[Effectiveness comparison of operative and non-operative treatment for complex proximal humeral fractures in elderly patients]

OBJECTIVE

To compare the effectiveness between operative and non-operative treatment for 3- and 4-part proximal humeral fractures in elderly patients.

METHODS

Between January 2009 and January 2011, 35 patients with 3- or 4-part proximal humeral fractures were treated with open reduction and locking plate internal fixation (n = 20, operative group) and with closed reduction and splint or cast fixation (n = 15, non-operative group). There was no significant difference in gender, age, etiology, fracture type, and disease duration between 2 groups (P > 0.05). The postoperative rehabilitation protocol was performed in 2 groups.

RESULTS

All patients of the operative group achieved healing of incision by first intention. All patients were followed up 16 months on average (range, 12-20 months). The X-ray films showed that the other fractures healed except 1 case (5.0%) nonunion in operative group. Varus malunion was found in 1 case (6.7%) of non-operative group and 2 cases (10.0%) of operative group. Humeral head necrosis was found in 1 case respectively in 2 groups (5.0% and 6.7%). There was no significant difference in complication incidence between 2 groups (P > 0.05). The Constant-Murley scores of non-operative group and operative group were 64.7 +/- 9.9 and 66.8 +/- 11.8 at last follow-up respectively, showing no significant difference (t = 0.59, P = 0.47).

CONCLUSION

Operative treatment has similar effectiveness to non-operative treatment for 3- and 4-part proximal humeral fractures. In elderly patients, non-operative treatment should be chosen.

Piezoelectric device vs. conventional rotative instruments in impacted third molar surgery: relationships between surgical difficulty and postoperative pain with histological evaluations

PURPOSE

To investigate and compare the influence of surgical difficulty on postoperative pain after treatment of impacted mandibular third molars by rotatory osteotomy or Piezoelectric surgery.

MATERIALS AND METHODS

A prospective, randomized, split-mouth study was performed of 52 patients with bilateral and symmetrically oriented impacted mandibular third molars, who were surgically treated using a burr (Group A) on one random side of the lower jaw and a Piezoelectric device (Group B) on the contralateral side. Surgical difficulty was evaluated using a modified version of the Parant scale to categorize "simple extractions" and "complex extractions". Primary outcome parameters were the comparison of the postoperative pain evaluation rated on the Visual Analogue Scale from day 0 to day 6 postsurgery, and the assessment of differences in surgery time between the groups. Bone biopsies were taken during surgery to assess differences in bone tissue damage levels between the two different techniques.

RESULTS

In "complex extractions" lower pain evaluation and significantly shorter surgery times were recorded when rotatory instruments were used. In "simple extractions", similar surgery times were observed for both techniques, but pain was greatest on the day of surgery when the burr was used. Bone heat osteonecrosis was observed only in the rotatory group and a high level of alkaline phosphatase was noted only in the Piezoelectric group.

CONCLUSION

Pain after extraction of a mandibular third molar increases with increased surgical difficulty and especially in longer interventions. The integrity of the bony structure observed after the ultrasonic technique may favour the bone healing process.

Symptomatic osteonecrosis of the femoral head after adult orthotopic liver transplantation

BACKGROUND

With the increase of survival in liver transplantation recipients, more patients are at a high risk of developing osteonecrosis, especially in the femoral head, due to immunosuppressive treatment. The purpose of this study was to report the incidence, possible risk factors, and outcome of symptomatic osteonecrosis of the femoral head (ONFH) in adult patients with current immunosuppressive agents and individual protocol after liver transplantation in China.

METHODS

A retrospective analysis was performed on 226 adult patients who underwent orthotopic liver transplantation (OLT) at a single liver transplantation institution between January 2004 and December 2008. The posttransplant survival time (or pre-retransplantation survival time) of all the patients were more than 24 months. The possible pre- and post-transplantation risk factors of symptomatic ONFH were investigated and the curative effects of the treatment were also reported.

RESULTS

The incidence of ONFH was 1.33% in patients after OLT. ONFH occurred at a mean of (14 ± 6) months (range, 10 - 21 months) after transplantation. Male patients more often presented with osteonecrosis as a complication than female patients. The patients with lower pre-transplantation total bilirubin and direct bilirubin levels (P < 0.05). There was no difference in the cumulative dose of corticosteroids or tacrolimus between the patients with or without symptomatic ONFH. Patients were treated either pharmacologically or surgically. All patients showed a nice curative effect without major complications during the 18 - 63 months post-treatment follow up.

CONCLUSIONS

The symptomatic ONFH does not occur commonly after adult OLT in the current individual immunosuppressive protocol in China.

Treatment for avascular necrosis of bone in people with sickle cell disease

BACKGROUND

Avascular necrosis of bone is a frequent and severe complication of sickle cell disease and its treatment is not standardised.

OBJECTIVES

To determine the impact of any surgical procedure compared with other surgical interventions or non-surgical procedures, on avascular necrosis of bone in people with sickle cell disease in terms of efficacy and safety.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional trials were sought from the reference lists of papers identified by the search strategy.Date of the most recent search of the Group's Haemoglobinopathies Trials Register: 21 February 2012.

SELECTION CRITERIA

Randomised clinical trials comparing specific therapies for avascular necrosis of bone in people with sickle cell disease.

DATA COLLECTION AND ANALYSIS

Each author independently extracted data and assessed trial quality. Since only one trial was identified, meta-analysis was not possible.

MAIN RESULTS

One trial (46 participants) was eligible for inclusion. After randomisation eight participants were withdrawn, mainly because they declined to participate in the trial. Data were analysed for 38 participants at the end of the trial. After a mean follow up of three years, hip core decompression and physical therapy did not show clinical improvement when compared with physical therapy alone using the score from the original trial (an improvement of 18.1 points for those treated with intervention therapy versus an improvement of 15.7 points with control therapy). There was no significant statistical difference between groups regarding major complications (hip pain, relative risk (RR) 0.95 (95% confidence interval (CI) 0.56 to 1.60; vaso-occlusive crises, RR 1.14 (95% CI 0.72 to 1.80); and acute chest syndrome, RR 1.06 (95% CI 0.44 to 2.56)). This trial did not report results on mortality or quality of life.

AUTHORS' CONCLUSIONS

We found no evidence that adding hip core decompression to physical therapy achieves clinical improvement in people with sickle cell disease with avascular necrosis of bone compared to physical therapy alone. However, we highlight that our conclusion is based on one trial with high attrition rates. Further randomised controlled trials are necessary to evaluate the role of hip-core depression for this clinical condition. Endpoints should focus on participants' subjective experience (e.g. quality of life and pain) as well as more objective 'time-to-event' measures (e.g. mortality, survival, hip longevity). The availability of participants to allow adequate trial power will be a key consideration for endpoint choice.

A case of posterior element fracture in Kummell's disease

Kummell's disease is a rare, delayed posttraumatic collapse of a vertebral body that can occur several months or even years after an osteoporotic compression fracture. However, there are few reports of posterior element fractures associated with Kummell's disease. A 72-year-old man who had sustained an L1 osteoporotic compression fracture 14 months prior was admitted to our institution with incapacitating back pain. Plain radiographs showed progressive collapse of the L1 vertebral body and severe kyphosis at the thoracolumbar junction. Magnetic resonance imaging revealed a posterior element fracture as well as osteonecrosis of the L1 vertebral body. An L1 percutaneous vertebroplasty was performed, followed by bone cement-augmented screw fixation to maintain stability and correct the kyphotic deformity. After surgery, pain relief was immediate, and the patient was able to walk unassisted. This case illustrates that continuous axial distraction stress caused by aggravated kyphosis secondary to Kummell's disease may result in posterior element fractures. Our discussion concludes with a literature review.

Two escalated followed by six standard BEACOPP in advanced-stage high-risk classical Hodgkin lymphoma: high cure rates but increased risk of aseptic osteonecrosis

BACKGROUND

From 1999, Norwegian guidelines recommend two escalated (esc) BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisolone) followed by six standard (s) BEACOPP for patients with advanced-stage classical Hodgkin lymphoma (HL) with an international prognostic score (IPS) ≥ 4. We evaluated retrospectively the experience with this recommendation at the Norwegian Radium Hospital, also including all IPS 3 patients treated with the same regimen.

PATIENTS AND METHODS

Forty-seven patients were treated between June 1999 and December 2008. IPS was 3 in 10 patients and ≥ 4 in 37.

RESULTS

Thirty-five patients received eight cycles of BEACOPP, 12 patients received one to six cycles only, mainly due to toxicity. Sixty percent of patients had dose reductions. With median follow-up of survivors of 89 months, 5-year progression-free and overall survival are 84% [95% confidence interval (CI) 73% to 95%] and 91% (95% CI 82% to 100%), respectively. Toxicity was considerable with grade 3 or more infections/febrile neutropenia in 66% of patients, including one death and three cases of Pneumocystis jiroveci pneumonia. Of note, 10 patients (21%) experienced symptomatic aseptic osteonecrosis, of whom 3 have had hip replacement surgery after treatment.

CONCLUSION

Two escBEACOPP plus six sBEACOPP is efficacious in advanced-stage high-risk HL. We document a high incidence of aseptic bone necrosis, possibly related to prednisolone.

Glucocorticoid-induced osteonecrosis

Awareness of the need for prevention of glucocorticoid-induced fractures is growing, but glucocorticoid administration is often overlooked as the most common cause of nontraumatic osteonecrosis. Glucocorticoid-induced osteonecrosis develops in 9-40% of patients receiving long-term therapy although it may also occur with short-term exposure to high doses, after intra-articular injection, and without glucocorticoid-induced osteoporosis. The name, osteonecrosis, is misleading because the primary histopathological lesion is osteocyte apoptosis. Apoptotic osteocytes persist because they are anatomically unavailable for phagocytosis and, with glucocorticoid excess, decreased bone remodeling retards their replacement. Glucocorticoid-induced osteocyte apoptosis, a cumulative and unrepairable defect, uniquely disrupts the mechanosensory function of the osteocyte-lacunar-canalicular system and thus starts the inexorable sequence of events leading to collapse of the femoral head. Current evidence indicates that bisphosphonates may rapidly reduce pain, increase ambulation, and delay joint collapse in patients with osteonecrosis.

Plasma thrombospondin-1 is increased during acute sickle cell vaso-occlusive events and associated with acute chest syndrome, hydroxyurea therapy, and lower hemolytic rates

Platelets are activated in sickle cell disease (SCD), and particularly during vaso-occlusive episodes (VOE). Thrombospondin-1 (TSP1), a major secretory product of activated platelets, is increased in the circulation in VOE and binds to sickle red blood cells (RBC) promoting vascular adhesion. Thus, we hypothesized that TSP1 may represent a plasma biomarker of disease severity in SCD. We tested the plasma collected from patients in steady state (n = 27) and VOE (n = 14), as well as healthy controls (n = 17) at the University of Pittsburgh Medical Center (UPMC), and from patients in steady state enrolled in the walk-PHaSST clinical trial (n = 483). We found that TSP1 levels were increased in VOE in the UPMC cohort. Among steady-state patients at UPMC, TSP1 values correlated positively with lifetime history of acute chest syndrome (r = 0.72, P < 0.0001) and hemoglobin concentration (r = 0.49, P = 0.01), and negatively with markers of hemolysis, such as LDH (r = -0.50, P = 0.009). Analysis of the walk-PHaSST cohort also showed a positive association between TSP1 levels and hydroxyurea use (r = 0.14, P = 0.003), and confirmed the negative associations with the severity of hemolysis. Our results suggest that TSP1 levels are associated with more VOE, hydroxyurea use and lower rates of hemolysis. High TSP1 concentrations may indicate higher risk of the viscosity/vaso-occlusion phenotype of SCD.

[Pott's puffy tumor, a rare complication of frontal sinusitis]

Port's puffy tumour (PPT), corresponding to frontal osteomyelitis causing erosion of the anterior wall of the frontal sinus and subperiosteal abscess, is a rare but serious complication of frontal sinusitis or trauma to the region. It can occur even despite the use of antibiotics and requires surgical drainage of the abscess, excision of pathological tissues and obliteration of the frontal sinus by various materials. It can rarely progress to life-threatening intracranial extension. Practitioners must be extremely cautious in the presence of clinical signs suggestive of Pott's puffy tumour. The aim of this article is to present a case of progressively evolving PPT in a patient of 28 years by frontal headaches that are aggravated by painful swelling front soft and fluctuating by palpation and that has fistulated at the right upper eyelid. CT scan of the face revealed the presence of a discontinuity bone at the anterior wall of the right frontal sinus. The treatment consisted of surgery and antibiotics. The patient remained asymptomatic after a decline of 18 months.

Glucocorticoids affect the metabolism of bone marrow stromal cells and lead to osteonecrosis of the femoral head: a review

OBJECTIVE

To review the recent developments in the mechanisms of glucocorticoids induced osteonecrosis of femoral head (ONFH) and introduce a new theory of ONFH.

DATA SOURCES

Both Chinese- and English-language literatures were searched using MEDLINE (1997 - 2011), Pubmed (1997 - 2011) and the Index of Chinese-language Literature (1997 - 2011).

STUDY SELECTION

Data from published articles about mechanisms of glucocorticoids induced ONFH in recent domestic and foreign literature were selected. Data extraction Data were mainly extracted from 61 articles which are listed in the reference section of this review.

RESULTS

Glucocorticoids are steroid hormones secreted by the adrenal cortex that play a pivotal role in the regulation of a variety of developmental, metabolic and immune functions. However, high dose of exogenous glucocorticoids usage is the most common non-traumatic cause of ONFH. Glucocorticoids can affect the metabolisms of osteoblasts, osteoclasts, bone marrow stromal cells and adipocytes which decrease osteoblasts formation but increase adipocytes formation and cause ONFH finally.

CONCLUSIONS

Glucocorticoids affect the differentiation of mesenchymal stem cells, through activating or inhibiting the related transcript regulators of osteogenesis and adipogenesis. At last, the size and volume of mesenchymal stem cells derived adipocytes will increase amazingly, but the osteoblasts will be decreased obviously. In the meantime, the activity of the osteoclasts will be activated. So, these mechanisms work together and lead to ONFH.

Alveolar osteitis and osteomyelitis of the jaws

Postoperative bone healing after oral surgical procedures occurs uneventfully in most cases. However, in certain patients, the normal process of healing can be delayed and, in some cases, often because of multiple coexisting factors, the sites can become infected, with extension of the infection into medullary bone. This process is termed osteomyelitis. This article outlines the pathogenesis, microbiology, and surgical and medical therapies of this condition and specifically addresses osteomyelitis cases related to patients with no documented history of radiation or bisphosphonate exposure and in whom the principal factor in the development of the condition is infection by pyogenic microorganisms.

Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant

INTRODUCTION

Treatment of displaced proximal humerus fractures remains challenging. The introduction of locking plates has renewed interest in treating these fractures with joint-preserving techniques rather than hemiarthroplasty, but high complication rates are still reported. Avascular necrosis is not solely dependent on the initial fracture pattern, but can also result from intraoperative and postoperative vascular insults.

METHOD

We describe a technique to minimize disruption of humeral head blood supply and maximize fracture fixation. A total of 34 patients with complex proximal humerus fractures were treated with a locking plate and endosteal implant through an anterolateral approach and followed for an average of 66 weeks to determine the rates of avascular necrosis.

RESULTS

No patient suffered complete osteonecrosis (0%) and only one patient suffered partial necrosis (2.8%) of the humeral head. The length of the posteromedial hinge was not predictive of this complication.

CONCLUSION

Use of the anterolateral approach and endosteal augment of a lateral locking plate can minimize avascular necrosis following proximal humerus fracture.

Pathophysiology of atypical femoral fractures and osteonecrosis of the jaw

In recent years, atypical femoral fractures and osteonecrosis of the jaw have emerged as potential complications of long-term bisphosphonate therapy; osteonecrosis of the jaw has also been reported in patients receiving high doses of denosumab. The pathophysiology of both conditions is poorly defined, and the underlying mechanisms are likely to differ. The initiation of atypical fractures in the lateral femoral shaft suggests that reduced tensile strength, possibly secondary to alterations in the material properties of bone resulting from low bone turnover, may be an important pathogenetic factor. Osteonecrosis of the jaw is characterised by infection, inflammation, bone resorption and bone necrosis, but the sequence in which these occur has not been established. However, the observation that bone resorption occurs in close proximity to microbial structures suggests that infection may be the most important trigger, often as a result of dental disease. Other possible pathogenetic factors include suppression of bone turnover, altered immune status and adverse effects of bisphosphonates on the oral mucosa.

[The image diagnosis of dysbaric osteonecrosis]

OBJECTIVE

To investigate the imaging features of dysbaric osteonecrosis.

METHODS

The imaging appearances of four patients with dysbaric osteonecrosis caused by diving, were analyzed retrospectively.

RESULTS

In four cases with dysbaric osteonecrosis including case 1 with stage I, case 2 with stage II, case 3 and case 4 with stage III, there were a case with the lesion in a bone and other 3 cases with lesions in multiple bones,and a case with the lesion in unilateral bone and 3 cases with the lesions in lateral bones. (1) The juxta-articular lesions: there were 10 long bones with the head lesions, including 6 humerus with the head lesions and 4 femurs with the head lesions in 4 cases. In four cases, 10 sclerosis lesions appeared in the heads of long bones, each case had a "snow-capped" sclerosis lesion for case 2, case 3 and case 4. There were 7 small radiolucent lesions and a large radiolucent lesion involved in femur neck. The ringlike, linear, bending and punctuate calcification lesions were found on CT films of case 2. The osseous collapse in one femur head and the fragmentations in three femur heads could be seen in case 3 and case 4; 2 crescent signs can be seen in the bilateral femur heads of case 4 with secondary osteoarthritis in left hip joint. (2) The diaphyseal and metaphyseal lesions: the X ray film of case 4 showed the streak and irregular calcifications in the shaft of right humerus; there are strip calcifications in diaphyseal and metaphyseal of the left humerus on MPR coronal view in case 2.

CONCLUSION

The diagnosis of dysbaric osteonecrosis suggested that the increased bone density or sclerosis lesions appeared in the heads of long bones, and osteonecrosis lesions were found in multiple bones or lateral bones.

Musculoskeletal complications of sickle cell disease in Enugu, Nigeria

BACKGROUND

Sickle cell disease (SCD) is one of the most important haemoglobinopathies. It is an autosomal recessive genetic condition in which a defective form of haemoglobin, haemoglobin S (HbS) results from a single amino acid substitution. The amino acid valine replaces glutamic acid at position 6 in the beta globin gene. Musculoskeletal complications are often observed in the evolution of this disease and are common causes of morbidity and disability in these patients. The objective of this study is to describe the pattern and presentation of musculoskeletal complications in sickle cell disease at the National Orthopaedic Hospital Enugu Nigeria.

METHOD

a retrospective review of the patients with musculoskeletal complications who are genotype-confirmed sicklers who were treated in our hospital from January 1993 to December 2007 was carried out. The data collected included age, sex, complications, anatomic site, grade of disease, treatment, outcome of management and follow up. Patients with incomplete data were excluded from the study.

RESULTS

Twenty seven patients with musculoskeletal complications of SCD were treated within the study period. Two patients were excluded from the study because of incomplete data. Twenty-five patients with 44 complications were analyzed. The age range was between 7 years to 30 years with a mean age of 19.2 years. Fifty six percent of patients were males. Malleolar ulcers were the commonest complications. This was followed by avascular necrosis (AVN) of the femoral head and osteomyelitis. Septic arthritis and osteomyelitis were most common in children less than 10 years while avascular necrosis and malleolar ulcers occurred more commonly in patients more than 15 years. Majority of the malleolar ulcers were treated by split skin grafting. Seventy five percent of the femoral head avascular necrosis was treated conservatively

CONCLUSION

Musculoskeletal complications are common causes of morbidity and disability in sickle cell disease. Malleolar ulcers were the commonest musculoskeletal complications. The predominant presentation in children below the age of 10 years is osteomyelitis and septic arthritis while AVN and malleolar ulcers occurred mostly in adolescents.

Complications of hip fractures in children

BACKGROUND

Hip fractures account for < 1% of all pediatric fractures. Most are caused by a high-energy mechanism. Complications occur at a high rate because the vascular and osseous anatomy of the child's proximal femur is vulnerable to injury. The purposes of this study were to evaluate whether osteonecrosis influences the functional results and to analyze the risk factors for the development of osteonecrosis.

METHODS

We conducted a retrospective review of the complications of hip fractures (3 transepiphyseal fractures, 13 transcervical fractures, 6 cervico-trochanteric fractures, and 1 intertrochanteric fracture) in 23 patients (15 boys and 8 girls) between January 1988 and December 1997. Most injuries were caused by falling from a height or a motorcycle accident. The medical records and serial radiographs of all patients were reviewed. The function of the injured site was evaluated using Ratliff's criteria.

RESULTS

The ages of these children at the time of injury ranged from 1.5 to 16 years (average 11.1 years). The mean follow-up was 4.91 years (range, 1 year to 12 years and 7 months). Overall, complications included osteonecrosis in 11 (48%) patients, premature physeal closure in 11 (48%), coxa vara in 3 (13%) and coxa valga in 2 (9%). There was no nonunion. Poor outcomes were related to the development of osteonecrosis. The time to surgery (≤ 12 hours) and the quality of reduction significantly influenced the occurrence of osteonecrosis. The occurrence and severity of femoral head osteonecrosis significantly influenced the functional results (p < 0.001, and p < 0.048, respectively).

CONCLUSION

Osteonecrosis is the most severe complication after hip fractures in children and is associated with poor functional results. The time to surgery and the quality of reduction were the significant predictors in our study.

Potential and pitfalls of using large administrative claims data to study the safety of osteoporosis therapies

Long-term bisphosphonate use may be associated with several rare adverse events. Such associations are not optimally evaluated in conventional randomized controlled trials due to the requirements of large numbers of patients and long-term follow-up. Alternatively, administrative claims data from various sources such as Medicare have been used. Because claims data are collected for billing and reimbursement purposes, they have limitations, including uncertain diagnostic validity and lack of detailed clinical information. Using such data for pharmacoepidemiologic research requires complex methodologies that may be less familiar to many researchers and clinicians. In this review, we discuss the strengths and limitations of using claims data for osteoporosis drug safety research, summarize recent advancements in methodologies that may be used to address the limitations, and present directions for future research using claims data.

Periodontal disease and bisphosphonates induce osteonecrosis of the jaws in the rat

Bisphosphonates (BPs) are medications used commonly to treat primary and metastatic bone cancer, as well as osteoporosis. Although BPs improve bone mineral density, reduce fracture risk, and reduce hypercalcemia of malignancy, some patients develop BP-related osteonecrosis of the jaws (BRONJ). This devastating complication is defined as clinically exposed bone in the maxillofacial region for more than 8 weeks. Despite an increasing number of BRONJ cases since first reported, the disease pathophysiology remains largely unknown. Since published studies suggest a significant role for dental disease in the pathophysiology of BRONJ, we developed a BRONJ animal model where aggressive periodontal disease is induced by ligature placement around the crown of the right maxillary first molar in the presence of vehicle (veh) or zoledronic acid (ZA), a potent BP. Ligature placement induced significant alveolar bone loss, which was attenuated by ZA treatment. Osteonecrosis was observed associated with ligature-induced periodontitis in the ZA-treated group. This was seen as sequestration and extensive periosteal alveolar bone formation on micro-computed tomography (µCT) in the ligated site of BP-treated animals. Histologic examination confirmed these findings, seen as necrotic bone with diffuse loss of osteocytes and empty lacunae, rimming of the necrotic bone by squamous epithelium and inflammation, and exposure to the oral cavity. Importantly, the rat lesions were strikingly similar to those of BRONJ patients. Our data suggest that dental disease and potent BP therapy are sufficient for BRONJ development in the rat.

[CT and MRI in diagnosis of avascular necrosis of the vertebral body]

OBJECTIVE

To evaluate the value of CT and MRI in the diagnosis of avascular necrosis of the vertebral body (ANV).

METHODS

Twelve ANV patients were retrospectively analysed by their medical history, clinic manifestation, CT and MRI. Twelve AVN patients were treated with percutaneous vertebroplasty (PVP). The pain level of each patient was assessed, both before and after the procedure, using a visual analogue scale (VAS).

RESULTS

All the patients had ANV in the thoracolumbar spine. The intravertebral vaccum phenomenon (VP), with gas or fluid-like collection, was seen on computed tomographic (CT) images and magnetic resonance images (MRI). In the early stages, the VP zone was characterized by fluid-like collection, and was low intensity on T1, high intensity on T2. In the latter stages, the margin of VP zone had sclerotic change on CT scan. VAS score decreased from preoperative (9.08 +/- 0.76) to (2.33 +/- 1.43) at 3 days after PVP.

CONCLUSION

ANV must be considered as a possible diagnosis of VP secondary to osteoporotic vertebral fractures. Both CT and MRI could provide reliable diagnostic proof for ANV. PVP is proved to be an effective and safe procedure for the treatment of ANV, and could provid quick pain relief.

The use of radiofrequency energy for arthroscopic chondroplasty in the knee

We present a review of the current literature surrounding the use of radiofrequency energy for arthroscopic chondroplasty in the knee. This review article summarizes basic science, clinical efficacy, and recent advances in the understanding of radiofrequency energy use for the treatment of chondral lesions. Laboratory evidence of increased mechanical stability and decreased release of inflammatory mediators associated with the use of radiofrequency energy chondroplasty is described with clinical evidence of decreased pain and increased functional scores when compared with mechanical chondroplasty. We re-examine concerns about the immediate side effects of radiofrequency energy use, including damage to local structures, in light of new potentially contradictory results, as well as the progression of techniques and probe design. However, although reported complications are few, because the quality of clinical evidence about safety and efficacy remains low, we suggest cautious and judicious use of this technology until future research has clearly defined the long-term clinical outcomes and risks.

[Analysis of therapeutic effects of cannulated compression screws for the treatment of femoral neck fractures]

OBJECTIVE

To evaluate the therapeutic effects of cannulated compression screws for the treatment of femoral neck fractures, and to investigate the related factors influencing the avascular necrosis of femoral head after surgery.

METHODS

A retrospective review was done for 96 patients with femoral neck fractures treated with cannulated compression screws from January 2003 to June 2009. Among them, there were 44 males and 52 females with 21 to 88 years old (averaged 56.3 years old). According to Garden classification, 4 patients were type I, 34 patients were type II, 37 patients were type III and 21 patients were type IV. Factors such as patients' age, gender, fracture type, duration from injury to surgery and fracture reduction quality were statistically analysed to find correlations with nonunion and avascular necrosis of femoral head.

RESULTS

Eighty-four patients were followed up ranging from 9 to 60 months and the mean time was 25.4 months. Postoperative complications included deep venous thrombosis of lower extremity in 2 cases, bone nonunion in 8 cases and avascular necrosis of femoral head in 11 cases. According to Harris criterion, the total postoperative Harris score was 86.20 +/- 11.00, and 40 patients got an excellent result, 32 good, 7 fair and 5 poor. The incidence of avascular necrosis of femoral head in nondisplaced fracture group and displaced fractures group were 3.22% and 18.87% respectively;and there were significant difference between the two groups (P = 0.037). The incidence of avascular necrosis of femoral head in anatomical reduction group and non-anatomical reduction group were 5.00% and 20.45% respectively; also,significant difference was existed between the two groups (P = 0.036). However, there was no statistically significant difference of the incidence of avascular necrosis of femoral head according to different age, sex, operative time.

CONCLUSION

The therapeutic effect of cannulated compression screws for non-displaced femoral neck fractures is good. The fracture type and reduction quality are found to be main factors correlated with avascular necrosis of femoral head statistically. For young patients with a displaced femoral neck fracture,in order to avoid incidence of avascular necrosis of femoral head, anatomical reduction should be ensured. For elder patients with a severe displaced femoral neck fracture, the total hip replacement should be recommended.

Etiology of Kienböck disease

The etiology of Kienböck disease is still unknown and, consequently, the ideal treatment is in doubt. Many different hypotheses have been suggested. There are reasons to believe that there are mechanical, vascular, and metabolic factors predisposing to the disease, and probably some factors triggering the development of the process. Among mechanical factors, the short ulna has been thought to be the most relevant. However, presently there are insufficient data to support a significant association between negative ulnar variance and Kienböck disease. With regard to vascular factors, anatomical studies have shown consistent dorsal and palmar arteries entering the bone, and thus, the most likely site for vascular impairment may be at the subchondral level. Many triggering factors have been proposed during the past years, but until this is truly clarified, finding the real cause of Kienböck disease will continue to be a real challenge.

Health-related quality of life in adults with sickle cell disease (SCD): a report from the comprehensive sickle cell centers clinical trial consortium

Adults with Sickle Cell Disease (SCD) experience multiple disease-related complications, but few studies have examined relationships between these events and health-related quality of life (HRQOL). We determined the number and type of previous or co-occurring SCD-related complications and their reported HRQOL in a cohort of 1,046 adults from the Comprehensive Sickle Cell Centers (CSCC). Participants had a median age of 28.0 years (48% male, 73% SS or Sβ⁰ thalassemia) and had experienced several SCD-related complications (mean 3.8 ± 2.0), which were influenced by age, gender, and hemoglobinopathy type (P < 0.0001). In multivariate models, increasing age reduced all SF-36 scales scores (P < 0.05) except mental health, while female gender additionally diminished physical function and vitality scale scores (P < 0.01). Of possible complications, only vaso-occlusive crisis, asthma, or avascular necrosis diminished SF-36 scale scores. Chronic antidepressants usage predominantly diminished scores on bodily pain, vitality, social functioning, emotional role, and mental health scales, whereas chronic opioid usage diminished all scale scores (P < 0.01). Our study documents substantial impairment of HRQOL in adults with SCD that was influenced by only a few of many possible medical complications. It suggests that more effective treatments of persistent pain and depression would provide the largest HRQOL benefit.

The diagnosis and management of spontaneous and post-arthroscopy osteonecrosis of the knee

Spontaneous osteonecrosis of the knee (SPONK) and osteo necrosis in the postoperative knee (ONPK) are two clinical entities that have the potential to cause significant morbidity in affected patients. In addition to the knowledge of the patient population at risk and the classic presentation and imaging characteristics of SPONK and ONPK, the treating orthopaedic surgeon needs to maintain a high index of suspicion for these disorders since early diagnosis and treatment may allow for an improved clinical outcome. The following review presents the current knowledge regarding these two pathological processes of the knee.

Surgical results and complications of developmental dysplasia of the hip--one stage open reduction and Salter's osteotomy for patients between 1 and 3 years old

BACKGROUND

Reports of the efficacy of Salter's osteotomy have often been based on groups of patients with complex disease conditions and treatment. The purposes of this study were to document the results of patients with well-defined conditions, focusing on the onset and sequelae of osteonecrosis.

METHODS

The study participants consisted of 63 patients with unilateral hip dislocation who had undergone one-stage open reduction and Salter's innominate osteotomy between the ages of 1 and 3 years. The results were evaluated clinically by McKay's classification and radiologically by the modified Severin's classification. Early signs of osteonecrosis were identified by neck widening, epiphysis fragmentation, and presence of a metaphyseal growth disturbance line in the first year after the operation.

RESULTS

After a follow-up of 10 years on average, good clinical and radiographic results were noted in 89% and 92% of the patients, respectively. Osteonecrosis occurred in 30 hips, of which 14 subsequently developed femoral head deformity. Residual dysplasia was noted in 5 hips, mostly resulting from late-onset coxa valga. Eighty-five percent of the hips without osteonecrosis and 53% of the hips with osteonecrosis (p < 0.05) were classified as Severin class 1. No pre-operative factors were found to be associated with the occurrence of osteonecrosis.

CONCLUSION

One-stage open reduction and Salter's osteotomy was an effective treatment for developmental dysplasia of the hip after walking age. However, parents must be informed of the two major complications, osteonecrosis and residual dysplasia, that can lead to long-term morbidity.

Does a longer delay in fixation of talus fractures cause osteonecrosis?

This retrospective study investigated active duty soldiers with delayed definitive fixation of combat-related talus fractures. The authors predicted a longer delay to internal fixation and a correlation between the timing of fixation and development of osteonecrosis and posttraumatic arthritis. The Joint Theater Trauma Registry was queried by ICD-9 codes for talus fractures. Soldiers, ages 18 to 40, with talus fracture between 2001 and 2008 were included. Radiographs identified the injury type, Hawkins sign, osteonecrosis, and posttraumatic arthritis. Mean time to fixation was 12.9 days. Hawkins sign was observed in 59% of fractures at a mean of 7 weeks. No correlation was found between osteonecrosis or posttraumatic arthritis and open fractures, comminuted fractures, or timing of fixation. Average follow-up was 16 months. This case series has the longest mean time to fixation by more than threefold. There was no correlation of delayed timing of fixation and development of osteonecrosis or posttraumatic arthritis.

Osseous manifestations of adult Gaucher disease in the era of enzyme replacement therapy

Enzyme replacement therapy (ERT) for Gaucher disease with mannose-terminated glucocerebrosidase has proved its therapeutic position with salutary effects on hematologic abnormalities, visceral infiltration, and quality of life. The frequency of new bone complications is reduced but not eliminated. Established osteonecrosis is beyond salvage. A systematic description of the burden of bone manifestations, persisting despite ERT, should inform future remedial strategies. Thus, we conducted this study to quantify the burden of residual skeletal disease and to explore putative relationships between clinical, radiologic, and biochemical factors and bone sequelae associated with disability.Consecutive adult patients attending 3 referral centers in the United Kingdom were invited to participate. A representative group of 100 patients agreed to a structured interview, clinical examination, radiologic review, and completion of questionnaires. Osteonecrosis was evident in 43%, Erlenmeyer flask deformity in 59%, fragility fracture in 28%, osteomyelitis in 6%, and lytic lesions in 4%. Mobility was impaired in 32% of patients, while 15% experienced significant pain. The EuroQol 5D (EQ5D) quality of life summary measure was reduced and was associated with osteonecrosis and fragility fracture. Eight patients experienced new osteonecrosis after the start of ERT, though the presentation and evolution were often atypical. Nine patients had been treated from childhood and had an excellent outcome. Osteonecrosis was associated with age of presentation and with splenectomy-indeed, we observed a strong temporal association between splenectomy and incidence of osteonecrosis.The biomarkers PARC/CCL18 and chitotriosidase were associated with prevalent osteonecrosis, and, in particular, with osteonecrosis occurring despite treatment. This study documents significant residual skeletal pathology and disability in patients in the mature phase of their treatment in a developed region. The temporal association between splenectomy and osteonecrosis implies causation. The relationship between clinical and biochemical markers and existing bone complications sets the scene for future prospective studies that will focus on management strategies informed by credible assessment of risk.

Kienböck's disease: unusual cause of acute onset wrist pain in a dialysis patient

Kienböck's disease is a rare disorder that presents with wrist pain and limitation of motion and is caused by avascular necrosis of the lunate bone. Dialysis patients occasionally present with wrist pain. However, Kienböck's disease is rarely reported in dialysis patients. We report a case of 52-year-old woman with a 28-year history of hemodialysis who presented with acute wrist pain. T1-weighted magnetic resonance imaging showed diffuse low intensity of the lunate bone, consistent with the diagnosis of Kienböck's disease. Because this disease can lead to chronic debilitating wrist pain, prompt diagnosis, accurate staging, and provision of appropriate treatment is mandatory.

[Development of aseptic osteonecrosis during the treatment of acute lymphoblastic leukemia: review of the literature and author's own data]

We report a case of aceptic osteonecrosis (AON) of the left hymerus epiphysis in programmed treatment of a male patient with lymphoblastic lymphoma to illustrate clinical, laboratory, epidemiological, pathogenetic, diagnostic and therapeutic aspects of AON in programmed therapy of acute lymphoblastic leukemia (ALL). We believe that AON is a rather frequent but often missed for early diagnosis complication of ALL treatment. Even a weak pain in bones and joints under mechanical load in patients on long-term treatment with glucocorticosteroids is an alarming symptom which may indicate a risk of an osteodestructive process and relevant diagnostic and therapeutic measures may be needed.

Top 10 pediatric orthopaedic surgical emergencies: a case-based approach for the surgeon on call

Pediatric patients who require orthopaedic surgical emergency care are often treated by orthopaedic surgeons who primarily treat adult patients. Essential information is needed to safely evaluate and treat the most common surgical emergencies in pediatric patients, including hip fractures; supracondylar humeral, femoral, and tibial conditions of the hip (such as slipped capital femoral epiphysis and septic arthritis); and limb- and life-threatening pathologies, including compartment syndrome, the dysvascular limb, cervical spine trauma, and the polytraumatized child. To provide optimal care to pediatric patients, it is important to be aware of the key points in patient evaluation and surgical care as well as expected complications.

[Predictive factors of chronic complications in adult sickle cell anemia patients in Dakar, Senegal]

PURPOSE

Chronic complications of sickle cell disease (SS) usually involve irreversible organ damage. Several genetic factors have been shown to have predicative value for chronic complications but these data are not always available. The purpose of this study was to assess the value of sociodemographic and clinicobiological features in predicting chronic complications.

METHODS

This study included a total of 229 adult SS patients who underwent quarterly follow-up examinations for at least 10 years (range, 10 - 16). All sociodemographic and clinicobiological data were recorded. Screening for complications was performed at least once every three years. The risk of developing chronic complications was analyzed in function of patient follow-up data.

RESULTS

Mean patient age was 28.6 years (range, 20 - 57) and sex ratio was 1.3. Prevalence of chronic complications was 34.9% (80/229). The most common complication was bone necrosis in 27 cases (11.7%) followed by gallstones in 24 (10.4%). The only sociodemographic factor with predictive value was patient age (p=0.0008). Multivariate analysis identified two clinicobiological factors with predictive value. History of transfusion was associated with a 3-fold higher risk while hemoglobin F level was associated with decreased risk.

CONCLUSION

In this study, age and low hemoglobin F level were the only predictive factors of chronic complications in SS patients.

Osteonecrosis in an adolescent with non-Hodgkin lymphoma resembling a new metastatic lesion on (18)F-FDG PET/CT

Osteonecrosis may result from complications in a variety of pediatric diseases and, in the early stages of healing, may be characterized by inflammation and hyperemia. While traditionally assessed by bone scintigraphy, osteonecrosis may also present upon [F-18]2-fluoro-2-deoxyglucose PET/CT. Differentiation of osteonecrosis from metastatic lesions is important to ensure accurate disease staging and to avoid unnecessary imaging and biopsy. Osteonecrosis typically presents at the interface of weight-bearing joints after prolonged chemotherapy with corticosteroid administration, although prevalence is greater in adults than in children. We describe a case of unilateral osteonecrosis in the tibia of an adolescent lymphoma patient, which first presented on FDG-PET/CT imaging after 2 months of combination chemotherapy with corticosteroid administration. This report should aid in recognizing rapid-onset osteonecrosis with atypical sites of involvement in pediatric patients.

Development and validation of a pediatric severity index for sickle cell patients

There is no instrument to measure severity of sickle cell disease (SCD) in pediatric patients that is generally accepted. The aim of this study was to develop and validate a severity index for SCD in children. We developed an index consisting of 12 items and tested its validity of the index using data from 92 children. We tested whether different scores were obtained for patients classified by severity both subjectively and objectively by a partially validated existing index. Furthermore, we tested whether the index could differentiate patients classified according to genotype or the number of α-gene deletions and evaluated whether the score on the index was correlated with the average number and days of hospitalizations/year, age and a risk of death score. We explored the effect of three different weighting systems (Score A, B, and C) to summarize these items. All weightings demonstrated a significant difference between the scores of mild, moderate, and severely affected patients, as classified by a subjective rating or with an existing index (P < 0.01). The index clearly differentiated patients by genotype (P < 0.01) or α-gene deletions (P < 0.01). The correlation with hospitalization was moderate. Age and the risk of death score were weakly associated with the pediatric severity index for SCD. This is the first pediatric SCD severity index that was developed and validated using modern clinimetric methodology. The validity and reliability of this index should be further evaluated in a prospective study including a larger cohort, preferably diagnosed at birth.

Dysbaric osteonecrosis in recreational divers: a study using magnetic resonance imaging

OBJECTIVE

We set out to identify whether magnetic resonance imaging (MRI) would identify evidence of dysbaric osteonecrosis (DON) in a group of experienced recreational scuba divers.

DESIGN

Local British Sub Aqua Club divers of at least Trainee Dive Leader grade were offered MRI scans (T1 and TIRM sequences) of hips, femora and shoulders. Anonymous images were interpreted separately by two radiologists, and cases not considered unequivocally normal were discussed for consensus opinion.

RESULTS

Of 26 divers imaged, five merited discussion. Four of these were considered to show unrelated normal variants or incidental findings. Only one case (abnormalities in the right humerus and left femur) could have possibly represented osteonecrotic lesions. After obtaining plain radiographs and more detailed clinical and dive history, these lesions were considered "indeterminate" but probably not DON by both reviewers and after taking further specialist musculoskeletal MRI opinion.

CONCLUSION

This study found no evidence that DON is a significant risk in recreational scuba diving and as such concurs with prevailing current opinion.

Updates on osteonecrosis of the jaw

PURPOSE OF REVIEW

Osteonecrosis of the jaw (ONJ) is an uncommon condition noted to occur in patients with cancer who are receiving intravenous bisphosphonates. The cause of ONJ remains unknown. The leading hypotheses addressing the mechanism of ONJ are reviewed here.

RECENT FINDINGS

The present clinical data suggest that ONJ may occur in approximately 5% of patients with metastatic bone disease. The ability to predict an individual's risk of developing ONJ remains elusive. It is likely that an altered bone microenvironment and/or host defense mechanisms effected by medications used to treat patients with metastatic bone disease contributes to the development of ONJ. Medications that significantly reduce osteoclastic activity are associated with ONJ. Preclinical models of ONJ are being developed but to establish such an intricate systemic condition in animals is challenging.

SUMMARY

The ONJ field has progressed via knowledge gained by case reports, population-based studies, and emerging animal models. Still, there are myths that need to be resolved and important clues that need to be investigated. Understanding the pathophysiology of this condition will be critical to improve patient care. Communications between oncologists, dentists, basic scientists, and patients are central to effective treatment and research for this condition.

Avascular necrosis of bone in children with leukemia: experience of pediatric hematology unit in kuwait

Avascular necrosis of the bone (AVNB) is an uncommon serious complication of acute leukemia. Between the years 1997-2007, seven children with acute leukemia of different risk groups presented with symptoms, signs and investigational evidence of avascular necrosis of bone. They were all diagnosed during their maintenance chemotherapy except one patient who had AVNB post-transplant following hematological relapse. Six patients had avascular necrosis of the hip (AVNH), and one patient had avascular necrosis of the foot. Other complications for steroids, such as hyperglycemia were observed in some of the patients. The steroids were omitted in almost all patients immediately. Two patients had surgical intervention and the rest received conservative management. Two patients recovered fully and the rest are still under follow-up at orthopedic clinic pending further management.

Prosthodontic treatment of a patient with bisphosphonate-induced osteonecrosis of the jaw using a removable dental prosthesis with a heat-polymerized resilient liner: a clinical report

Bisphosphonate-induced osteonecrosis of the jaws (BONJ) is reported frequently in patients receiving oral or intravenous bisphosphonates. To minimize potential complications, dental treatment must be performed with care. There are invasive and noninvasive treatment options for patients with active BONJ or a history of this complication. This clinical report describes the prosthodontic treatment of a patient who developed BONJ after receiving intravenous bisphosphonates (pamidronate). Because of the recurrent incidence of BONJ, noninvasive prosthetic therapy with telescopic overdentures and a heat-polymerized resilient liner was provided. After 2 years, there were no biological or technical complications.

Osteonecrosis of the scaphoid after scapholunate interosseous ligament repair and dorsal capsulodesis: case report

Scapholunate interosseous ligament repair with dorsal capsular augmentation is an established surgical treatment for traumatic scapholunate instability. We report a case of scaphoid osteonecrosis that developed after this procedure and discuss the possible causes of this complication.

[Treatment of non-traumatic avascular talar necrosis by transposition of vascularized cuneiform bone flap plus iliac cancellous bone grafting]

OBJECTIVE

To evaluate the outcome of cancellous bone grafting plus iliac cancellous bone in the treatment of non-traumatic avascular talar necrosis.

METHODS

Twenty patients, 14 males and six females, eight at stage II, ten at stage III and three at stage IV according to the modified Ficat & Arlet necrosis classification system, were treated with vascularized bone flap from January 2000 to June 2005.

RESULTS

All patients were followed up for a mean of 37 months (range: 14 to 68 months). The clinical function outcome evaluated by Kenwright criteria were excellent in 8 cases, good in 10 cases, fair in 1 case and poor in 1 case. Clinical symptom was completely or partially relieved. The necrotic area was filled with newly formed bone and the excellent-to-good rate was 90%.

CONCLUSION

Transposition of vascularized cuneiform bone flap plus iliac cancellous bone grafting may be an ideal therapeutic method for non-traumatic avascular talar necrosis. And the clinical outcome is satisfactory.

[Balloon kyphoplasty for osteoporotic vertebral compression fractures with osteonecrosis]

OBJECTIVE

To explore the clinical efficacy of the percutaneous balloon kyphoplasty for osteoporotic vertebral compression fractures with osteonecrosis.

METHODS

The clinical data of 31 patients with osteoporotic vertebral compression fractures associated with osteonecrosis from January 2005 to January 2008 were analyzed retrospectively. There were 13 male and 18 female in this study. The mean age of the patients was 71 years (range from 57 to 84 years). The back pain lasted for 4.2 months (from 1 month to 10 years). Radiography, MRI and CT examination were performed. The patients were treated by percutaneous balloon kyphoplasty and the vertebral body tissue was extracted to perform common pathological examination. The anterior vertebral height was measured on a standing lateral radiograph before operation, after operation (one day after operation) and at the final follow-up. A Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) were chosen to evaluate pain status and functional activity.

RESULTS

The mean follow-up was for 27 months (range, 18 to 48 months). The anterior vertebral body height of fracture vertebra was restored from (34.7 +/- 3.1)% preoperatively to (71.4 +/- 2.3)% postoperatively, and to (70.2 +/- 2.5)% at the final follow-up. There was a significant improvement between preoperative and postoperative values (P < 0.05) and no difference between postoperatively and at the final follow-up (P > 0.05). The VAS was 8.7 +/- 0.4 preoperatively, 2.3 +/- 0.7 postoperatively, and 1.9 +/- 0.2 at the final follow-up; and the ODI was 89.1 +/- 2.7 preoperatively, 31.7 +/- 3.1 postoperatively, and 29.1 +/- 2.7 at the final follow-up. There was statistically significant increment in the VAS and ODI postoperatively compared with preoperatively (P < 0.05), while there was no statistically significant differences between postoperatively and at the final follow-up (P > 0.05). There was a significant increment between preoperative and final follow-up values (P < 0.05). Asymptomatic cement leakage occurred in two cases. New vertebral fracture occurred in one case.

CONCLUSION

Balloon kyphoplasty is a safe and effective procedure for osteoporotic vertebral compression fractures with osteonecrosis.

The epidemiology of osteonecrosis: findings from the GPRD and THIN databases in the UK

We conducted a case-control study to examine osteonecrosis (ON) incidence, patient characteristics, and selected potential risk factors using two health record databases in the UK. Statistically significant risk factors for ON included systemic corticosteroid use, hospitalization, referral or specialist visit, bone fracture, any cancer, osteoporosis, connective tissue disease, and osteoarthritis.

INTRODUCTION

The purpose of this case-control study was to examine the incidence of osteonecrosis (ON), patient characteristics, and selected potential risk factors for ON using two health record databases in the UK: the General Practice Research Database and The Health Improvement Network.

METHODS

ON cases (n = 792) were identified from 1989 to 2003 and individually matched (age, sex, and medical practice) up to six controls (n = 4,660) with no record of ON. Possible risk factors were considered for inclusion based on a review of published literature. Annual incidence rates were computed, and a multivariable logistic regression model was derived to evaluate selected risk factors.

RESULTS

ON of the hip represented the majority of cases (75.9%). Statistically significant risk factors for ON were systemic corticosteroid use in the previous 2 years, hospitalization, referral or specialist visit, bone fracture, any cancer, osteoporosis, connective tissue disease, and osteoarthritis within the past 5 years. Only 4.4% of ON cases were exposed to bisphosphonates within the previous 2 years.

CONCLUSIONS

This study provides further perspective on the descriptive epidemiology of ON. Studies utilizing more recent data may further elucidate the understanding of ON key predictors.

Prospective bone ultrasound patterns during childhood acute lymphoblastic leukemia treatment

OBJECTIVE

Bone impairment is a well-known complication in childhood acute lymphoblastic leukemia (ALL) survivors but less is known about bone dynamics during ALL therapy. We longitudinally assessed by Quantitative Ultrasound (QUS) skeletal modifications during this treatment.

MATERIALS AND METHODS

Forty-four newly diagnosed ALL children underwent bone measurement by QUS parameters BTT (Bone Transmission Time) and AD-SoS (Amplitude-Dependent Speed of Sound), mainly reliant on bone density and cortical thickness, respectively. Measurements were performed at diagnosis, and 6, 12, and 24 months thereafter. The occurrence of skeletal complications such as fractures, vertebral collapse, osteonecrosis, and osteopenia was related to measurement outcome.

RESULTS

A rapid deterioration of bone properties measured by BTT and AD-SoS was evident in the first semester of therapy (p<0.001). Subsequently, the next measurements were characterized by progressive uncoupling of the two QUS parameters (p<0.001). These were both significantly reduced at the end of therapy (p<0.001). Twelve subjects with in-treatment skeletal complications displayed an almost two-fold decrease of both parameters (p<0.001). BTT decreasing more than 1 Standard Deviation (SD) over 6 months of therapy was able to predict skeletal complication occurrence (p<0.001).

CONCLUSION

This report represents the largest longitudinal cohort systematically submitted to bone condition assessment from the beginning to the end of therapy for childhood ALL. Bone deterioration occurs early and persists throughout therapy, consistent with bone properties uncoupling. This pattern possibly reflects an initial impairment of both mineral density and cortical thickness with a subsequent recovery of this latter. QUS permits an early detection of bone deterioration and related skeletal complications in childhood ALL.