A cross-sectional study of the relationship between cortical bone and high-impact activity in young adult males and females

CONTEXT

The factors that govern skeletal responses to physical activity remain poorly understood.

OBJECTIVE

The aim of this study was to investigate whether gender or fat mass influences relationships between cortical bone and physical activity, after partitioning accelerometer outputs into low (0.5-2.1 g), medium (2.1-4.2 g), or high (>4.2 g) impacts, where g represents gravitational force.

DESIGN/SETTING

We conducted a cross-sectional analysis in participants from the Avon Longitudinal Study of Parents and Children.

PARTICIPANTS

We studied 675 adolescents (272 boys; mean age, 17.7 yr).

OUTCOME MEASURES

We measured cortical bone parameters from peripheral quantitative computed tomography scans of the mid-tibia, adjusted for height, fat mass, and lean mass.

RESULTS

High-impact activity was positively associated with periosteal circumference (PC) in males but not females [coefficients (95% confidence intervals), 0.054 (0.007, 0.100) and 0.07 (-0.028, 0.041), respectively; showing sd change per doubling in activity]. There was also weak evidence that medium impacts were positively related to PC in males but not females (P=0.03 for gender interaction). On stratifying by fat mass, the positive relationship between high-impact activity and PC was greatest in those with the highest fat mass [high impact vs. PC in males, 0.01 (-0.064, 0.085), 0.045 (-0.040, 0.131), 0.098 (0.012, 0.185), for lower, middle, and upper fat tertiles, respectively; high impact vs. PC in females, -0.041 (-0.101, 0.020), -0.028 (-0.077, 0.022), 0.082 (0.015, 0.148), P=0.01 for fat mass interaction]. Similar findings were observed for strength parameters, cross-sectional moment of inertia, and strength-strain index.

CONCLUSIONS

In late adolescence, associations between high-impact activity and PC are attenuated by female gender and low body fat, suggesting that the skeletal response to high-impact activity is particularly reduced in young women with low fat mass.

Combination therapy with eldecalcitol and alendronate has therapeutic advantages over monotherapy by improving bone strength

Eldecalcitol (ED-71), a 2β-hydroxypropyloxy derivative of 1α,25(OH)(2)D(3), inhibits bone resorption more potently than does alfacalcidol while maintaining osteoblastic function in an estrogen-deficient, high-turnover osteoporosis rat model. Alendronate (ALN) has been reported to increase bone mass by suppressing bone resorption mainly by inducing apoptosis of osteoclasts. The aim of this study was to clarify the combination effect of ED-71 and ALN on bone loss in ovariectomized rats. Wistar-Imamichi rats (32weeks old) were ovariectomized and randomly assigned to 10 groups (n=9-11); 11 rats were sham-operated. Rats were orally administered either vehicle alone, ALN (0.05, 0.2mg/kg), ED-71 (0.015, 0.03μg/kg), or a combination of ALN and ED-71. The treatment started 2weeks after surgery and continued for 12weeks. ED-71 significantly increased calcium and phosphorus in serum and urine; however, the mean values were within the normal range. Bone mineral density (BMD) and maximum load in both the lumbar spine and femur significantly increased with ED-71 monotherapy, and showed a tendency to increase with ALN monotherapy. Compared with ALN monotherapy, the combination of ALN and ED-71 significantly increased BMD and maximum load in both the lumbar spine and femur, suggesting that the combination therapy is more beneficial than ALN monotherapy in this protocol. The combination treatment had an additive suppressive effect on eroded surface and osteoclast number, with the suppressive effect more potent than either ALN or ED-71 monotherapy. Moreover, the combination therapy partially counteracted the suppressive effects of ALN on bone formation and on the histomorphometric indices of osteoblast number and activity. Interestingly, ALN had no effect on the anabolic action of ED-71. In conclusion, the combination therapy of ALN and ED-71 has therapeutic advantages over ALN monotherapy in terms of improving bone mechanical strength without excessive suppression of bone turnover.

Cell autonomous requirement of connexin 43 for osteocyte survival: consequences for endocortical resorption and periosteal bone formation

Connexin 43 (Cx43) mediates osteocyte communication with other cells and with the extracellular milieu and regulates osteoblastic cell signaling and gene expression. We now report that mice lacking Cx43 in osteoblasts/osteocytes or only in osteocytes (Cx43(ΔOt) mice) exhibit increased osteocyte apoptosis, endocortical resorption, and periosteal bone formation, resulting in higher marrow cavity and total tissue areas measured at the femoral mid-diaphysis. Blockade of resorption reversed the increased marrow cavity but not total tissue area, demonstrating that endocortical resorption and periosteal apposition are independently regulated. Anatomical mapping of apoptotic osteocytes, osteocytic protein expression, and resorption and formation suggests that Cx43 controls osteoclast and osteoblast activity by regulating osteoprotegerin and sclerostin levels, respectively, in osteocytes located in specific areas of the cortex. Whereas empty lacunae and living osteocytes lacking osteoprotegerin were distributed throughout cortical bone in Cx43(ΔOt) mice, apoptotic osteocytes were preferentially located in areas containing osteoclasts, suggesting that osteoclast recruitment requires active signaling from dying osteocytes. Furthermore, Cx43 deletion in cultured osteocytic cells resulted in increased apoptosis and decreased osteoprotegerin expression. Thus, Cx43 is essential in a cell-autonomous fashion in vivo and in vitro for osteocyte survival and for controlling the expression of osteocytic genes that affect osteoclast and osteoblast function.

Balicatib, a cathepsin K inhibitor, stimulates periosteal bone formation in monkeys

Balicatib, an inhibitor of the osteoclastic enzyme cathepsin K, was tested in ovariectomized monkeys, a model for osteoporosis. As expected, ovariectomy-induced bone mass changes were partially prevented by balicatib treatment. Bone turnover was significantly decreased at most sites, but unlike most bone resorption inhibitors, periosteal bone formation rates were increased.

INTRODUCTION

Selective inhibitors of the osteoclastic enzyme cathepsin K have potential in osteoporosis treatment. This study evaluated the efficacy of balicatib (AAE581), a novel inhibitor of human cathepsin K, on bone mass and dynamic histomorphometric endpoints in ovariectomized monkeys.

METHODS

Eighty adult female Macaca fascicularis underwent bilateral ovariectomies and were dosed twice daily by oral gavage with balicatib at 0, 3, 10, and 50 mg/kg for 18 months (groups O, L, M, H, respectively). Approximately 1 month after treatment initiation, the 50 mg/kg dose was decreased to 30 mg/kg. Twenty animals underwent sham-ovariectomies (group S). Bone mass was measured at 3-6 month intervals. At 18 months, vertebra and femur were collected for histomorphometry.

RESULTS

In both spine and femur, group O animals lost bone mineral density (BMD), and all other groups gained BMD between 0 and 18 months. In balicatib-treated animals, BMD change in the spine was intermediate between group S and O, with groups L and M significantly different from group O. In femur, all three doses of balicatib significantly increased BMD gain relative to group O, and group mean values were also higher than group S. Most histomorphometric indices of bone turnover in vertebra and femoral neck were significantly lower than group O with balicatib treatment, except that periosteal bone formation rates (Ps.BFR) were significantly higher. Ps.BFR in mid-femur was also significantly increased by treatment.

CONCLUSIONS

Balicatib partially prevented ovariectomy-induced changes in bone mass, inhibited bone turnover at most sites, and had an unexpected stimulatory effect on periosteal bone formation.

Histogenetic and taxonomic considerations on a case of post-traumatic bizarre parosteal osteochondromatous proliferation (BPOP)

A case of bizarre parosteal osteochondromatous proliferation (BPOP) arising in the head of the fibula of a young man following injury on the lateral aspect of the knee is reported. Microscopically, four zones could be recognized proceeding from the periphery to the deep portion: 1) an outer thick fibrous cap showing an abundant cellular component, composed of thin spindled elements of fibroblastic appearance, haphazardly arranged and exhibiting intense and diffuse immunohistochemical expression of S100 protein (a previously unreported observation); 2) an irregular and atypical cartilaginous cap beneath the fibrous cap; 3) a layer of blue bone in which islands of atypical chondrocytes are still present but gradually decreasing, moving towards the deeper areas; 4) a layer of mature bone, pink bone, which is implanted in the skeletal segment (the deep margin is devoid of periosteum). The intratrabecular spaces of blue or pink bone did not contain haematopoietic marrow, but rather a loose myxoid stroma. This case confirms the fact that BPOP can occur in skeletal segments other than those indicated in the original report of Nora, and that trauma, even if minor, is an important factor in the development of the lesion. The latter begins at the periosteal level, where fibroblasts may acquire a chondroformative function (becoming chondrofibroblasts), as witnessed by the strong and widespread expression of P S100, first documented in this report.

[The effect of periosteum on the union of the autoclaved bone graft-host bone: experimental study in rabbits]

OBJECTIVES

In this study, we investigated the effect of periosteum on the union of autoclaved segmental bone grafts harvested from rabbit radii and replanted to their beds with intramedullary fixation to host bone.

MATERIALS AND METHODS

Segmental bone defects, 15 milimeters long, in the middle of the left radius were created in 16 adult rabbits. The resected bones were autoclaved 15 minutes at 120 °C and reimplanted and fixed with intramedullary Kirschner wires. The rats were divided into two groups; in the first group, eight rabbits' graft-host bone junctions were covered with periosteal flaps and in the second group, graft-host bone junctions were deperiostized. Plain X-rays were taken at 2, 4, 6 and 8 weeks after the operation. At the end of the 8(th) week radiological results were evaluated with modified Yang's radiological scoring system.

RESULTS

Radiological results revealed more callus tissue and early, better healing in the first group (mean 10.94), than in the second group (mean 6.06) at 8(th) week. The difference was statistically significant (p=0.04, <0.05).

CONCLUSION

Periosteal flaps are biologic tissues that can be easily performed and enhance the healing of graft-host junctions. The periosteal flap technique is effective on the healing of graft-host bone junctions and this technique is worth applying to structural allografts.

Exostosis-like intra-articular periosteal osteoblastoma: a rare case

Osteoblastoma is a relatively rare benign bone tumor, most often located in the vertebral column or metaphysis of the long bones, particularly the femur and the tibia. Periosteal osteoblastoma is the least common type. Exostosis-like appearance is not common even in periosteal osteoblastoma, a very rare type of this tumor. In addition, an intraarticular location is uncommon for osteoblastomas. Here we report the case of a 25-year-old man with intra-articular exostosis-like periosteal osteoblastoma of the hip that resulted in impingement and osteoarthritis.

A pseudoaneurysm within a subperiosteal collection in a patient with sickle cell disease

Sickle cell disease involves long bones in the form of infection or subperiosteal collections. Rare pseudoaneurysm/aneurysm formation is also known to occur in the intracranial and visceral territories. We report a small subperiosteal pseudoaneurysm that developed within a subperiosteal abscess in the tibia in a patient with sickle cell disease. This case adds to the known spectrum of musculoskeletal abnormalities resulting from this condition.

Physiological periostitis in a 2.5-month-old baby

Periosteal reaction has different etiologies in early infancy. Physiological periostitis is a well-documented X-ray finding seen in both preterm and term babies aged between 1-6 months and can easily be misdiagnosed as child abuse or pathological periostitis. Here, we present a 2.5-month-old infant admitted with a history of fever, swollen right upper arm after vaccination and X-rays findings revealing periosteal reactions on both sides of the humeri, radii, tibiae and femora. Initial diagnosis was child abuse or congenital syphilis. Due to the normal physical findings and normal serological-biochemical data, physiological periostitis was diagnosed. Physiological periostitis should also be considered in patients with periosteal reactions of the long bones in infants aged between 1-6 months.

The effect of periosteal resection on tibial growth velocity measured by microtransducer technology in lambs

BACKGROUND

Disruption of the periosteum, whether traumatic or elective, has long been known to accelerate growth in the developing skeleton. However, the extent, timing, and mechanism of the resultant increase in growth velocity (if any) remain undefined. The primary research questions were: Does periosteal resection result in a change (increase) in growth velocity of a long bone at the growth plate? When does the effect start after the resection and for how long? Finally, which of several cellular mechanisms is most likely responsible for the change in growth velocity?

METHODS

Five lambs underwent proximal tibial growth plate periosteal resection with subsequent measurement of growth velocity by implantable microtransducers or fluorochrome labeling. This former technique provided real-time growth velocity data with a resolution of about 10 microm (width of a proliferative zone chondrocyte). These measurements were accurate at up to 4 weeks postoperative, as verified by fluorochrome labeling, and radiographic measurement. Two lambs were continued on the study for an additional 3 weeks. Histomorphometric and stereological assessments of chondrocytic kinetic parameters were performed on control and experimental tibiae after euthanasia.

RESULTS

Periosteal resection increased growth velocity in every lamb, at every time point, and in a consistent and sustained manner. Histomorphometric correlation to this phenomenon indicated that the cellular basis of this acceleration was most likely the result of hypertrophic chondrocyte axial elongation rather than changes in chondrocyte proliferation, magnitude of hypertrophic chondrocytic swelling, or increased matrix production.

CONCLUSIONS

Periosteal resection creates immediate and sustained acceleration of growth resulting from axial elongation of the hypertrophic chondrocyte. Although the increase in growth velocity was consistent, the absolute magnitude of the acceleration suggests that periosteal resection be considered as an adjunct to other primary procedures. Periosteal resection may serve as a useful clinical adjunct to provide a modest growth stimulus in cases of hemihypertrophy or angular limb deformity or to counteract the growth inhibition seen when performing distraction osteogenesis.

[Limb fractures: ultrasound imaging features]

US, a non-irradiating imaging modality, is complementary to radiographs in the evaluation of limb fractures. US may in some cases demonstrate or suggest the presence of a fracture without corresponding abnormality on radiographs, or confirm or exclude a possible fracture detected on radiographs. Knowledge of the US features of fractures is necessary. In this article, the different direct and indirect US findings of fractures will be reviewed, with radiographic correlation. Direct findings include cortical discontinuity or irregularity. Indirect findings include subperiosteal or juxtaphyseal hematoma suggesting cortical or physeal fractures respectively.

Single photon emission computerized tomography and histological evaluation in the validation of a new technique for closure of oro-antral communication: an experimental study in pigs

Various bone regeneration techniques have evolved recently but controversies regarding vascularization and integration of such bone grafting techniques have led occasionally to animal experiment to validate such techniques. The objective of this study was to evaluate the evidence of vascularization and osseo-integration of a new bone regeneration technique utilized for the closure of oro-antral communication (OAC) by an experimental model in which Single Photon Emission computerized Tomography and histological studies were conducted in pigs. We conclude that the sandwich technique used for the closure of OAC results in a vascularized new bone formation which eventually osseo-integrate with the surrounding bone. Also, this experimental study confirmed that autogeneous bone graft was superior to xenografts when used within the sandwich unit.

Glucocorticoid excess affects cortical bone geometry in premenopausal, but not postmenopausal, women

Glucocorticoid (GC) excess causes a great increase in fracture risk, but the effects of GC excess on cortical bone geometry are unknown. The present study was performed to examine the effects of GC excess on cortical bone geometry in both premenopausal and postmenopausal women. Ninety-six women receiving oral GC treatments and 10 women with Cushing syndrome (CS) were each compared to age-matched control subjects using peripheral quantitative computed tomography. Total area, periosteal circumference, and polar strength strain index (SSIp) were significantly lower in GC-treated patients compared with control subjects in premenopausal women but not in postmenopausal women. Moreover, cortical area and thickness as well as periosteal circumference and SSIp were significantly lower in patients with CS compared to controls in premenopausal women but not in postmenopausal women. Total area, cortical area, cortical thickness, periosteal circumference, as well as SSIp were significantly lower in GC-treated patients with vertebral fractures compared to those without vertebral fractures in premenopausal women but not in postmenopausal women. In conclusion, endogenous or exogenous GC excess affects bone geometry of forearms of premenopausal, but not postmenopausal, women. These effects of GC excess on bone geometry may provide a strength loss mechanism beneath increased vertebral fracture risk.

[Evaluation of images of periosteum on computed tomography in children with malignant bone tumours before and after chemotherapy]

AIM

to assess the value of different images of periosteal reaction on computed tomography (CT) in children with malignant bone tumours in determining the effectiveness of the chemotherapy. To evaluate the prognostic value of particular symptoms of the periosteal reaction.

MATERIAL AND METHODS

material includes documentation of CT imaging of periosteum in children with malignant bone tumours. Investigations were performed in 80 children (39 boys and 41 girls), aged from 3 years and 6 months to 20 years and 5 months, treated at the Institute of Mother and Child in the years 1995-2000. Osteogenic sarcoma (59 patients), Ewing's sarcoma/PNET (14 patients) and other mesenchymal tumours (7 patients) were diagnosed. The assessment of the periosteum was carried out before and after preliminary chemotherapy. Eleven symptoms of the periosteal reaction were distinguished: 1) changes in calcification, 2) thickness and 3) outlines of the periosteum, 4) change of number of stratifications, 5) reconstruction of the broken periosteum and 6) rebuilding of the Codman's triangle, 7) changes of calcification, 8) incorporation and 9) the number of spicules as well as 10) changes in the zone of unreactive areas and 11) distance from the periosteum to the bones. Each symptom was evaluated according to a three-grade scale: favourable, uncertain, unfavourable. The kind of response to chemotherapy was determined on the basis of these symptoms relations. The response was good if there were at least twice as many favourable as uncertain signs. Poor response was indicated if there were more uncertain than favourable symptoms or if an unfavourable symptom was found. The remaining situations accounted for medium response. CT scan assessment was compared with the tumour histopathological examination after surgical excision. The data underwent statistical analysis.

RESULTS

the relationship of symptoms of the periosteal reaction and histopathological response to chemotherapy was determined. Assessment of tumour reaction to chemotherapy based on own system of evaluation was in agreement with the histopathological results in 96.9% in the group of good responses (31/32), in 66.7% in group of medium responses (10/15) and in 87.9% in the group of poor responses (29/33), (dSomers coefficient 0.840, chi2 v=100.739 df=4 p<0.001).

CONCLUSIONS

1. The author's own scheme of evaluation of periosteal reactions on CT provides good correlation and concordance with the histopathological assessment of the kind of response to chemotherapy in children with malignant bone tumours. 2. Analysis of manifestations of periosteal reaction on CT demonstrates full prognostic conformity of the so-called unfavourable symptoms to findings of the histopathological examination in the estimation of poor response. 3. Favourable periosteal reactions are found in all types of response, but three of them, i.e. reduced number of periosteal proliferations, total reconstruction of the broken periosteum and total rebuilding of the Codman's triangle, show significant frequency only in cases of good response. 4. Uncertain symptoms: unchanged periosteal thickness, lack of incorporation of spicules, decreased of number of unincorporated spicules, increased or unchanged size of unreactive (uncalcified and necrotic) areas - did not appear in cases of good response. They were found in medium and poor responses, which supports the suggestion of excluding the so-called medium response from the criteria of response assessment. 5. Decreased size of the tumour (i.e. distance between periosteum and bone) appears in all types of response to chemotherapy and it cannot be regarded as a manifestation of good response. 6. Own system of evaluation of tumour response to chemotherapy, based on the relationship manifestations of periosteal reaction is confirmed by statistical analysis.

La lésion de Nora ou Bizarre Parosteal Osteochondromatous Proliferation

The lesion Nora described in 1983 as a bizarre parosteal osteochondromatous proliferation (BPOP) is a member of a group of osteocartilaginous surface lesions. BPOP is infrequent but new cases are regularly reported. We report two new cases with an unusual localization (ilion and distal humerus) and unusual size (9 cm for the iliac lesion). In light of these cases and reports in the literature, the main differential diagnoses of BPOP are exostosis and parosteal osteosarcoma.

Biological Assessment of Porous-Implant Hydroxyapatite Combined With Periosteal Grafting in Maxillary Defects

PURPOSE

To investigate the use of porous hydroxyapatite (HA) combined with periosteal graft to repair an induced maxillary bone defect.

MATERIALS AND METHODS

A defect was produced in the premaxillary bone of rats. Four groups were used: 1) those treated with the mucoperiosteal graft from the premaxilla; 2) those treated with HA combined with mucoperiosteal graft from the premaxilla; 3) those treated with HA combined with periosteal graft from the femur; and 4) those treated with periosteal graft from the femur.

RESULTS

The radiographic aspects from all groups showed no signs of bone formation after 2 weeks. After 16 weeks, there was evidence of points of radiolucency inside the HA implants. Cell proliferation occurred from the periosteum covering the defect. Bone tissue grew from the defect margin to inside the defect in all cases. Mature bone was seen around the HA implants after 8 and 16 weeks.

CONCLUSION

The periosteal graft provides satisfactory support to the HA implant, allowing the growth of new bone.

Radiological appearances of appendicular osteosarcoma: a comprehensive pictorial review

Osteosarcoma is the most common primary malignant tumour of bone in adolescents and young adults. Hence, a comprehensive knowledge of the common and unusual imaging appearance of this tumour is essential. Correct diagnosis of the various varieties of osteosarcoma is important for optimal clinical management including staging, biopsy, treatment and follow-up of patients. This review article provides a comprehensive approach to the radiological diagnosis of the different types of appendicular osteosarcoma and illustrates the role of CT and MRI in further characterisation.

Medical and surgical management of subperiosteal orbital abscess secondary to acute sinusitis in children

OBJECTIVE

To evaluate the presentations and outcomes of pediatric subperiosteal orbital abscesses (SPOA) secondary to acute sinusitis.

STUDY DESIGN

Case series

SETTING

Tertiary children's hospital.

PATIENTS

Forty-three admissions diagnosed with SPOA by clinical presentation and contrast enhanced computed tomography (CECT) were retrospectively reviewed.

MAIN OUTCOME MEASURES

Clinical presentations, CECT dimensions, treatment, outcomes, and microbiology.

RESULTS

Eighteen/43 (42%) patients resolved their infection with medical management only, including five children older than nine. Twenty-five/43 (58%) children underwent surgical drainage. Purulence was identified in 22 of 25 surgical patients, and the most common organism was Streptococcus milleri (7 patients). Compared to 22 patients with drained purulence, the 18 patients with abscesses managed medically had significant differences for: chemosis in 2/18 (11.1%) versus 14/22 (63.6%, p=0.001), proptosis in 10/18 (55.6%) versus 20/22 (90.9%, p=0.025), elevated intraocular pressure (IOP) in 0/18 (0%) versus 11/22 (50%, p<0.001), severe restriction of extraocular movements in 1/18 (5.6%) versus 12/22 (54.5%, p=0.002), and length of stay (4.3 versus 5.8 days, p=0.038). The dimensions of medial SPOA managed medically were significantly smaller on CECT compared to surgically drained purulent SPOA: width (0.25 versus 1.46cm, p<0.001), height (0.73 versus 1.35cm, p=0.002), and length (1.1 versus 1.86cm, p=0.004). Persistent morbidities occurred in no patients managed medically and in 2/25 (8%) managed surgically.

CONCLUSIONS

Children with small medial SPOA without significant ocular signs may be managed medically with favorable outcomes. Proposed criteria for medical management of medial SPOA include: (1) normal vision, pupil, and retina; (2) no ophthalmoplegia; (3) IOP<20mmHg; (4) proptosis of 5mm or less; and (5) abscess width of 4mm or less. In contrast to prior series, older children with SPOA were managed successfully with medical therapy.

Apophysenausriss der Tuberositas tibiae und Fraktur der dorsalen Tibiakopfepiphyse

Avulsion fractures of the tibial tuberosity are rare. In general, juvenile male athletes sustain this fracture. A combination of Ogden type 3A fracture in combination with a posterior fracture of the proximal tibial epiphysis type Salter 2 is described for the first time. The necessity for immediate surgical intervention to prevent secondary soft tissue injury is stressed.

Indications for surgery in acute mastoiditis and their complications in children

OBJECTIVE

To review the clinical charts of 45 paediatric patients treated for acute otomastoiditis at the ORL Department of the University of Brescia (Italy) between January 1994 and March 2005 and to discuss the diagnostic workup and the outcome of treatment.

METHODS

Twenty-six males and 19 females were admitted with acute mastoiditis and subperiosteal abscess. Thirteen of them (28.9%) presented an intracranial complication. Only three of them were not operated upon; one received a ventilation tube (VT); all the others underwent a mastoidectomy within 48-72 h. Twenty out of 32 uncomplicated mastoiditis were treated conservatively and the remaining 12 underwent myringotomy+/-VT, associated with a mastoidectomy in 9 cases.

RESULTS

Antibiotics alone or with VTs achieved a full recovery in 28 out of 32 uncomplicated cases. Mastoidectomy resolved the disease in 13 patients (9 with complications). In severe complications, a canal wall down (CWD) (n=2) or an intact canal wall (ICW) mastoidectomy (n=7) were preferred, based on the extent of the lesions and the degree of hearing loss. All children recovered completely at 1 year follow-up. In the uncomplicated cases that were operated upon, the mean hospital stay was 7.8 days (versus 4.3 days for the conservative group). In children with intracranial complications the mean hospital stay was 12.8 days, significantly less than the four non-surgical patients, who remained hospitalized for an average of 18 days.

CONCLUSION

Acute mastoiditis can fully recover with conservative treatment or myringotomy+VTs. Immediate surgical treatment is indicated for intracranial complications, if the neurological conditions are not critical. A simple mastoidectomy+/-tympanoplasty is warranted in: (1) exteriorization, if the child is older than 30 months or >15 kg of weight, (2) intracranial complications (combined with a neurosurgical procedure as needed) and (3) cholesteatoma or granulation tissue.

Ultrasound in the Diagnosis of Craniosynostosis

Diagnosis of craniosynostosis is based on clinical aspects but may be difficult in some cases where characteristic features are missing and radiographic imaging is necessary. In this context near-field high-frequency ultrasound has been used to evaluate the sonographic characteristics of synostotic sutures and its potential confirming the correct diagnosis. Sutures of 26 infants, aged 2-7 months, were investigated by ultrasound (Siemens Elegra, 7.5 MHz linear scanner). Sonographic features of synostotic sutures were correlated to CT imaging and compared to the sonographic and histopathological findings of normal cranial sutures. Hyperechogenic bridging of sutures with or without ridging were the characteristic aspects of synostotic sutures. All 26 patients could be reliable diagnosed showing partial (n = 21) or total fusion (n = 5) of one or more sutures consisting with craniosynostosis. Length of synostosis was identified exactly by sonography and imaging found to enable a classification of ultrastructural details of bony and soft tissue next to the synostotic suture. Ultrasound is a less expensive, nonradiating and easy-to-handle tool ensuring the diagnosis of craniosynostosis. Sonography offers the potential to be a standard investigation for infants with head deformities suspecting a suture pathology and has been therefore integrated in our craniofacial outpatient clinic as a daily routine method.

Concurrent periosteal chondroma and enchondroma of the fibula mimicking chondrosarcoma

We present a rare concurrence of enchondroma and periosteal chondroma in the right distal fibula that mimicked chondrosarcoma in a 13-year-old boy. Radiographs and CT scans showed a periosteal lesion producing saucerization without periosteal reaction and calcification in the distal metaphysis of the right fibula. MRI showed an intramedullary lesion adjacent to the periosteal lesion, although it was invisible at CT. There was no cortical breach on imaging and gross examination. Because both lesions represented benign cartilaginous tumors on histology, concurrent periosteal chondroma and enchondroma of the fibula was diagnosed. This combination in the same bone in a patient without enchondromatosis is exceedingly rare. Such imaging features may be confused with those of chondrosarcoma.