Utility of osteon circularity for determining species and interpreting load history in primates and nonprimates.

OBJECTIVES: Histomorphological analyses of bones are used to estimate an individual's chronological age, interpret a bone's load history, and differentiate species. Among various histomorphological characteristics that can influence mechanical properties of cortical bone, secondary osteon (Haversian system) population density and predominant collagen fiber orientation are particularly important. Cross-sectional shape characteristics of secondary osteons (On.Cr = osteon circularity, On.El = osteon ellipticality) are considered helpful in these contexts, but more robust proof is needed. We sought to determine if variations in osteon shape characteristics are sufficient for accurately differentiating species, load-complexity categories, and regional habitual strain-mode distributions (e.g., tension vs. compression regions). MATERIALS AND METHODS: Circularly polarized light images were obtained from 100-micron transverse sections from diaphyses of adult deer calcanei; sheep calcanei, radii, and tibiae; equine calcanei, radii, and third metacarpals (MC3s); chimpanzee femora; and human femora and fibulae. Osteon cross-sectional area (On.Ar), On.Cr, and On.El were quantified indiscriminately and in the contexts of load-complexity and regional strain-mode distributions. RESULTS: On.Cr and On.El, when examined independently in terms of all data, or mean (nested) data, for each bone, exceeded 80% accuracy in the inter-species comparisons only with respect to distinguishing humans from nonhumans. Correct classification among the nonhuman species was <70%. When On.Cr and On.El were coupled together and with On.Ar in discriminant function analyses (nested and unnested data) there were high misclassifications in all but human vs. nonhuman comparisons. DISCUSSION: Frequent misclassifications in nonhuman comparisons might reflect influences of habitual load complexity and/or strain-mode distributions, or other factors not accounted for by these two considerations.

Failed Reverse Total Shoulder Arthroplasty Caused by Recurrent Candida glabrata Infection with Prior Serratia marcescens Coinfection.

This report describes a 58-year-old insulin-dependent diabetic male patient who initially sustained a proximal humerus fracture from a fall. The fracture fixation failed and then was converted to a humeral hemiarthroplasty, which became infected with Candida glabrata and Serratia marcescens. After these infections were believed to be cured with antibacterial and antifungal treatments and two-stage irrigation and debridement, he underwent conversion to a reverse total shoulder arthroplasty. Unfortunately, the C. glabrata infection recurred and, nearly 1.5 years after implantation of the reverse total shoulder, he had a resection arthroplasty (removal of all implants and cement). His surgical and pharmacologic treatment concluded with (1) placement of a tobramycin-impregnated cement spacer also loaded with amphotericin B, with no plan for revision arthroplasty (i.e., the spacer was chronically retained), and (2) chronic use of daily oral fluconazole. We located only three reported cases of Candida species causing infection in shoulder arthroplasties (two C. albicans, one C. parapsilosis). To our knowledge, a total shoulder arthroplasty infected with C. glabrata has not been reported, nor has a case of a C. glabrata and S. marcescens periprosthetic coinfection in any joint. In addition, it is well known that S. marcescens infections are uncommon in periprosthetic joint infections.

Histocompositional organization and toughening mechanisms in antler.

Mechanical testing studies by Krauss et al. (2009) and Gupta et al. (2013) suggest that the extraordinary toughness of antler bone is primarily achieved by intrinsic/nanostructural mechanisms instead of extrinsic/microstructural mechanisms. However, this conclusion is based on data from extremely small specimens from one antler loaded only in tension, which impedes discernment of the relative importance of intrinsic vs. extrinsic mechanisms. In the present study we conducted analyses into the microstructural features of antler for details of potential additional microscale toughening characteristics, as suggested by recent mechanical testing studies of bulk specimens. The data are also considered in view of the above-mentioned studies concluding that extrinsic/microstructural toughening mechanisms are less important than nanoscale/intrinsic toughening mechanisms in antler. Mule deer antlers were evaluated using: (1) backscattered electron imaging for micro-mineralization, (2) circularly polarized light for osteonal interfacial complexity and collagen fiber orientation (CFO) heterogeneity, and (3) X-ray 3D micro-computed tomography for osteon/vessel orientation, density, and size. Results showed: (1) hyper-mineralized seams of approximately 3-4 microns thickness within relatively hypermineralized "zones" that course circuitously along osteonal interfaces, (2) highly heterogeneous CFO, including increased oblique-to-transverse CFO near/adjacent to osteon peripheries, and (3) osteons are often highly elongated in 2D. 3D reconstructions show that a considerable percentage of the vascular canals course obliquely with respect to the antler long axis. While results show multiple possible extrinsic-level histological characteristics in antler bone, it remains to be determined if microstructural characteristics become subsidiary to nanostructural characteristics in enhancing toughness during the majority of post-yield behavior of antler bone when loaded in a biologically relevant fashion.

Candida glabrata olecranon bursitis treated with bursectomy and intravenous caspofungin.

Orthopedic surgeons are becoming more involved in the care of patients with septic arthritis and bursitis caused by yeast species. This case report involves a middle-aged immunocompromised female who developed a Candida glabrata septic olecranon bursitis that developed after she received a corticosteroid injection in the olecranon bursa for presumed aseptic bursitis. Candida (Torulopsis) glabrata is the second most frequently isolated Candida species from the bloodstream in the United States. Increased use of fluconazole and other azole antifungal agents as a prophylactic treatment for recurrent Candida albicans infections in immunocompromised individuals is one reason why there appears to be increased resistance of C. glabrata and other nonalbicans Candida (NAC) species to fluconazole. In this patient, this infection was treated with surgery (bursectomy) and intravenous caspofungin, an echinocandin. This rare infectious etiology coupled with this intravenous antifungal treatment makes this case novel among cases of olecranon bursitis caused by yeasts.

Secondary osteon size and collagen/lamellar organization ("osteon morphotypes") are not coupled, but potentially adapt independently for local strain mode or magnitude.

In bone, matrix slippage that occurs at cement lines of secondary osteons during loading is an important toughening mechanism. Toughness can also be enhanced by modifications in osteon cross-sectional size (diameter) for specific load environments; for example, smaller osteons in more highly strained "compression" regions vs. larger osteons in less strained "tension" regions. Additional osteon characteristics that enhance toughness are distinctive variations in collagen/lamellar organization (i.e., "osteon morphotypes"). Interactions might exist between osteon diameter and morphotype that represent adaptations for resisting deleterious shear stresses that occur at the cement line. This may be why osteons often have a peripheral ring (or "hoop") of highly oblique/transverse collagen. We hypothesized that well developed/distinct "hoops" are compensatory adaptations in cases where increased osteon diameter is mechanically advantageous (e.g., larger osteons in "tension" regions would have well developed/distinct "hoops" in order to resist deleterious consequences of co-existing localized shear stresses). We tested this hypothesis by determining if there are correlations between osteon diameters and strongly hooped morphotypes in "tension", "compression", and "neutral axis" regions of femora (chimpanzees, humans), radii (horse, sheep) and calcanei (horse, deer). The results reject the hypothesis-larger osteons are not associated with well developed/distinct "hoops", even in "tension regions" where the effect was expected to be obvious. Although osteon diameter and morphotype are not coupled, osteon diameters seem to be associated with increased strain magnitudes in some cases, but this is inconsistent. By contrast, osteon morphotypes are more strongly correlated with the distribution of tension and compression.

A patient with clavicle fracture and recurrent scapular winging with spontaneous resolutions.

Injury to the long thoracic nerve with resulting serratus anterior palsy is a typical cause of medial scapular winging. We report a case of a 70-year-old female with scapular winging in the setting of a mildly comminuted midshaft clavicle fracture. The winging persisted for three months after the fracture, which became a nonunion. The winging spontaneously resolved prior to open reduction and internal fixation of the nonunion. The winging recurred after this surgery. The recurrence was attributed to transient irritation and/or inflammatory neuropathy of the brachial plexus caused by the surgical manipulation. This second episode of winging again spontaneously resolved. There are few reported cases of scapular winging in the setting of a clavicle fracture and only one case of recurrent scapular winging. In that case, which was in the setting of an acromioclavicular joint separation, the second episode of winging required long-term use of a brace. By contrast, our patient did not require bracing because the recurrent winging spontaneously resolved, making this a novel case. This case is important because it illustrates that recurrent scapular winging can occur, and spontaneously resolve, in the setting of a mid-shaft clavicle fracture after subsequent reconstruction of a fracture nonunion.

Analysis of osteon morphotype scoring schemes for interpreting load history: evaluation in the chimpanzee femur.

Osteon morphotype scores (MTSs) allow for quantification of mechanically important collagen/lamellar variations between secondary osteons when viewed in circularly polarized ight (CPL). We recently modified the 6-point MTS method of Martin et al. (Martin RB, Gibson VA, Stover SM, Gibeling JC, Griffin LV (1996a) Osteonal structure in the equine third metacarpus. Bone 19, 165-71) and reported superiority of this modified method in correlating with 'tension' and 'compression' cortices of both chimpanzee proximal femoral diaphyses and diaphyses of other non-anthropoid bones that are loaded in habitual bending (Skedros et al. 2009, 2011). In these studies, the 'tension' and 'compression' cortices differed significantly in predominant collagen fiber orientation (CFO) based on weighted-mean gray levels (CFO/WMGLs) in CPL images. In chimpanzee femora, however, some osteons were difficult to score with the 6-point method; namely, 'hybrids' with peripherally bright 'hoops' and variability in alternating rings within the osteon wall. We hypothesized that some of these hybrids would be more prevalent in regions subject to torsion than bending. In this perspective the present study was aimed at expanding our 6-point scoring method (S-6-MTS) into two 12-point methods with six additional morphotypes that considered these hybrids. Three- and 4-point methods were also evaluated. We hypothesized that at least one of these other methods would out-perform the S-6-MTS in terms of accuracy, reliability, and interpreting torsion vs. bending load histories. Osteon morphotypes were quantified in CPL images from transverse sections of eight adult chimpanzee femora (neck, proximal diaphysis, mid-diaphysis), where the mid-diaphysis and base- and mid-neck locations have relatively more complex loading (e.g. torsion + bending) than the proximal diaphysis, where bending predominates. Correlation coefficients between CFO/WMGL and MTSs showed that the S-6-MTS method was either stronger or equivalent to the 12-point methods, and typically stronger than the 3- and 4-point methods for all load environments. In nearly all instances the S-6-MTS is more reliable and accurate when it is applied to cases where interpreting load history requires distinguishing habitual bending from torsion. Consequently, in studies of osteonal adaptations for these load histories the 3- and 4-point methods are not stronger correlates, and the extra time required to assign additional scores in the 12-point methods is both unnecessary and can be highly unreliable.