The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate?

Sacral insufficiency fractures are an often unsuspected cause of low back pain in elderly women with osteoporosis who have sustained minimal or no trauma. Many of the references in the literature advocate bed rest initially; however, we support early mobilization, because most of these fractures are stable and require no surgical intervention. With good pain control, patients can begin progressive ambulation with assistive devices in a supervised environment and minimize the complications of immobility.

Polymorphisms in the vitamin D receptor gene and bone mass, bone turnover and osteoporotic fractures

BACKGROUND

Vitamin D is essential for normal bone metabolism. Polymorphisms in exon 2, intron 8 and exon 9 of the vitamin D receptor (VDR) gene have previously been found to be associated with bone mass and bone turnover.

MATERIALS AND METHODS

We examined the effect of these polymorphisms, separately and in combination, on bone mineral density (BMD), bone turnover, and the prevalence of osteoporotic fractures in 192 osteoporotic patients and 207 normal controls. The four polymorphisms were determined by RFLP using Fok I (T2-C), Bsm I (intron 8), Apa I (intron 8) and Taq I (T1055-C) after PCR.

RESULTS

We did not find any association between the Fok I polymorphism and bone mass, bone turnover or prevalence of osteoporotic fractures. We found that BB + Bb-genotypes were more frequent in patients with osteoporotic fractures (chi2 = 3.50, P = 0. 06). Furthermore, BMD of the intertrochanteric region (P < 0.0001, ANOVA) as well as the total hip (P < 0.01, ANOVA) were higher in individuals with the bb-genotype. The Apa I and the Taq I polymorphisms were not distributed differently among osteoporotic patients and normal controls. Apa I was not associated with differences in BMD. BMD of the intertrochanteric region was higher in individuals with the TT-genotype compared with individuals with the Tt- or tt-genotypes (P < 0.01, ANOVA), while no differences could be demonstrated in BMD of the lumbar spine, femoral neck, trochanter or Wards triangle. Combining the genotypes generally reflected the differences caused by the Bsm I polymorphism.

CONCLUSION

We have found that the B-allele of the Bsm I polymorphism in the 3' untranslated region of the VDR was associated with low BMD at the hip, and tended to be associated with osteoporotic fractures. The translation initiation polymorphism in the VDR does not affect BMD and is not associated with osteoporotic fractures in men or women.

Pathologic supracondylar fracture due to osteolytic pseudotumor of knee following cementless total knee replacement

Wear debris of polyethylene, polymethylmethacrylate, and metal have been recognized to be associated with foreign body reactions, osteolysis, and aseptic prosthetic loosening after joint replacement arthroplasty. Further, foreign body reaction due to the presence of extensive wear debris can cause aggressive granulomatous lesions and pathologic fracture. To our knowledge, there has been no previous report of pathologic fracture of the femur due to an agressive pseudotumor. This report describes a case of pathologic supracondylar fracture of the femur 6 years and 5 months after cementless total knee replacement arthroplasty. The fracture occurred through an aggressive expanding soft tissue mass that was a tumorlike lesion secondary to polyethylene wear debris. The lesion was associated with massive osteolysis around the femoral component of the total knee prosthesis.

Orthopedic emergencies in cancer patients

The most frequent orthopedic emergency in oncology patients is fracture. Stabilization of the entire fractured bone restores function and relieves pain. The site, quality, and extent of the lesion can identify impending fractures that should be stabilized. New methods of pelvic stabilization effectively bypass periacetabular bone deficiency. Spinal cord decompression is important to maintain neurologic function. Advances in segmental fixation of the spine have improved the outcome over what was achieved by radiation alone. Infection is common in neutropenic patients, and should be treated aggressively with antibiotics and drainage of abscesses of the musculoskeletal system. Extravasation of doxorubicin requires prompt local debridement to limit the extent of necrosis propagation. These treatments can effectively improve the quality of life of patients with metastatic cancer. They should be included as "best supportive care" for patients with more than 1 month to live.

"Dem bones": osteochondral injuries of the knee

MR imaging plays a valuable role in the diagnosis and staging of osteochondral injuries of the femorotibial joint. Bone contusions may be the source of a patient's pain, and MR imaging characteristics of certain types may help to predict which contusions might progress to more serious osteochondral lesions. MR imaging also is vital in the diagnosis of occult osteochondral fractures and in accurately classifying displaced intra-articular fractures. Although osteochondral dissecans usually is diagnosed radiographically, MR imaging is the best noninvasive test for determining if an osteochondral fragment is unstable. Unstable lesions are a treatable cause of knee pain.

Identification of vertebral deformities in women: comparison of radiological assessment and quantitative morphometry using morphometric radiography and morphometric X-ray absorptiometry

Our aim was to compare normal vertebral reference values for morphometric radiography (MRX) and morphometric X-ray absorptiometry (MXA) and to compare these methods for the identification of vertebral deformities. We calculated MXA reference values (Hologic QDR 4500 A) for 327 women (ages 22-88 years) randomly selected from local General Practice lists in Sheffield, U.K. MRX reference values were calculated from spinal radiographs for 123 of these subjects (ages 56-88 years). We used these reference values to identify deformities in the MRX and MXA reference populations and in 83 women with osteoporosis (ages 49-87 years). We observed differences in mean deformity of vertebral height ratios measured by MRX and MXA, especially for the mid-to-posterior ratio. We compared agreement between quantitative methods (MRX and MXA) and qualitative radiological assessment. Severity of deformity was defined by semiquantitative (SQ) assessment. Agreement was moderate for MRX (k = 0.59; 95% CI = 0.43-0.77) and for MXA (k = 0.47; 95% CI = 0.29-0.66) in the reference population. Agreement was good for MRX (k = 0.86; 95% CI = 0.82-0.89) and MXA (k = 0.71; 95% CI = 0.66-0.75) in the osteoporotic population. MRX and MXA correctly identified a greater proportion of moderate or severe deformities compared with mild deformities. Sensitivity, specificity, predictive values, and accuracy were slightly better for MRX than for MXA. Although MXA agrees well with qualitative radiological assessment, the large proportion of vertebrae excluded from analysis because of poor image quality limits the diagnostic value of the technique. Reference intervals should be technique specific.

Primary leiomyosarcoma of the cervical spine causing spontaneous compression fracture: report of an autopsy case

An extremely rare case of the primary leiomyosarcoma of the cervical spine presenting as a compression fracture is reported. A 69-year-old man complained of dysesthesia of both hands. A plain radiograph, computed tomography and magnetic resonance imaging of the cervical spine showed a compression fracture of the vertebral body at C7 without the formation of an obvious mass. From radiological findings, the fracture was considered to be caused by an infiltrative vertebral bone tumor. Biopsy of the tumor revealed a leiomyosarcoma, a metastatic tumor being ruled out by a systemic investigation. The patient died of pleural metastasis 6 months later, and an autopsy confirmed the primary site of the tumor as the cervical spine.

Cross-sectional area of lumbar vertebrae in peri- and postmenopausal patients with and without osteoporosis

The purpose of this study was to analyze the midvertebral area of lumbar vertebrae in osteoporotic and nonosteoporotic female patients and to find out whether the midvertebral area may be used as an additional parameter in the diagnosis of osteoporosis. In 195 peri- and postmenopausal patients (average age 51.7 +/- 5.2 years) trabecular and cortical bone mineral density (BMD) were determined using quantitative CT (QCT) in L2-4. In addition, midvertebral cross-sectional area was measured in a standardized fashion on the CT sections and the height of the second lumbar vertebra was determined on the lateral digital radiographs. Body height and weight were obtained and vertebral fracture status was determined. According to WHO criteria 29 patients (average age 57.2 years) were considered osteoporotic, 93 osteopenic (average age 52.2 years) and 73 normal (average age 48.6 years). Body weight and size did not show significant differences between the individual groups. Average midvertebral area was 1278 +/- 173 mm2 in the osteoporotic patients, 1186 +/- 125 mm2 in the osteopenic patients and 1126 +/- 127 mm2 in the normals. A correlation of r = -0.39 (p < 0.05) was obtained between BMD and area. Thirty-six of 195 patients showed osteoporotic vertebral fractures. Midvertebral area in these patients was 1266 +/- 171 mm2 versus 1159 +/- 133 mm2 in the nonfractured females (p < 0.05). We therefore conclude that the lumbar midvertebral area is larger in osteoporotic and osteopenic patients compared with women with normal BMD. In contrast to biomechanical considerations midvertebral area seems not to be suited as an additional measure of bone strength in vivo.

Repair of a multiply recurrent giant cell reparative granuloma of the hand with wide resection and fibular grafting

A patient with multiply recurrent giant cell reparative granuloma of the third metacarpal is reported. Three prior excisions failed to prevent recurrence. A wide resection and replacement with a nonvascularized fibular bone graft resulted in elimination of the tumor at the 7-year follow-up visit.

Hip fracture and bone histomorphometry in a young adult with cystic fibrosis

A 25-yr-old male with cystic fibrosis sustained a fragility fracture of the left femoral neck, which required surgical correction. He had several risk factors for the development of low bone density and despite treatment with an oral bisphosphonate, his bone mineral density reduced further. The patient died 2 yrs after sustaining the fracture. Bone specimens obtained at post mortem demonstrated severe cortical and trabecular osteopenia, but the histological features were not typical of osteoporosis or osteomalacia. Osteoporosis is thought to be a common complication of cystic fibrosis. The novel histomorphometric appearances reported here suggest that the bone disease of cystic fibrosis may be more complex and possibly unique. Labelled bone biopsies are required to clarify the bone defect leading to low bone density in cystic fibrosis patients so that appropriate therapeutic strategies can be developed.

Analysis of routine histological evaluation of tissues removed during primary hip and knee arthroplasty

BACKGROUND

It has often been hospital policy to send all resected specimens obtained during a total hip or knee arthroplasty for histological evaluation. This practice is expensive and may be unnecessary. We sought to determine the ability of surgeons to diagnose primary joint conditions correctly, and we attempted to identify any possible risks to the patient resulting from the omission of routine histological evaluation of specimens at the surgeon's discretion. Our objective was to ascertain whether routine histological evaluation could be safely omitted from the protocol for primary hip and knee arthroplasty without compromising the care of the patient.

METHODS

A total of 1388 consecutive arthroplasties in 1136 patients were identified from a database of primary total hip and knee arthroplasties that was prospectively maintained by the senior one of us. Follow-up data obtained at a mean of 5.5 years (range, two to ten years) were available after 92 percent (1273) of the 1388 arthroplasties. The preoperative diagnosis was determined from the history, findings on clinical examination, and radiographs. The intraoperative diagnosis was determined by gross inspection of joint fluid, articular cartilage, synovial tissue, and the cut surfaces of resected specimens. The combination of the preoperative and intraoperative diagnoses was considered to be the surgeon's clinical diagnosis. All resected specimens were sent for routine histological evaluation, and a pathological diagnosis was made. Attention was given to whether a discrepancy between the surgeon's clinical diagnosis and the pathological diagnosis altered the management of the patient. The original diagnoses were updated with use of annual radiographs and clinical assessments. The cost of histological examination of specimens obtained at arthroplasty was determined by consultation with hospital administration, accounting, and pathology department personnel.

RESULTS

A pathological fracture or an impending fracture was diagnosed preoperatively and confirmed intraoperatively during twelve of the 1388 arthroplasties. Histological analysis demonstrated malignancy in specimens obtained during eleven of these arthroplasties and evidence of a benign rheumatoid geode in the specimen obtained during the twelfth arthroplasty. The preoperative and intraoperative diagnoses made before and during the remaining 1376 arthroplasties were benign conditions, which were confirmed histologically in all patients. No diagnosis changed during the follow-up period. As demonstrated by a comparison with the histological diagnosis, the surgeon's clinical diagnosis of malignancy had a sensitivity of 100 percent (95 percent confidence interval, 74.0 to 100 percent), a specificity of 99.9 percent (95 percent confidence interval, 99.6 to 100 percent), a positive predictive value of 91.7 percent (95 percent confidence interval, 64.6 to 98.5 percent), and a negative predictive value of 100 percent (95 percent confidence interval, 99.7 to 100 percent). There was a discrepancy between the preoperative and intraoperative diagnoses associated with eleven arthroplasties. All eleven intraoperative diagnoses were correct, as confirmed histologically. Excluding the patients who had a pathological or impending fracture, the accuracy of the surgeon's preoperative diagnosis was 99.2 percent (95 percent confidence interval, 98.6 to 99.5 percent). When the intraoperative and preoperative diagnoses were combined, the accuracy was 100 percent (95 percent confidence interval, 99.7 to 100 percent). Histological evaluation at our hospital resulted in total charges, including hospital costs and professional fees, of $196.27 and a mean total reimbursement of $102.59 per evaluation. In our series of 1136 patients with 1388 arthroplasties, these costs could have been eliminated for all but the twelve patients who had a suspected malignant lesion and the one patient in whom pigmented villonodular synovitis was found. (ABSTRACT

Pathological fracture in non-ossifying fibroma with histological features simulating aneurysmal bone cyst

A 12-year-old-girl presented with a fracture of an osteolytic lesion of the distal radius. A 7-year-old girl presented with a fracture of an osteolytic lesion of the femoral shaft. In both cases it was a non-ossifying fibroma with fracture misdiagnosed at pathology as aneurysmal bone cyst. Fractures through non-ossifying fibromas may alter the histological pattern of the initial lesion in two ways: firstly, by the presence of blood pigments due to the fracture, and secondly, by formation of new bone. Radiological-pathological correlation is essential to avoid histological errors after pathological fracture in a non-ossifying fibroma.

[Pathological fracture of the mandible: a report of a clinical case treated with clodronate]

Oral squamous cell carcinoma often invades the mandible. However, the incidence of pathological fractures of the maxillofacial bones is low and their treatment is rarely satisfactory. A patient, too weak to undergo surgery, affected by squamous cell carcinoma of the mandibular region with bone involvement and pathological fracture of the mandible, underwent chemotherapy with carboplatin associated with diphosphonate.

Musculoskeletal manifestations of osteomalacia: report of 26 cases and literature review

OBJECTIVE

This study was undertaken to describe the musculoskeletal manifestations in a selected population of 26 patients with biopsy-proven osteomalacia (OM) and provide a literature update.

METHODS

The 26 patients with biopsy-proven OM were selected from a total number of 79 patients who underwent anterior iliac crest biopsy. The diagnosis of OM was confirmed by the presence of an osteoid volume greater than 10%, osteoid width greater than 15 microm, and delayed mineralization assessed by double-tetracycline labeling.

RESULTS

OM was caused by intestinal malabsorption in 13 patients, whereas six other patients presented with hypophosphatemia of different causes. Five elderly patients presented with hypovitaminosis D, and in two patients the OM was part of renal osteodystrophy. Twenty-three patients presented with bone pain and diffuse demineralization, whereas three other patients had normal or increased bone density. Characteristic pseudofractures were seen in only seven patients. Six of the 23 patients with diffuse demineralization had an "osteoporotic-like pattern" without pseudofractures. Prominent articular manifestations were seen in seven patients, including a rheumatoid arthritis-like picture in three, osteogenic synovitis in three, and ankylosing spondylitis-like in one. Two other patients were referred to us with the diagnosis of possible metastatic bone disease attributable to polyostotic areas of increased radio nuclide uptake caused by pseudofractures. Six patients also had proximal myopathy, two elderly patients were diagnosed as having polymalgia rheumatica, and two young patients were diagnosed as having fibromyalgia. One of the patients who presented with increased bone density was misdiagnosed as possible fluorosis.

CONCLUSION

OM is usually neglected when compared with other metabolic bone diseases and may present with a variety of clinical and radiographic manifestations mimicking other musculoskeletal disorders.

Detection of experimentally produced occult microfractures at the bone-cartilage interface in decalcified sections

We compared three histological preparation methods to detect experimentally produced occult microfractures in decalcified human patellae: a paraffin tape-transfer technique, a paraffin slab-cut method, and a paraffin method with methyl salicylate as the clearing agent. Microfractures were observed at the bone-cartilage interface and were oriented either parallel or perpendicular to the tidemark. Both types of microfractures were documented with each preparation method. The slab-cut method was time-consuming, but the section thickness allowed detailed analysis of the architecture of microcracks as they passed into the depth of the section. The methyl salicylate method was efficient and produced thin, serial sections with good morphological detail and minimal cutting artifact. Reliable histological data were also derived from the tape-transfer technique, but this method was inconsistent. The methods summarized here for processing decalcified human joint tissues provide a basis for future orthopaedic studies investigating occult microfractures at the bone-cartilage interface.

Number and type of vertebral deformities: epidemiological characteristics and relation to back pain and height loss. European Vertebral Osteoporosis Study Group

Vertebral deformity is the classical hallmark of osteoporosis. Three types of vertebral deformity are usually described: crush, wedge and biconcave deformities. However, there are few data concerning the descriptive epidemiology of the individual deformity types, and differences in their underlying pathogenesis and clinical impact remain uncertain. The aim of this study was to compare the epidemiological characteristics of the three types of vertebral deformity and to explore the relationships of the number and type of deformity with back pain and height loss. Age-stratified random samples of men and women aged 50 years and over were recruited from population registers in 30 European centers (EVOS study). Subjects were invited to attend for an interviewer-administered questionnaire and lateral spinal radiographs. The presence, type and number of vertebral deformities was determined using the McCloskey-Kanis algorithm. A total of 13,562 men and women were studied; mean age in men was 64.4 years (SD 8.5), and in women 63.8 years (SD 8.5 years). There was evidence of variation in the occurrence of wedge, crush and biconcave deformity by age, sex and vertebral level. Wedge deformities were the most frequent deformity and tended to cluster at the mid-thoracic and thoraco-lumbar regions of the spine in both men and women. Similar predilection for these sites was observed for crush and to a lesser extent biconcave deformities though this was much less marked than for wedge deformities. In both sexes the frequency of biconcave deformities was higher in the lumbar than the thoracic spine and unlike the other deformity types it did not decline in frequency at lower lumbar vertebral levels. The prevalence of all three types of vertebral deformity increased with age and was more marked in women. There were no important differences in the effect of age on the different deformity types. All types of deformity were associated with height loss, which was greatest for individuals with crush deformity. Back pain was also associated with all types of deformity. Overall, these results do not suggest important differences in pathophysiology between the three deformity types. Biomechanical factors appear to be important in determining their distribution within the spine. All deformity types are linked with adverse outcomes, though crush deformities showed greater height loss than the other deformity types.

The use of pamidronate in three children with renal disease

The successful use of pamidronate, a bisphosphonate, for the treatment of hypercalcemia and/or osteopenia is reported in three children with renal failure or following renal transplant. Patient 1 was an 11-year-old post renal transplant male who received a single dose of i.v. pamidronate (0.5 mg/kg) for the treatment of acute hypercalcemia associated with a pathological fracture and subsequent immobilization. Prompt resolution of the hypercalcemia was seen. He received a second course of pamidronate (0.5 mg/kg per day for 3 days) for the treatment of osteopenia and has had a subsequent 15% increase in lumbar spine bone mineral content (BMC). Patient 2, a 14-year-old male on peritoneal dialysis, presented with symptomatic hypercalcemia associated with tertiary hyperparathyroidism. A single dose of i.v. pamidronate (0.4 mg/kg) was given with prompt resolution and prolonged control of his hypercalcemia. The third patient was a 16-year-old female, also in renal failure on peritoneal dialysis. Her course had been complicated by marked osteopenia. I.v. pamidronate (0.5 mg/kg per dose) was given on 3 successive days before and after renal transplant in an attempt to stabilize her bone mineral density (BMD) around the time of renal transplantation, when additional glucocorticoid was necessary. Her total body BMC and BMD remained stable pre and post transplant. The treatment was effective and well tolerated in all three patients. Hence pamidronate is safe and effective for the management of hypercalcemia and osteopenia in children with renal failure and/or renal transplant.

Fluid-fluid levels in a simple bone cyst on magnetic resonance imaging

An unusual case is presented here of simple bone cyst (SBC) with fluid-fluid levels on MR and cementum-like substance on microscopy in an atypical location in the distal femur. Fluid-fluid levels are commonly described in the literature within aneurysmal bone cysts, giant cell tumour, chondroblastomas and telangiectatic osteosarcomas, but a literature review revealed only one reported case with multiple fluid levels occurring in a simple bone cyst on MRI. A cementum-like matrix is diagnostic of SBC and is seen in approximately 10% of cases.

Dual-energy X-ray absorptiometry in osteonecrosis of the femoral head

Osteonecrosis of the hip classically produces a heterogeneous density in the femoral head, although the bone marrow ischemia extends down to the femoral neck and trochanters. Also, bone insufficiency fractures due to diffuse bone loss have been implicated in the genesis of osteonecrosis.

OBJECTIVES

To use dual-energy X-ray absorptiometry to quantify the bone changes produced by osteonecrosis of the hip and to compare bone mineral density values in patients with osteonecrosis of the hip and in controls.

METHODS

Bone mineral density was measured at the femoral neck (total femoral neck, Ward's triangle, and trochanter), femoral head and lumbar spine using dual-energy X-ray absorptiometry (DPX, L Lunar) in 22 patients with osteonecrosis of the hip and in 22 age- and sex-matched controls.

RESULTS

In the patients with osteonecrosis, bone mineral density on the affected side was higher than on the opposite side at the femoral head (+18%), femoral neck (+7%), and Ward's triangle (+6%) and lower at the trochanter (-4%). These differences were most marked at the more advanced end of the osteonecrosis spectrum. As compared to age-specific normative values, the osteonecrosis patients had moderately decreased bone mineral density values at the lumbar spine (-0.53 +/- 1.1 SD or -6 +/- 1.5%) and at the femoral neck on the normal side (-0.9 +/- 1.4 SD or 12 +/- 1.8%). As compared to the controls, bone mineral density was significantly decreased at Ward's triangle (-25%; P: 0.04) and nonsignificantly decreased at the lumbar spine (-4.7%; P: 0.15) and at the femoral neck (-15%; P: 0.09).

Pathological fractures of the mandible. A review of the etiology and treatment

A retrospective study was undertaken to analyse the etiology, site and treatment procedures of 30 pathological fractures of the mandible. Fifty percent of the fractures had an inflammatory cause. The remaining cases were associated with severe atrophy of edentulous mandibles (4), benign tumours (3), cysts (3), and primary or secondary malignancies (5). Regardless of the cause, the majority of the fractures occurred in the body of the mandible. Pathological fractures of the mandible most often have to be treated by eliminating the cause of the underlying condition while immobilizing the fragments either with osteosynthesis or archbars and intermaxillary fixation.