Disuse osteopenia following leg fracture in postmenopausal women: Implications for HIP fracture risk and fracture liaison services

IntroductionDisuse osteopenia is a known consequence of reduced weight-bearing and has been demonstrated at the hip following leg injury but has not been specifically studied in postmenopausal women.MethodBilateral DXA (GE Lunar Prodigy) bone mineral density (BMD) measurements were taken at the neck of femur (NOF), total hip region (TH) and lumbar spine in postmenopausal female groups comprising controls (N = 43), new leg fractures (#<3wks) (N = 9), and participants who had sustained a leg fracture more than one year previously (#>1yr) (N = 24). #>1yr were assessed at a single visit and the remaining groups at intervals over twelve months. Weight-bearing, function, 3-day pedometer readings, and pain levels were also recorded.ResultsThe #<3wks demonstrated significant (p < 0.05) losses in ipsilateral TH BMD at 6 weeks from baseline 0.927 ± 0.137 g/cm², to 0.916 ± 0.151 g/cm² improving to 0.946 ± 0.135 g/cm² (n.s) at 12 months following gradual return to normal function and weight-bearing activity. The #>1yr scored significantly below controls in almost all key physical and functional outcomes demonstrating a long-term deficit in hip bone density on the ipsilateral side.ConclusionThe clinical significance of post-fracture reduction in hip BMD is a potential increased risk of hip fracture for a variable period that may be mitigated after return to normal function and weight-bearing. Improvement at 12 months in #<3wks is not consistent with #>1yr results indicating that long-term impairment in function and bone health may persist for some leg fracture patients. Unilateral bone loss could have implications for Fracture Liaison Services when assessing the requirement for medication post fracture.     

实测法在半髋关节置换术中确保下肢等长的应用

目的分析实测法在半髋关节置换术中确保下肢长度的有效性。方法笔者自2010-01—2012-12共采用非骨水泥固定型双动头人工半髋关节置换术治疗279例移位股骨颈骨折。随机分成实测法组(应用实测法)和经验测量法组(应用解剖标志测量法),比较2组术后双下肢长度差异、手术时间、Harris评分、平均住院日及术后并发症。结果所有患者获得平均47.5(30~69)个月随访。实测法组与经验测量法组术后双下肢平均长度差异分别为(4.15±2.68)mm和(6.93±3.71)mm,实测法组小于经验测量法组,差异有统计学意义(t=-2.276,P=0.031)。实测法组和经验测量法组在手术时间、术后及末次随访时髋关节Harris评分、平均住院日、术后并发症方面比较差异无统计学意义(P0.05)。2组各1例发生脱位,无坐骨神经麻痹、伤口感染、假体周围骨折发生。结论实测法是一种在半髋关节置换术中减小下肢长度差异的简单、有效、准确的方法。     

Relationship and significance of gait deviations associated with limb length discrepancy: A systematic review

Controversy still exists as to the clinical significance of leg length discrepancy (LLD) in spite of the fact that further evidence has been emerging regarding the relationship between several clinical conditions and LLD. The objectives of our study were to review the available research with regard to LLD as a cause of clinically significant gait deviations, to determine if there is a relationship between the magnitude of LLD and the presence of gait deviations and to identify the most common gait deviations associated with LLD. In line with the PRISMA guidelines, a literature search was carried out throughout the Medline, CINAHL and EMBASE databases. Twelve articles met the predetermined inclusion criteria and were included in the review. Quality assessment using the Methodological Index for Non-Randomized Studies (MINORS) scale was completed for all included studies. Two main methodologies were found in 4 studies evaluating gait asymmetry in patients or healthy participants with anatomic LLD and 8 studies evaluating gait deviations while simulating LLD by employing artificial lifts of 1–5 cm on healthy subjects. A significant relationship was found between anatomic LLD and gait deviation. Evidence suggests that gait deviations may occur with discrepancies of >1 cm, with greater impact seen as the discrepancy increases. Compensatory strategies were found to occur in both the shorter and longer limb, throughout the lower limb. As the discrepancy increases, more compensatory strategies occur. Sagittal plane deviations seem to be the most effective deviations, although, frontal plane compensations also occur in the pelvis, hip and foot.     

Association of leg length with overweight and obesity in children aged 5–15 years: A cross-sectional study

Background: Short leg length (LL) and childhood obesity have been independently associated with a higher risk for adult disease. However, the contribution of relative LL to overweight and obesity in children remains an under-researched area.

Aim: To utilize data from a large cross-sectional anthropometric survey to assess the association of LL to height ratio (LLHR, leg length/height) with measures of overweight and obesity in British children.

Methods: Children were analysed from the bottom and top body mass index (BMI) standard deviation score (SDS) quartiles (3825 children, boys=1686) or waist circumference (WC) SDS quartiles (3824 children, boys=1687). The top quartile was defined as the ‘high’ BMI or WC SDS group and the lower bottom quartile as the ‘low’ BMI or WC SDS group. Height and LL were expressed as SDSs using current references and LLHR was calculated.

Results: Children in the ‘high’ groups were taller with longer legs but had a lower LLHR across most ages. The magnitude of the difference was greater for BMI than WC in both genders.

Conclusion: Altered body dimensions appear to be linked to measures of overweight and obesity in children but longitudinal studies are needed to confirm this suggestion.     

Wireless micro current stimulation – an innovative electrical stimulation method for the treatment of patients with leg and diabetic foot ulcers

Clinical experience with a new electrical stimulation (ES) technique, the wireless micro current stimulation (WMCS), for the treatment of chronic wounds is described. WMCS transfers the current to any surface wound from a distance, by using oxygen's and nitrogen's ability to exchange electrons. We studied 47 patients with hard‐to‐heal wounds. Patients with venous, arterial and mixed leg ulcers were predominant; other aetiologies such as diabetic foot lesions, pressure ulcers, vasculitis and pyoderma were also included. WMCS treatment protocol specified treatment twice or thrice per week, for 45–60 minutes per session, with 1·5 μA current intensity. Standard wound care was applied to all patients, including compression bandages, if necessary. Clear progress of wound healing, even after 2 weeks, was observed in all cases. The mean reduction of the wound surface after WMCS treatment was 95% in 8 weeks. Complete healing was achieved within 3 months for the majority of the cases. No clinical side effects were observed. WMCS technology significantly accelerated wound healing for patients with hard‐to‐heal wounds of different aetiologies. This new therapy offers multiple advantages compared with the previous methods of ES, as it is contactless, free of pain and very easy to use.     

电针为主治疗腰椎间盘突出所致坐骨神经痛:多中心随机对照试验

目的:筛选以电针为主治疗腰椎间盘突出所致坐骨神经痛的简便优效方案。方法:开展多中心随机对照试验,将198例腰椎间盘突出所致坐骨神经痛患者随机分成电针治疗组(A组)66例、电针联合牵引治疗组(B组)67例、电针联合牵引治疗组(C组)65例。3组均第1~2 w,5次/w,第3~4 w每周治疗3次,第5~6 w每周治疗2次,第12 w随访。比较各组治疗前后腿痛VAS视觉模拟评分(Vas LP)、改良罗兰功能问卷(Roland)、Likert总体恢复自我评价量表的改变。结果:治疗6 w后,3组Vas LP评分、Roland评分均显著降低(均P0.01),Likert总体恢复评分逐渐增高,且在治疗后第12 w疗效更加显著。3组Vas LP评分、Roland评分、Likert总体恢复组间差异均无统计学意义(均P0.05)。结论:三种治疗方案对腰椎间盘突出所致坐骨神经痛均有减轻患腿疼痛、增强患腿运动功能、促进总体恢复的疗效,且三者疗效相当,并未随着疗法的增加出现明显的疗效叠加效应。     

Anatomic guide and sonography for surgical repair of leg muscle lacerations

Background

There were over 110,000 leg laceration cases reported in the United States in 2011. Currently, muscle laceration is repaired by suturing epimysium to epimysium. Tendon-to-tendon repair is stronger, restores the muscle's resting length, and leads to a better functional recovery. Tendons retract into the muscle belly following laceration and surgeons have a difficult time finding them. Many surgeons are unfamiliar with leg muscle anatomy and the fact that the leg muscles have long intramuscular tendons that are not visible in situ. A surgical anatomic guide exists to help surgeons locate forearm tendons; no such guide exists for tendons in the leg.

Materials and methods

The leg tendon ends of 11 cadavers were dissected, measured, and recorded as percentages of leg length. High-frequency ultrasound was used to locate tendon ends in three additional cadavers. These locations were compared with the actual tendon ends located via dissection.

Results

There was little variation in tendon end position within the cadaver group, between men and women or right and left legs. The data are presented as an anatomic guide to inform surgeons of the tendon ends' likely locations in the leg.

Conclusion

The location of leg intramuscular tendon ends is predictable and the anatomic guide will help surgeons locate tendon ends and perform tendon-to-tendon repairs. Ultrasound is a potentially effective tool for detection of accurate location of repairable tendon ends in leg muscle lacerations.     

Exercise-induced leg pain in athletes: diagnostic,assessment, and management strategies

The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as ‘shin splints’. We aimed to review clinical entities that come under the umbrella term ‘Exercise-induced leg pain’ (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.     

Cost‐effectiveness of treating vascular leg ulcers with UrgoStart® and UrgoCell® Contact

Although chronic wounds have a high socio‐economic impact, data on comparative effectiveness of treatments are rare. UrgoStart^® is a hydroactive dressing containing a nano‐oligosaccharide factor (NOSF). This study aimed at evaluating the cost‐effectiveness of this NOSF‐containing wound dressing in vascular leg ulcers compared with a similar neutral foam dressing (UrgoCell^® Contact) without NOSF. Cost‐effectiveness analysis from the perspective of the German statutory health care system was performed using a decision tree model for a period of 8 weeks. Cost and outcome data were derived from the clinical study ‘Challenge’ suggesting a response rate (≥40% wound size reduction) of UrgoStart^® of 65·6% versus 39·4% for the comparator. In the treatment model, effect‐adjusted costs of €849·86 were generated after 8 weeks for treatment with UrgoStart^® versus €1335·51 for the comparator resulting in an effect‐adjusted cost advantage of €485·64 for UrgoStart^®. In linear sensitivity analyses, the outcomes were stable for varying assumptions on prices and response rates. In an 8‐week period of treatment for vascular leg ulcers, UrgoStart^® shows superior cost‐effectiveness when compared with the similar neutral foam dressing without any active component (NOSF). As demonstrated within a randomised, double‐blind clinical trial, UrgoStart^® is also more effective in wound area reduction than the neutral foam dressing. Wound healing was not addressed in this clinical trial. Follow‐up data of 12 months to allow for reulceration assessment were not generated.