Osseous malrepair in calcium-deficient states

A primary body tissue involved in metabolic change under the influence of gravity is bone. Osseous integrity is obviously essential for normal musculoskeletal activity; this is of particular importance in long manned space flights where some evidence suggesting calcium loss from bone exists. Studies in our laboratory, utilizing an avian model, have been on the effects of chronic calcium deficiency (or "nutritional secondary hyperparathyroidism"), particularly on bone repair. Quantitative methods to determine both the rate and quality of osseous defects have been developed. A calcium-deficient synthetic diet (0.002% calcium by weight, but otherwise nutritionally complete) has been formulated to permit the induction of true calcium deficiency states in adult, skeletally mature, male domestic fowl. This report is concerned with the effects of long-term calcium depletion on bone repair. It has been classically taught that bone injury repair is always preferentially treated by the body, despite skeletal calcium depletion. For the first time, we have been able to demonstrate that this is incorrect; in the chronic calcium-deficient state, an osseous defect will not be preferentially calcified at the expense of an already-decalcifying skeleton. Quantitative data demonstrate that healing patterns in bone vary in response to the duration of the calcium deficiency. In adult male fowl, calcium-deficient for ten months, bone repair is almost completely absent; in those calcium-deficient for six months, bone repair is both retarded and imperfect; repair is absent even when supplemental calcium is administered at the time of osseous injury induction and thereafter. The conclusions to be drawn from this study are that (i) bone repair is adversely affected in the calcium-deficient state, (ii) the rate and quality of bone repair are directly related to the duration of the calcium-deficient state, and (iii) supplemental calcium administration in chronic calcium-deficient states initially retards, rather than enhances, bone repair. These conclusions have direct relevance to long-term manned space flight.

[Hidden bone erosions]

The aim of this pictorial essay was to demonstrate the diagnostic efficacy of high-resolution sonography in detecting bone erosions in a patient with rheumatoid arthritis. Standard X-Ray of the feet did not reveal clearly evident erosions. Ultrasonography was able to detect the presence of bone erosions of the metatarsal heads of both the first toes and of the V toe of the left foot. Because the appearance of bone erosions on radiographs of a patient with a recent onset arthritis indicates a poor prognosis, the possibility of demonstrating small hidden erosions at the level of the early targets of the disease is of relevant practical value.

[Bone lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique]

OBJECTIVES

We evaluated the results of lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique.

METHODS

We treated congenitally short metacarpus (n=7) and metatarsus (n=4) of five patients (4 females, 1 male; mean age 15 years; range 10 to 21 years) by callotasis. Callus distraction was performed with the use of mini-Orthofix or Ilizarov type semicircular external fixators. The distraction rate was 0.25x2 mm/day for both types. The mean follow-up period was 23 months (range 12 to 33 months).

RESULTS

The mean metacarpal and metatarsal lengthenings were 20 mm (range 15 to 25 mm) and 25 mm (range 20 to 30 mm), respectively. The mean healing index was 1.4 months/cm for metacarpal lengthening, and 1.8 months/cm for metatarsal lengthening. No neurovascular complications were encountered. One patient required autogenous fibular grafting for union. Pin tract infections were found in three patients. The overall complication rate was 36%.

CONCLUSION

Callotasis is an effective and reliable method for lengthening of short metacarpal and metatarsal bones. In addition, it preserves the periosteal bone tissues, which has a favorable effect on the duration of treatment.

Reproducibility of the radiographic metatarsophalangeal angle in hallux surgery

BACKGROUND

Five different methods have been described to define the longitudinal axis of the first metatarsal for radiographic measurements of the first metatarsophalangeal angle. None of these methods has been validated for both preoperative and postoperative assessment of patients undergoing hallux valgus surgery. Previous studies have demonstrated conflicting results regarding the measurement accuracy of these methods.

METHODS

To evaluate the measurement accuracy of these five methods, we calculated the intraobserver and interobserver coefficients of repeatability for all five methods with use of twenty preoperative and twenty postoperative standardized plain dorsoplantar weight-bearing radiographs of patients undergoing chevron distal osteotomy.

RESULTS

The preoperative assessment of the metatarsophalangeal angle revealed small differences among the five methods. The intraobserver coefficient of repeatability ranged from 2.10 degrees to 3.34 degrees, and the interobserver coefficient ranged from 2.17 degrees to 3.44 degrees. The postoperative assessment demonstrated substantial differences between methods in which the diaphysis of the first metatarsal is used as a reference (intraobserver coefficient, 5.06 degrees to 7.23 degrees; interobserver coefficient, 5.29 degrees to 8.19 degrees) and methods in which there is one reference point in the metatarsal head and one reference point in the base of the first metatarsal (intraobserver coefficient, 1.88 degrees to 2.67 degrees; interobserver coefficient, 1.86 degrees to 2.34 degrees).

CONCLUSIONS

For the assessment of patients undergoing a distal metatarsal osteotomy, we cannot recommend methods in which the metatarsal shaft is used as a reference for the axis of the first metatarsal. Such methods had poor measurement accuracy, especially postoperatively. Methods with reference points distal and proximal to any possible osteotomy site had much better measurement reproducibility. We recommend the method described by Miller in 1974, in which a line is drawn from the center of the first metatarsal head through the center of the base of the first metatarsal, as it was the most precise method and was least biased by postoperative effects.

Ultrasonographic diagnosis of foreign bodies associated with chronic draining tracts and abscesses in dogs

This is a retrospective study that describes the historical, physical exam, radiographic, fistulographic, ultrasonographic, and surgical findings associated with non-gastrointestinal and extrathoracic foreign bodies in six dogs. All dogs had a chronic draining tract or abscess. Although radiographs were obtained in five of the six dogs, no foreign bodies were identified with this modality. Fistulography was performed in four of the six dogs, and a filling defect consistent with a foreign body was found in two of four dogs. A foreign body was identified in five of the six dogs with ultrasound. Foreign bodies were removed surgically in five of six dogs. This report clarifies the importance of ultrasound in the evaluation of chronic draining tracts and abscesses in dogs.

[Ultrasound diagnosis of congenital foot deformities]

Assessment of tarsometatarsal skeletal malalignment in congenital foot deformities such as clubfoot and vertical talus is possible with ultrasound. Sonography can be useful in deciding on the therapeutic concept and evaluating therapeutic effects.

North American male reference population for speed of sound in bone at multiple skeletal sites

Alternatives to dual-energy X-ray absorptiometry (DXA) have been sought to increase access to low-cost osteoporosis risk assessment. Early quantitative ultrasound (QUS) systems measured speed of sound (SOS) and broadband ultrasound attenuation (BUA) at the calcaneus, and these were demonstrated to be good predictors of hip fracture risk. Recent studies have demonstrated the usefulness of other peripheral sites to assess bone status. The Sunlight Omnisense (Sunlight Medical, Rehovot, Israel) is a portable, inexpensive QUS device capable of multiple-site SOS measurement. To provide a robust male reference database, 588 healthy Caucasian males aged 20-90 yr were recruited from 6 centers across North America. SOS measurements were taken at the distal 1/3 radius, proximal third phalanx, midshaft tibia, and fifth metatarsal. A female reference database has previously been collected at North American sites. The results indicate that SOS in males exhibits an age-related decline beginning in the fifth decade at the radius, phalanx, and metatarsal, whereas the tibial SOS remains nearly constant until the ninth decade. Although females reach a higher-peak SOS than males at most sites, SOS is higher in males at all sites after the sixth decade, as a result of a more gradual decline in SOS. Longitudinal monitoring of healthy men should be performed to confirm these cross-sectional results.

Our results in the treatment of fractures dislocations of Lisfranc's joint

The authors report their experience in the treatment of traumatic injuries of Lisfranc's joint based on 30 cases treated by surgery between 1984 and 1999. All of the patients were re-evaluated clinically and radiographically. What emerges from the study is the need for surgical stabilization with percutaneous Kirschner wires or by open procedure in cases where there are doubts or where reduction is impossible. The prognosis is worse in injuries of the medial column and in exposed fractures or when mortification of the soft tissues is present.

Crescentic proximal metatarsal osteotomy for moderate to severe hallux valgus: a mean 12.2 year follow-up study

The senior author's (R.C.) first 25 patients (37 feet) treated with a combination proximal crescentic osteotomy and distal soft-tissue reconstruction made up the patient cohort. All 25 patients were reviewed at a minimum of one year post-op (short-term follow-up) and 20/25 (31/37 feet) were reviewed again at a mean 12.2 years (range 11.4 to 13.0 yrs) post-op (long-term follow-up). This allowed for a comparison of short- and long-term results and led to a long-term follow-up rate of 84% (31/37 feet, mean 12.2 yrs). Clinical, radiographic and patient outcome measures were obtained and compared pre-op and at short- and long-term follow-up. The mean preoperative hallux valgus (HVA) and intermetatarsal angles (IMA) were 37degrees and 16 degrees respectively. The mean HVA correction was 24 degrees and IMA correction 10 degrees at long-term follow-up with no tendency toward recurrence. Sesamoid position and first MTP subluxation was markedly improved postoperatively and the correction was maintained at long-term follow-up. Patients were asked about their satisfaction in terms of pain, appearance and motion. At long-term follow-up, more than 90% of patients were completely satisfied with pain and motion and greater than 80% with their appearance. Ninety-four percent of patients said they would have the operation again. The AOFAS clinical rating scale for the hallux was calculated retrospectively for pre-op and short-term follow-up and prospectively for long-term follow-up. The mean pre-op score was 37/100 (16 to 60) which significantly improved to 92/100 (67 to 100) at both follow-up periods, suggesting no evidence of decrease in outcome over time. Complications included two patients (5%) that were over-corrected into varus (one symptomatic, one asymptomatic), and four patients (11%) that were undercorrected, developing asymptomatic recurrences (>10 degrees increase HVA) at long-term follow-up. In addition, two patients (5%) developed new transfer lesions postoperatively, likely related to technical error (one varus overcorrection, one dorsiflexion malunion). In conclusion, the long-term results, with a mean follow-up of 12.2 years, of the resection realignment procedure for moderate to severe hallux valgus are generally excellent and the complication rate is low and acceptable. Attention to detail, avoiding both undercorrection, which can lead to recurrence, and overcorrection, which can cause symptomatic varus, is essential.

Assessment of bone status using speed of sound at multiple anatomical sites

Studies in vitro and in vivo have shown that quantitative ultrasound (QUS) is a valid tool for the assessment of bone status. Current QUS methods using the transmission technique are limited to one peripheral bone site. A new system, Sunlight Omnisense (Omnisense, Sunlight Medical Ltd., Rehovot, Israel), measures speed of sound (SOS, in m/s) along the surface of the bone based on an axial transmission technique. The Omnisense can measure SOS at several anatomical sites. This study evaluated the SOS at different anatomical sites in a healthy population. A total of 334 adult women from three research centers in the USA and Canada with a mean (+/- SD) age of 48.8 (+/- 17.4) years were enrolled in this study. SOS was measured at the proximal third phalanx, distal one third radius, midshaft tibia, and fifth metatarsal. The mean SOS (+/- SD) values for the phalanx, radius, tibia and metatarsal were 3984 (+/- 221), 4087 (+/- 147), 3893 (+/- 150) and 3690 (+/- 246) m/s, respectively. Each anatomical site SOS was significantly different (p < 0.001) from that of the other sites. SOS at the different anatomical sites was modestly, but significantly, correlated (r = 0.31 to 0.56, p < 0.001). Similar correlation coefficients were obtained for the T scores. The mean T scores for subjects over the age of 60 years were -1.94, -2.01, -0.97 and -1.42 for the phalanx, radius, tibia and metatarsal, respectively. The age of peak SOS and the rate of change thereafter varied with anatomical site, implying that the prevalence of osteopenia and osteoporosis was site-dependent if only one T score cut-off point was used. Comparing individuals, 10% to 17% of patients had T scores that differed by more than a factor of 2 between sites. Weight and age were some of the contributing factors to this heterogeneity. The Omnisense provides an opportunity to assess bone status at different anatomical sites. Whether or not combining measurements from all these anatomical sites will improve osteoporosis management still needs to be determined.

Study of straight metatarsal osteotomy for the treatment of plantar callosities

BACKGROUND AND AIMS

[corrected] To evaluate the outcome of transverse distal metatarsal osteotomies for intractable plantar callosity without hammer toe deformity and associated toe corns.

MATERIAL AND METHODS

Twenty-five plantar callosities were treated in 19 feet of 13 patients (mean age 48 years, 5 male, 8 female) with transverse distal metatarsal osteotomy.

RESULTS

Twenty-four of the osteotomies united primarily, one after revision. After a 7-year follow-up, 23 of the callosities had healed, two of them after an oblique reosteotomy. Eight hammer toe deformities had developed in the involved rays of four feet. Eight plantar callosities had developed outside the operated rays in five feet. Hallux valgus was a frequent finding in both operated and non-operated feet.

CONCLUSION

It seems that transverse distal metatarsal osteotomy is an effective treatment of intractable plantar callosities. Harmful hammer toe deformities and transfer lesions below adjacent metatarsal heads tend to develop over time.

Midline metatarsal dysplasia associated with absent fibula

In 5 patients with congenital deficiency of the fibula, the degree of fibular deficiency ranged from unilaterally short to bilaterally absent. The patients each had at least one missing metatarsal and, in addition, dysplasia of a midline metatarsal. In view of these findings, some missing metatarsals associated with congenital fibular deficiency could be midline metatarsals. The abnormality could represent a deficiency acquired after the development of the embryonic limb bud cartilage models.

Cavovarus foot treated with combined calcaneus and metatarsal osteotomies

Twenty-one feet in fifteen patients underwent osteotomies of the calcaneus and one or more metatarsals for symptomatic cavovarus foot deformity. Seven (nine feet) were male, and eight (twelve feet) were female. The etiology included hereditary motor sensory neuropathy (HMSN) (fifteen feet), post-polio syndrome (two feet), sacral cord lipomeningocele (two feet), parietal lobe porencephalic cyst (one foot), and idiopathic peripheral neuropathy (one foot). Presenting complaints were metatarsalgia (fifteen feet), ankle instablility (five), and ulceration beneath the second metatarsal head (one foot). Eleven feet were assessed using the Maryland Foot Rating Score. Maryland Foot Rating Score (University of Maryland, Baltimore, MD) improved from 72.1 (avg.) preoperatively to 89.9 (avg.) post-operatively (follow-up 70.9 months avg.). Eight feet were assessed using the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot and Midfoot Scores. The AOFAS Ankle-Hindfoot Score improved from 46.3 (avg.) pre-operatively to 89.1 (avg.) post-operatively, and the AOFAS Midfoot Score improved from 40.9 (avg.) pre-operatively to 88.8 (avg.) post-operatively (follow-up 20.8 months avg.). The postoperative AOFAS Ankle-Hindfoot Score for all nineteen feet was 90.8 (avg.) and the post-operative AOFAS Midfoot Score for all nineteen feet was 90.2 (avg.). Two patients were lost to follow-up and were not included in the study. Ankle, hindfoot, and midfoot motion was maintained or improved in sixteen feet. Complications included delayed union in two and nonunion in three of 66 metatarsal osteotomies. While three patients required an AFO (ankle-foot orthosis) for ambulation preoperatively, all patients were brace free postoperatively. All patients expressed willingness to undergo the same procedure again if it were necessary. Weight-bearing radiographs were available for 17 feet. Radiographic analysis revealed a decrease in forefoot adduction (9.6 degrees avg.) and a reduction in both hindfoot (9.1 degrees avg.) and forefoot cavus (10.6 degrees) leading to an overall 13 percent reduction in the height of the longitudinal arch. Lateral sliding elevating calcaneal osteotomy combined with dorsolateral closing wedge osteotomies of one or more metatarsal bases in the severe symptomatic cavovarus foot can provide a pain-free, plantigrade foot with a lowered longitudinal arch and a stable ankle without sacrificing motion.

Distal soft tissue procedure and proximal metatarsal osteotomy in hallux valgus

The results of a distal soft tissue procedure and a proximal metatarsal osteotomy in patients with symptomatic hallux valgus deformity were reviewed. The series consisted of 33 patients (47 feet; mean age of patients, 44 years). The average followup period was 48 months. At followup, 41 feet (29 patients, 85%) were free from pain at the first metatarsophalangeal joint. In six feet (four patients), the pain was improved but persisted. The mean hallux valgus angle was 38 degrees before surgery and 13.8 degrees after surgery. The mean intermetatarsal angle was 17.7 degrees before surgery and 7 degrees after surgery. The postoperative hallux valgus angle and intermetatarsal angle in patients who had pain at the first metatarsophalangeal joint after surgery were greater than those in patients without pain after surgery. This procedure corrects the hallux valgus deformity and relieves the symptoms, but careful attention should be paid to the surgical technique to obtain consistent and satisfactory results.

Tissue-engineered bone regeneration

Bone lesions above a critical size become scarred rather than regenerated, leading to nonunion. We have attempted to obtain a greater degree of regeneration by using a resorbable scaffold with regeneration-competent cells to recreate an embryonic environment in injured adult tissues, and thus improve clinical outcome. We have used a combination of a coral scaffold with in vitro-expanded marrow stromal cells (MSC) to increase osteogenesis more than that obtained with the scaffold alone or the scaffold plus fresh bone marrow. The efficiency of the various combinations was assessed in a large segmental defect model in sheep. The tissue-engineered artificial bone underwent morphogenesis leading to complete recorticalization and the formation of a medullary canal with mature lamellar cortical bone in the most favorable cases. Clinical union never occurred when the defects were left empty or filled with the scaffold alone. In contrast, clinical union was obtained in three out of seven operated limbs when the defects were filled with the tissue-engineered bone.

Avulsion fracture of the base of the fifth metatarsal not seen on conventional radiography of the foot: the need for an additional projection

OBJECTIVE

To our knowledge, this article is the first to describe a series of patients with avulsion fractures of the base of the fifth metatarsal that were not seen on conventional radiography using the standard three views of the foot but that were seen on radiography of the ankle.

CONCLUSION

Because routine radiographs of the foot may fail to reveal an avulsion fracture of the base of the fifth metatarsal, an additional projection should be obtained to better assess this region in the symptomatic patient. The additional view should be an anteroposterior radiograph of the ankle that includes the base of the fifth metatarsal because this projection has been shown to help in the diagnosis of this avulsion fracture.

Giant cell reparative granuloma of the small bones of the hands and feet: a report of three cases

Giant cell reparative granuloma (GCRG) involving the small tubular bones of the hands and feet is a rare entity that can have a wide range of morphologic presentations and can be confused with more aggressive tumors. Awareness of this lesion is important to avoid diagnostic errors and potential mismanagement. We report three cases of GCRG that involve the small tubular bones of the hands and feet, with long-term follow-up periods that confirm a benign course. Previous reports included the differential diagnosis of giant cell tumor, brown tumor of hyperparathyroidism, aneurysmal bone cyst, and non-ossifying fibroma. The presence of chondroid material in two of our cases, one of which also shows atypical nuclei and a periosteal reaction, expands the differential diagnosis to include bone- and cartilage-forming neoplasms.

Effect of estrogen replacement therapy on speed of sound at multiple skeletal sites

OBJECTIVES

To evaluate the effect of estrogen replacement therapy (ERT) on postmenopausal bone loss by multi-site ultrasound measurement.

METHODS

A cross-sectional comparison of postmenopausal women, ERT users and non-users. The two study groups were enrolled for the reference database collection for the Sunlight Omnisense (Omnisense) and were matched by years since menopause. Speed of sound (SOS) was measured at the distal radius (RAD), mid-shaft tibia (TIB), fifth metatarsus (MTR) and proximal phalanx (PLX).

RESULTS

143 ERT users for 5.2+/-3.6 years were compared with 139 ERT non-users (age: 57.0+/-5.3 and 57.5+/-5.5, respectively). Both groups were 7.1+/-5.0 years since menopause. SOS, expressed in T-score units, was higher at the RAD in ERT users as compared to ERT non-users (-0.55+/-1.30 and -1.36+/-1.60, respectively, P<0.0001), and at the TIB (-0.73+/-1.34 and -1.28+/-1.45, respectively, P=0. 003). Same trend was observed at the MTR and PLX, but not statistically significant because of fewer observations. In early post menopause period, the ERT-non users RAD data shows an annual SOS decrease of 0.17 versus annual increase of 0.12 T-score units (P=0.037). Similar effect is observed at the TIB, though not statistically significant (non-users decrease of 0.20 vs. users increase of 0.08 T-score units/year, P=0.086).

CONCLUSIONS

SOS measurements by Omnisense at multiple skeletal sites support the ERT protective effect on bone.

[Long-term outcome of metatarsal head resection in rheumatoid arthritis]

Between January 1983 and December 1987, metatarsal head-resections were performed on 203 patients, comprising a total of 370 feet, using the Hueter/Mayo and Hoffmann procedure. Seventy-two patients, comprising a total of 126 feet, were available for post-operative review after an average of 11.4 years from the date of the original operations. The information obtained from standardized questionnaires was compared to the information found in each patient's file. In addition, every available pre- and post-operative x-ray taken from 1983 to 1987 was analyzed. Thus, with an average follow-up period of 5.6 years, the changes found in the pre- and post-operative x-rays from a total of 183 feet could be compared. Before the operations, nearly 100% of the examined feet suffered from painful synovial hypertrophy and erosion of the metatarsophalangeal joints with dislocation and subluxation, causing approximately 70% of all patients to have great difficulties in walking. After the operations, however, 90.2% of the patients reported that this condition had noticeably improved or had completely disappeared. In fact, 87.5% of all patients reported a lasting improvement in their ability to walk longer distances. As the main criteria in determining the success of an operation (namely, the noticeable reduction of pain and increased mobility) were achieved in 87.5% of the patients, we consider the metatarsal head-resection a reliable method of correcting forefoot deformities in rheumatoid arthritis.

Progressive osseous heteroplasia: an uncommon cause of ossification of soft tissues

Whereas the deposition of calcium within soft tissues is not infrequent, the development of highly structured, mineralized tissue histologically identifiable as true bone is uncommon and can cause a variety of clinical features. This article reports the clinical and radiological features in a patient with progressive osseous heteroplasia (POH), a recently identified disorder characterized by heterotopic ossification. The patient, a female, was 20 years of age at presentation. In addition to abnormal ossifications, she had short metacarpals at the fourth and fifth rays and short metatarsals at the second rays. Her parents were unaffected. Until the results of Rosenfeld and Kaplan in 1995 reporting POH in two boys, typical features had only been reported in females (n=8). POH is usually sporadic; however, familial associations and atypical phenotypes have been reported.

Reference database for bone speed of sound measurement by a novel quantitative multi-site ultrasound device

The nonuniform skeletal involvement in osteoporosis argues for multi-site evaluation. The Sunlight Omnisense (Sunlight Ultrasound Technologies, Israel) is a multi-site device that measures speed of sound (SOS) at the appendicular skeleton. We report the reference database for SOS at the radius (RAD), tibia (TIB), metatarsus (MTR) and phalanx (PLX). The database was obtained from 1521 healthy Israeli women (age 20-90 years) out of 2051 respondents. SOS was determined in 97.6% of the participants at the PLX, 96.4% at the TIB, 93.6% at the RAD and 85.1% at the MTR; it was not measurable in 0.5%. Short-term coefficient of variation was lowest at the RAD and always less than 1%. Maximal SOS was noted at 35-45 years of age in three of the sites (RAD 4169 m/s, MTR 3663 m/s, PLX 4047 m/s, respectively) but 10 years earlier at the TIB (3939 m/s). In the perimenopausal period (age 46-55 years), SOS was always lower in post- as compared with premenopausal women (p<0.05). Immediately following the menopause, SOS annually declined close to the short-term CV: 16, 34, 37 and 13 m/s at the RAD, PLX, MTR and TIB, respectively. The average age-stratified SOS values at various measurement sites were highly correlated at the population level (0.96-0.99), but less so at the individual level (0.40-0.57). Therefore, multi-site SOS measurements are better than single-site assessment. After 79 years of age, the average T-score at the RAD and PLX was <--2.5. This is similar to that of dual-energy X-ray absorptiometry (DXA)-determined spine bone mineral density (BMD) and somewhat lower than hip BMD. Equivalent T-score curves obtained by percentile adjustment of SOS at various sites to that of the RAD (at age group 60-69 years) reveal convergence and indicate that 52-68% of women older than 79 years are osteoporotic. In conclusion, multi-site peripheral SOS measurements reveal age-dependent bone changes with a high degree of measurement precision and indicate a prevalence of osteoporosis similar to that obtained by DXA.

Bone mineral density of metatarsus in hemiplegic subjects

The cortical bone mineral density (BMD) of the first metatarsus was measured using computed x-ray densitometry in 84 hemiplegic subjects (35 men and 49 postmenopausal women) and 49 healthy age-matched controls (23 men and 26 postmenopausal women), and the determinants of paralysis-induced cortical osteopenia were investigated. In the hemiplegia group, ages were 63.9 +/- 9.8 yr (mean +/- standard deviation) for men and 66.6 +/- 11.0 yr for women. The duration of hemiplegia was 25.3 +/- 19.8 mo for men and 26.0 +/- 26.3 mo for women. The Brunnstrom stage (lower limb) was 4.0 +/- 1.1 for men and 3.8 +/- 1.4 for women. The walking ability, evaluated by walking score, was 3.6 +/- 1.3 (range, 1-5) for men and 3.2 +/- 1.5 (range, 1-5) for women. The time since menopause was 14.8 +/- 10.0 yr. The age and time since menopause were similar in the hemiplegia and control groups. On the paralyzed side, the BMD of men and women in the hemiplegia group was significantly lower than that of the control group on the nondominant side (by 6.1% and 11.6%, respectively). In hemiplegic men, Brunnstrom stage and walking score showed a significant positive correlation to the BMD (r = 0.418 and r = 0.349, respectively). In hemiplegic women, on the other hand, age, duration of hemiplegia, and years since menopause showed a significant negative correlation to the BMD (r = -0.260, r = -0.478, and r = -0.506, respectively), and Brunnstrom stage and walking score showed a significant positive correlation to the BMD (r = 0.526 and r = 0.406, respectively). These findings suggest that the determinant of metatarsal cortical BMD loss on the paralyzed side of the hemiplegic subject might be different according to gender. That is, although the degree of paralysis and walking ability could be a determinant of metatarsal cortical BMD loss on the paralyzed side of hemiplegic men, additional factors such as age, duration of hemiplegia, and years since menopause could play an important role in the determination of metatarsal cortical BMD loss in postmenopausal hemiplegic women.

Differences in second-intention wound healing between horses and ponies: macroscopic aspects

Second-intention healing of deep wounds was studied in 5 horses and 5 ponies. Standardised wounds were created on the distal limbs and hind quarters. Wounds on the metatarsi extended onto the metatarsal bone; the depth of the wounds in the femoral biceps muscle was 18 mm. The wound margins were marked by tattoos. Photographs were taken at weekly intervals to determine the wound area. The relative contribution of contraction and epithelialisation to wound closure was quantified by means of the tattoos. Swelling of the limbs was measured; and regularity and aspect of the granulation tissue were semi-quantitatively scored. Second-intention wound healing occurred significantly faster in ponies than in horses, and muscle wounds healed significantly faster than metatarsal wounds. These marked differences reflected the greater contribution of contraction to wound healing. Moreover, demarcation was seen earlier and a healthy granulation bed developed more rapidly in ponies, whereas in horses the granulation tissue remained irregular and purulent for longer. Healing of the metatarsal wounds of horses differed markedly from that of all other wounds: these wounds increased to almost twice their original size in the first 2 weeks, exuberant granulation tissue was persistent, epithelialisation started later, and contraction played a minor role in wound closure. Limb swelling was greater in horses than in ponies. Periosteal new bone formation was more extensive, and was active over a longer period in the metatarsal bones of horses than of ponies. From this study it is concluded that second-intention healing of deep wounds occurs faster in ponies than in horses. This difference can be largely attributed to a more pronounced and faster wound contraction in ponies than in horses. Therefore, attempts to improve second-intention wound healing in clinical practice should be directed at stimulation of wound contraction.