Quantifying cortical bone in fragmentary archeological second metacarpals.

OBJECTIVES: Skeletal variation in cortical bone thickness is an indicator of bone quality and health in archeological populations. Second metacarpal radiogrammetry, which measures cortical thickness at the shaft midpoint, is traditionally used to evaluate bone loss in bioarcheological and some clinical contexts. However fragmentary elements are regularly omitted because the midpoint cannot be determined. This methodological limitation reduces sample sizes and biases them against individuals prone to fracture, such as older individuals with low bone mass. This study introduces a new technique for measuring cortical bone in second metacarpals, the "Region of Interest" (ROI) method, which quantifies bone in archeological remains with less-than-ideal preservation while accounting for cortical heterogeneity. MATERIALS AND METHODS: The ROI method was adapted from digital X-ray radiogrammetry (DXR), a clinical method used to estimate bone mineral density, and tested using second metacarpals from Middenbeemster, Netherlands, a 19th century known age and sex skeletal collection. The ROI method quantifies cortical bone area within a 1.9 cm-long, mid-diaphyseal region, standardized for body size differences using total area (CAIROI ). CAIROI values were compared to traditional radiogrammetric cortical indices (CI) to assess the method's ability to identify age-related bone loss. RESULTS: CAIROI values have high intra- and interobserver replicability and are strongly and significantly correlated with CI values for both males (r[n = 39] = 0.906, p = 0.000) and females (r[n = 58] = 0.925, p = 0.000). CONCLUSION: The ROI method complements traditional radiogrammetry analyses and provides a reliable way to quantify cortical bone in incomplete second metacarpals, thereby maximizing sample sizes, allowing patterns in bone acquisition and loss to be more comprehensively depicted in archeological assemblages.

Maintaining mobility after fracture: A biomechanical analysis of fracture consequences at the Roman Sites of Ancaster (UK) and Vagnari (Italy).

OBJECTIVE: This study uses biomechanical data from tibiae to investigate the functional consequences of lower limb fractures. Adults with malunited fractures are hypothesized to have experienced altered mobility, indicated by asymmetric tibial cross-sectional geometries (CSG). MATERIALS: Ninety-three adults from Roman (1st to 4th centuries CE) Ancaster, UK and Vagnari, Italy (Ancaster n = 16 adults with lower limb fracture:53 without fracture; Vagnari n = 5:19) METHODS: Biplanar radiographs were used to quantify and compare tibial CSG properties and asymmetries between individuals with and without fractures to femora, tibiae, and/or fibulae. The amount of angulation, rotation, and overlap, indicative of linear deformity, were measured for each fracture. Individuals who loaded their fractured leg differently than their opposite, uninjured leg were identified using outlying amounts of CSG asymmetry. RESULTS: Two Ancaster individuals had poorly aligned fractures. None of the Ancaster or Vagnari individuals with lower limb fractures had CSG properties or asymmetries outside the calculated normal ranges. CONCLUSIONS: Regardless of how a fracture healed, individuals at Ancaster and Vagnari generally resumed mobility after trauma whenever possible. SIGNIFICANCE: This research contributes information about injury recovery and suggests that resilient behaviors and persistent mobility may have been valued or required responses to fracture in the study communities. This work advises that impairment should not be inferred based solely on the appearance of lesions. LIMITATIONS: Site, sex, and age patterns in injury recovery are not evaluated due to sample size limitations. SUGGESTIONS FOR FURTHER RESEARCH: Biomechanical assessments of post-traumatic function in varied cultural contexts are advised in order to further characterize the impact that physical and social factors have on injury recovery.

Chronology of the Radiographic Appearances of the Calcium Sulfate-Calcium Phosphate Synthetic Bone Graft Composite Following Resection of Bone Tumors: A Follow-up Study of Postoperative Appearances.

PURPOSE: The objective of the study was to characterize the radiographic appearance of graft resorption and new bone incorporation into a postresection defect of the calcium-sulfate calcium-phosphate synthetic bone graft composite following resection of benign bone tumours. METHODS: Twenty-five patients who underwent treatment with the CaSO4/CaPO4 synthetic graft following bone tumour resection were retrospectively identified from our oncology database. Postoperative radiographs were assessed for: 1) combined partial graft resorption and ingrowth at the graft site; 2) complete graft resorption with complete incorporation of new bone into the defect. After chronologically grouping radiographs, the volume of graft material used to fill bony defects, radiographic evidence of complications, and patterns of resorption were recorded. RESULTS: Partial resorption of graft material/partial ingrowth of new bone was seen in 21 patients at 2.5 months postoperatively. Complete resorption of graft with complete new bone incorporation at the graft site was seen in 94% of cases (15 of 16) by 10 months after surgery. Mean time to complete incorporation of new bone was 6.7 months. Time to resorption of the graft with new bone ingrowth was found to be related to the volume of graft used with smaller volumes showing earlier resorption. For all cases demonstrating resorption (21 of 21), the pattern observed was peripheral to central. Five patients developed complications, including tumour recurrence, cyst formation, and graft site infection. CONCLUSION: Our study suggests a characteristic time and volume related radiographic pattern of resorption and new bone ingrowth with the CaSO4/CaPO4 synthetic graft. Findings that deviate from this pattern may represent complication and warrant additional follow-up.

A double-blind, randomized controlled trial to compare the effect of biannual peripheral magnetic resonance imaging, radiography and standard of care disease progression monitoring on pharmacotherapeutic escalation in rheumatoid and undifferentiated inflammatory arthritis: study protocol for a randomized controlled trial.

BACKGROUND: Permanent joint damage is a major consequence of rheumatoid arthritis (RA), the most common and destructive form of inflammatory arthritis. In aggressive disease, joint damage can occur within 6 months from symptom onset. Early, intensive treatment with conventional and biologic disease-modifying anti-rheumatic drugs (DMARDs) can delay the onset and progression of joint damage. The primary objective of the study is to investigate the value of magnetic resonance imaging (MRI) or radiography (X-ray) over standard of care as tools to guide DMARD treatment decision-making by rheumatologists for the care of RA. METHODS: A double-blind, randomized controlled trial has been designed. Rheumatoid and undifferentiated inflammatory arthritis patients will undergo an MRI and X-ray assessment every 6 months. Baseline adaptive randomization will be used to allocate participants to MRI, X-ray, or sham-intervention groups on a background of standard of care. Prognostic markers, treating physician, and baseline DMARD therapy will be used as intervention allocation parameters. The outcome measures in rheumatology RA MRI score and the van der Heijde-modified Sharp score will be used to evaluate the MRI and X-ray images, respectively. Radiologists will score anonymized images for all patients regardless of intervention allocation. Disease progression will be determined based on the study-specific, inter-rater smallest detectable difference. Allocation-dependent, intervention-concealed reports of positive or negative disease progression will be reported to the treating rheumatologist. Negative reports will be delivered for the sham-intervention group. Study-based radiology clinical reports will be provided to the treating rheumatologists for extra-study X-ray requisitions to limit patient radiation exposure as part of diagnostic imaging standard of care. DMARD treatment dose escalation and therapy changes will be measured to evaluate the primary objective. A sample size of 186 (62 per group) patients will be required to determine a 36% difference in pharmacological treatment escalation between the three groups with intermediate dispersion of data with 90% power at a 5% level of significance. DISCUSSION: This study will determine if monitoring RA and undifferentiated inflammatory arthritis patients using MRI and X-ray every 6 months over 2 years provides incremental evidence over standard of care to influence pharmacotherapeutic decision-making and ultimately hinder disease progression. TRIAL REGISTRATION: This trial has been registered at ClinicalTrials.gov: NCT00808496 (registered on 12 December 2008).

Use of a calcium sulfate-calcium phosphate synthetic bone graft composite in the surgical management of primary bone tumors.

Benign primary bone tumors are commonly treated with intralesional curettage with or without the use of surgical adjuvants. The reconstructive approach to the resulting contained bone defects is controversial, and clinical practice is varied. Synthetic bone substitutes may provide early mechanical support while minimizing the risks of disease transmission, nonunion, infection, and donor-site morbidity. Limited data exists regarding the use of calcium sulfate-calcium phosphate composite bone substitute for this purpose. The authors retrospectively reviewed the clinical outcomes of 24 patients with benign primary bone tumors who underwent intralesional curettage followed by reconstruction with a calcium sulfate-calcium phosphate composite bone substitute. Mean follow-up was 23 months. The most common diagnosis was giant cell tumor of bone. Six patients had upper-extremity tumors and 18 had lower-extremity tumors. Mean preoperative radiographic tumor volume was 41.0 cm(3). Mean volume of PRO-DENSE (Wright Medical Technology, Arlington, Tennessee) used in each patient was 15.6 cm(3). Mean time to full weight bearing for all patients was 7.3 weeks. Two patients sustained local tumor recurrences. No postoperative fractures occurred, and no complications occurred related to the use of the calcium sulfate-calcium phosphate composite. One case of deep infection occurred secondary to wound breakdown. The use of a calcium sulfate-calcium phosphate composite was associated with rapid biological integration and an early return to activities of daily living, with no composite-related complications. This technique is a viable option in the reconstruction of cavitary bone defects following intralesional curettage of primary benign bone tumors.

Chronology of the radiographic appearances of the calcium sulphate-calcium phosphate synthetic bone graft composite following resection of bone tumours--a preliminary study of the normal post-operative appearances.

OBJECTIVE: To describe the normal chronological radiographic appearances of the calcium sulphate-calcium phosphate (CaSO(4)/CaPO(4)) synthetic graft material following bone tumour resection during the processes of graft resorption and new bone incorporation into the post-resection defect. MATERIALS AND METHODS: Retrospective review of our oncology database identified patients who had undergone serial radiographic assessment after treatment with the CaSO(4)/CaPO(4) synthetic graft following bone tumour resection. Post-operative radiographs were assessed for (1) partial resorption of graft material with partial ingrowth of new bone at the graft site and (2) complete resorption of graft material with complete incorporation of new bone into the graft site. The pattern of resorption of graft material was also documented. Any radiographic evidence of complication was recorded. Radiographs were also divided into groups according to their interval from surgery to establish a pattern of time-related changes. RESULTS: A total of 11 patients were identified from our database. Partial resorption of graft material/partial ingrowth of new bone was seen in nine patients, initially observed at a mean of 1.4 months from surgery. Resorption commenced peripherally with gradual inward progression in 100% (9 of 9) of cases. Complete resorption of graft/complete new bone incorporation at the graft site was seen in 89% (8 of 9) of cases followed up for more than 5 months after surgery. The other patient developed recurrence of tumour at 14 months, before complete incorporation was demonstrated. The mean time to complete incorporation of new bone was 5 months. Two patients have, to date, been followed up at 2 and 3 months respectively with a pattern of peripheral graft resorption observed so far in both cases. Ten of 13 (77%) radiographs performed 1-3 months after surgery demonstrated peripheral resorption of graft material with partial osseous ingrowth into the defect. Seven of eight (88%) radiographs performed 6-12 months after surgery demonstrated complete new bone incorporation at the graft site with graft material completely resorbed. Ten of 11 (91%) radiographs performed 1 year after surgery demonstrated complete new bone incorporation, the other examination demonstrating recurrence. CONCLUSION: Our preliminary observations suggest a characteristic, time-related radiographic pattern during the processes of CaSO(4)/CaPO(4) bone graft resorption and complete new bone incorporation. This pattern can be directly related to processes that occur at the molecular level. Radiographic findings that are not in keeping with this may merit closer follow-up.

Ultrasound of wrist pain.

Ultrasound is a valuable imaging modality for evaluation of patients presenting with wrist pain. An important advantage is the ability to correlate the site of pain or discomfort with the underlying sonographic appearance. The capacity to dynamically assess the wrist and use the contralateral asymptomatic wrist for comparison purposes are strengths of ultrasound as a diagnostic tool. This pictorial review deals with the sonographic assessment of the commonly encountered wrist pathologies.

Sonography of the superomedial part of the spring ligament complex of the foot: a study of cadavers and asymptomatic volunteers.

OBJECTIVE: To evaluate the ability of high-resolution sonography for assessing the thickness and echogenicity of the superomedial part of the normal spring ligament in the foot in cadavers and asymptomatic volunteers. MATERIALS AND METHODS: The superomedial part of the normal spring ligament of four cadaveric feet was imaged with a high-resolution linear array transducer. Upon localization, the ligament was injected with 0.1% methylene blue with sonographic guidance. A posteromedial approach was used to dissect the feet immediately following injection to confirm accurate identification of the ligament. The bilateral ligaments in 40 asymptomatic adult volunteers were subsequently imaged. RESULTS: Surgical dissection confirmed the accurate injection of methylene blue into all four cadaveric ligaments. The superomedial part of the normal spring ligament was identified bilaterally in all of the 40 asymptomatic volunteers, with a mean thickness of 3 mm in longitudinal short axes. The ligament was echogenic relative to surrounding fat, and it was thinner in women. Differences in ligament measurements with respect to age, sex, side (left vs. right) and foot dominance were not significant. The volunteers' height, weight and body mass index had a weakly positive correlation with ligament thickness. CONCLUSION: High-resolution ultrasound can be used to identify and measure the thickness of the superomedial part of the normal spring ligament. The provided baseline measurements for the normal ligament could prove valuable when assessing the abnormal ligament.