the macroscopic and histological appearance of periosteal formations are not specific for a particular pathological conditions. Nevertheless, the results support the conclusion that the morphology of periosteal lesions is a good biological indicator for inferring the rate of progression and duration of pathological processes. This study provides important reference data regarding the histomorphology of periosteal lesions that can be used for comparative purposes, as well as to narrow down the differential diagnosis in unidentified skeletal remains.     

Reduction of BMP6‐induced bone formation by calcium phosphate in wild‐type compared with nude mice

Nude mice have been extensively used to investigate the potency of tissue engineering strategies for bone repair. However, the contribution of pro‐inflammatory and proregenerative stimuli of the host for the process of new bone formation and integration remains poorly understood. In this study, ectopic bone formation was investigated in nude (Nu) versus wild‐type (WT) mice. Calcium phosphate (CaP) scaffolds (CopiOs [Zimmer] and Bio‐Oss [Geistlich]) were loaded with different concentrations of rhBMP6 (40, 120, and 240 ng/mm³ rhBMP6) and implanted subcutaneously in Nu (BALB/c and NMR1) and WT (BALB/c and c57BL/6) mice. CaP scaffolds loaded with rhBMP6 did not form bone in WT mice. However, in Nu mice, 40 ng/mm³ rhBMP6 was sufficient to generate relevant volumes of new bone at 6 weeks after implantation. Looking into potential underlying mechanisms, TNF‐α blocking antibodies were injected intraperitoneally but could not restore bone formation. Also, mouse periosteal cells (mPDCs) seeded in CopiOs loaded with rhBMP6 did not significantly improve the outcome. Abrogation of bone formation was associated with dense cellular infiltration, in particular with the presence of CD3+ T‐lymphocytes. To probe a correlation between calcium ions and impaired bone formation in WT mice, type 1 collagen gels were loaded with rhBMP6 and calcium chloride and injected subcutaneously. These gels generated new bone in WT mice despite the increased percentage of CD3+ cells at Day 3 after implantation as compared with control gels. Overall, this study illustrated the negative effect of the inflammatory host response on the bone‐forming capacity of rhBMP6 coated on bioceramic scaffolds.     

Analysis of the uninjured tibiofibular syndesmosis using conventional CT-imaging and axial force in different foot positions

BackgroundSyndesmosis measurments and indices have been controversial and showed interindividual variability. The purpose of this study was to analyze, by conventional axial computed tomography images and a simulated load device, the uninjured tibiofibular syndesmosis under axial force and forced foot positions.MethodsA total of 15 healthy patients (30 ankles) were studied using adjustable simulated load device (ASLD). This device allowed to perform bilateral ankle CT scans in two forced foot and ankle positions (30° of plantar flexion, 15° of inversion, 20° of internal rotation and 15° of dorsal flexion, 15° of eversion, 30° of external rotation). Axial load was applied simultaneously in a controlled manner (70% body weight). Measurements on the axial image of computed tomography were: syndesmotic area (SA), fibular rotation (FR), position of the fibula in the sagittal plane (FPS), depth of the incisura (ID) and direct anterior difference (ADD), direct middle difference (MDD) and direct posterior difference (PDD).ResultsIn patients without injury to the tibiofibular syndesmosis, the application of axial load and forced foot and ankle positions showed statistically significant differences on the distal tibiofibular measurements between the stressed and the relaxed position, it also showed interindividual variability : SA (median = 4.12 [IQR = 2.42, 6.63]) (p < 0.001), ADD (0.67 [0.14, 0.67]) (p < 0.001), MDD(0.45, [0.05, 0.9]) (p < 0.001), PDD (0.73 [?0.05, 0.73]) (p < 0.002). However, it did not detect statistically significant differences when the tibiofibular differences between the stressed and the relaxed position in one ankle were compared with the contralateral side: SA (?0.14, SD = 4.33 [95% CI = ?2.53, 2.26]), ADD (?0.42, 1.08 [?1.02, 0.18]), MDD (0.29, 0.54 [?0.01, 0.59]), PDD (?0.1, 1.42 [?0.89, 0.68]). Interobserver reliability showed an Intraclass correlation coefficient of 0.990 [95% CI = 0.972, 0.997].ConclusionsWide interindividual variability was observed in all syndesmotic measurements, but no statistically significant differences were found when comparing one ankle to the contralateral side. Measuring syndesmosis alignment parameters, may only be of value, if those are compared to the contralateral ankle.     

开放性胫腓骨骨折合并胫后动静脉血管损伤并发骨筋膜室综合征患者的护理

总结分析1例开放性胫腓骨骨折合并胫后静脉离断,胫后动脉损伤(GustiloⅢC型)并发骨筋膜室综合征患者的护理经验。其护理要点包括:严重创伤后病情观察与预防失血性休克,平稳过渡到手术;骨筋膜室综合征的应急处理;大面积皮肤缺损多次清创及VSD引流的护理及创面管理;胫跖牵引技术创新在足下垂护理中的运用;通过健肢、术肢及生活自理能力训练,使患者功能最大程度恢复。     

A pedicled palatal periosteal flap for the closure of oro-antral fistula

Various surgical techniques have been developed for oro-antral fistula (OAF) closure, all of which have some drawback. Twenty consecutive patients with an OAF were enrolled in this prospective study. A trapezoid full-thickness flap extending from the palatal area to the buccal gingiva was raised, including the fistula at its centre. The palatal free end aspect was split into two layers and the deep periosteal layer was folded deep to the flap over the bony defect, thereby sealing the fistula. The superficial layer was returned to its primary position and sutured. The patients were followed for 3 months. Nineteen patients showed immediate OAF closure. One patient showed a residual oro-antral communication of 0.5 mm in diameter that resolved spontaneously within 4 weeks. The pain level (on a visual analogue scale) was highest at the first follow-up week, with a mean score of 5.5, which decreased to a mean level of 2.5 in the second week and 0 in the fourth week. The mean satisfaction level was 9.85 on a scale of 0–10 (10 representing total satisfaction). The pedicled palatal periosteal flap is a simple and effective surgical technique with high predictability and patient satisfaction levels, offering one more alternative for the treatment of OAF.     

Technical aspects of the syndesmotic screw and their effect on functional outcome following acute distal tibiofibular syndesmosis injury

Introduction

Much of the currently available data on the technical aspects of syndesmotic screw placement are based upon biomechanical studies, using cadaveric legs with different testing protocols, and on surgeon preference. The primary aim of this study was to investigate the effect of the level of syndesmotic screw insertion on functional outcome. Further, the effects of number of cortices engaged, the diameter of the screw, use of a second syndesmotic screw and the timing of removal on functional outcome were tested.

Material and method

All consecutive patients treated for an ankle fracture with concomitant acute distal tibiofibular syndesmotic injury that had a metallic syndesmotic screw placed, between 1 January 2004 and 31 December 2010, were included. Patient characteristics (i.e., age at injury and gender), fracture characteristics (i.e., affected side, trauma mechanism, Weber fracture type and number of fractured malleoli), and surgical characteristics (i.e., level of screw placement, screw diameter, tri- or quadricortical placement, number of syndesmotic screws used and the timing of screw removal) were recorded. Outcome was measured using validated questionnaires, which were sent by post, and consisted of the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS), the Olerud–Molander Ankle Score (OMAS) and a single question Visual Analog Scale (VAS) for patient satisfaction with outcome.

Results

During the 7-year study period, 122 patients were treated for syndesmotic injury. A total of 93 patients (76%) returned the questionnaire. The median follow-up was 51 months. The outcome scoring systems showed an overall score for the entire group of 92 points for the AOFAS, 77 for the OMAS and 8.2 for the VAS. Outcome was statistically significantly influenced by the number of fractured malleoli, age, trauma mechanism and the level of screw insertion.

Conclusion

Overall, the functional outcome of acute syndesmotic injuries treated with a syndesmotic screw was good and mainly influenced by patient and fracture characteristics. Most different technical aspects of placement appeared not to influence these results. Only screw placement above 41 mm negatively influenced outcome.     

Early detection of peroneal neuropathy by ultrasound

A 12 year old boy presented with ankle sprain. The physical examination revealed mild weakness of ankle dorsiflexion. An ultrasound was done for the soft tissues of the ankle. In addition to relative atrophy of the peroneus longus muscle, a compressive common peroneal nerve (CPN) lesion with a synovial cyst at the level of the proximal tibiofibular joint (PTFJ) was accidently found. Since there were features of CPN compression by the synovial cyst, total excision of the cyst was performed. After the operation, muscle strength improved and the neurological deficit subsided. Therefore, the early diagnosis of PTFJ synovial cyst with nerve injury was crucial in order to achieve a better result. The obscure nature of clinical presentations can delay the diagnosis, which may potentially lead to a poor prognosis after treatment in such cases. This report highlights the fact that ankle sprain do need a thorough clinical work up in some cases.     

下胫腓联合损伤韧带重建的生物力学研究

目的比较下胫腓联合损伤采用腓骨长肌腱在不同方向上进行重建的生物力学特性,为临床韧带重建提供科学依据。方法采用新鲜成人尸体踝标本6具,运用生物力学实验方法和压敏片技术,测量不同韧带重建方式的内外踝的应变、位移、胫距间负重面积、接触应力。结果在下胫腓前韧带及骨间韧带之间方向上斜向重建下胫腓在内外踝应变、位移、负重面积、接触压力方面均优于其他重建方式,具有显著性差异（P〈0．05）。结论在下胫腓前韧带及骨间韧带之间方向上斜向重建下胫腓,既有利于增强生物力学性能,又有利于改善踝关节的稳定性,对临床上指导下胫腓联合损伤韧带重建方案有理论指导意义。