Radiographic evaluation of the forelimb bone development in maned wolves (Chrysocyon brachyurus).

This study aimed to assess the fusion of growth plates and the development of secondary ossification centres in the forelimb bones of maned wolves (Chrysocyon brachyurus), contrasting the findings with established data from domestic dogs. Three maned wolves, comprising one male and two females, initially aged between 3 and 4 months, were subjected to monthly radiographic evaluations until 10-11 months of age, followed by bimonthly assessments until 18-19 months of age, encompassing both forelimbs. The closure times of growth plates were observed as follows: supraglenoid tubercle (7-8 months), proximal humerus (17-19 months), distal humerus (8-9 months), medial epicondyle of the humerus (8-9 months), proximal ulna (9-10 months), proximal radius (13-15 months), distal ulna (13-15 months) and distal radius (17-19 months). Statistical analysis revealed significant differences in the areas of secondary ossification centres in the proximal epiphyses of the humerus and radius, respectively, observed from the initial evaluation at 8-9 months and 6-7 months. Conversely, the epiphyses of the supraglenoid tubercle, distal humerus, proximal ulna, distal ulna, medial epicondyle of the humerus and distal radius did not exhibit significant area differences between 3-4 months and 4-5 months, yet notable distinctions emerged at 5-6 months. In summary, while the radiographic appearance of epiphyseal growth plates and secondary ossification centres in maned wolves resembles that of domestic dogs, closure times vary. These findings contribute to understanding the dynamics of epiphyseal growth plates in this species.

Case report: Slipped capital femoral epiphysis: a rare adverse event associated with FGFR tyrosine kinase inhibitor therapy in a child.

We report a case of slipped capital femoral epiphysis (SCFE), an on target skeletal toxicity of a pan-FGFR TKI inhibitor, erdafitinib. A 13-year-old boy was diagnosed to have an optic pathway/hypothalamic glioma with signs of increased intracranial pressure and obstructive hydrocephalus requiring placement of ventriculo-peritoneal (VP) shunt. Sequencing of the tumor showed FGFR1-tyrosine kinase domain internal tandem duplication (FGFR1-KD-ITD). He developed hypothalamic obesity with rapid weight gain and BMI >30. At 12 weeks of treatment with erdafitinib, he developed persistent knee pain. X-ray of the right hip showed SCFE. Erdafitinib was discontinued, and he underwent surgical pinning of the right hip. MRI at discontinuation of erdafitinib showed a 30% decrease in the size of the tumor, which has remained stable at 6 months follow-up. Our experience and literature review suggest that pediatric patients who are treated with pan-FGFR TKIs should be regularly monitored for skeletal side effects.

Analysis of risk factors for difficult implant removal in children with slipped capital femoral epiphysis treated by cannulated screws.

Introduction: Cannulated screws are widely used in the treatment of slipped capital femoral epiphysis, which can be removed after physeal closure on patient's request. This study aimed to analysis the potential risk factors for difficult removal in children with slipped capital femoral epiphysis treated by cannulated screws. Patients and methods: This study enrolled 32 hips that had undergone removal of cannulated screws after treatment of slipped capital femoral epiphysis at our department. The primary outcomes were the difficult screw removal. The secondary outcomes were functional outcome assessed by using a modified Harris Hip Score and complications of fractures and surgical site infection. Related risk factors for difficult removal were recorded and analyzed by multivariable logistic regression. Results: In total, 32 hips were evaluated, with a mean age of 14.9 ± 1.3 years old (range, 13-19 years). Six (18.8%) hips presented with difficult removal, including 4 cases of screws' slip and 2 breakages. The average implantation time in the difficult removal group (5.7 ± 1.0) was also significantly longer than that in the easily removed group (3.8 ± 0.9, p = 0.001). The mean surgical time in patients with difficult removal was 66.3 ± 11.6 min, which was also significantly longer than that (54.8 ± 8.3) in the other patients (p = 0.008). The duration of screw implantation was an independent risk factor for difficult removal. Conclusions: Prolonged screw duration was a predictor for difficult removal in children with slipped capital femoral epiphysis treated by cannulated screws. An early surgery after physeal closure might benefit those with a request for screw removal.

Management of Chondroblastoma in Pediatric Patients: 21 Years of Single-Center Experience.

BACKGROUND: Chondroblastoma (CB), a rare benign bone tumor that produces chondrocytes, often develops in the epiphysis or apophysis of children and young adults. The treatment of these rare tumors is complex. The standard treatment protocol involves curettage with local adjuvants and bone graft or cement application. The authors examined 38 CBs to determine risk factors for local recurrence, complications, and functional outcomes following epiphyseal curettage. METHODS: Twenty-two girls and sixteen boys aged 10 to 17 years with histologically confirmed chondroblastoma who arrived at our hospital between January 2000 and June 2021 were reviewed retrospectively. Clinical data, radiographic images, histological results, treatment, functional outcomes, and the local recurrence rate were examined-surgical treatment involved total tumor curettage, followed by bone grafting and adjuvant techniques. Local recurrences have also been reported. RESULTS: The most frequently affected site was the proximal femur. Sites of involvement included the proximal femur in 10 (26.3%) cases, the proximal tibia in 8 (20.8%), the humerus in 5 cases (13.2%), the distal tibia in 4 cases (10.5%), the distal femur in 3 cases (7.9%), the supracetabular region in 3 cases (7.9%), the talus in 1 case (2.6%), the calcaneus in 1 case (2.6%), the scapula in 1 case (2.6%), the lumbar spine in 1 case (2.6%), and the iliac bone in 1 (2.6%) patient. The mean follow-up was 144.2 months (24 to 276). The local recurrence rate was 7.9%. The mean Musculoskeletal Tumor Society (MSTS) score was 28.3 points (17 to 30). The mean duration of symptoms at presentation was 5.8 (range, 1 to 28) months. CONCLUSION: Aggressive curettage and bone grafting resulted in local control and good outcomes in most pediatric patients. In a relatively small proportion of cases, long-term complications and recurrence can occur due to growth plate damage and late diagnosis. In patients admitted to the pediatric clinic with pain, which is often accompanied by localized edema and joint effusion, early detection via advanced radiological scans (X-ray, CT, or MRI) may prevent delays in diagnosis.

Does spinopelvic alignment affect femoral head cartilage and the proximal femoral physis in slipped capital femoral epiphysis? A finite element analysis.

BACKGROUND: Slipped capital femoral epiphysis is a prevalent pediatric hip disorder. Recent studies suggest the spine's sagittal profile may influence the proximal femoral growth plate's slippage, an aspect not extensively explored. This study utilizes finite element analysis to investigate how various spinopelvic alignments affect shear stress and growth plate slip. METHODS: A finite element model was developed from CT scans of a healthy adult male lumbar spine, pelvis, and femurs. The model was subjected to various sagittal alignments through reorientation. Simulations of two-leg stance, one-leg stance, walking heel strike, ascending stairs heel strike, and descending stairs heel strike were conducted. Parameters measured included hip joint contact area, stress, and maximum growth plate Tresca (shear) stress. FINDINGS: Posterior pelvic tilt cases indicated larger shear stresses compared to the anterior pelvic tilt variants except in two leg stance. Two leg stance resulted in decreases in the posterior tilted pelvi variants hip contact and growth plate Tresca stress compared to anterior tilted pelvi, however a combination of posterior pelvic tilt and high pelvic incidence indicated larger shear stresses on the growth plate. One leg stance and heal strike resulted in higher shear stress on the growth plate in posterior pelvic tilt variants compared to anterior pelvic tilt, with a combination of posterior pelvic tilt and high pelvic incidence resulting in the largest shear. INTERPRETATION: Our findings suggest that posterior pelvic tilt and high pelvic incidence may lead to increased shear stress at the growth plate. Activities performed in patients with these alignments may predispose to biomechanical loading that shears the growth plate, potentially leading to slip.

Combined Electromagnetic and Electrohydraulic Focused ESWT and EMTT for Delayed Calcaneal Union in an Adolescent Parkour Athlete - A Case Report.

This case report describes a novel and unique combination of both electromagnetic and electrohydraulic focused extracorporeal shockwave therapy (ESWT) and extracorporeal magnetotransduction therapy (EMTT) for accelerated healing in a calcaneus epiphyseal fracture with delayed healing in an adolescent Parkour athlete. After a 2.5m jump, the 14-year-old experienced significant heel pain, however avoided telling his parents. After eight weeks, the initial imaging using ultra low dose weight-bearing cone beam CT (WBCT) revealed a calcaneus non-union situation adjacent to the open calcaneal physis. To improve and accelerate bony healing substantially, we chose to apply both combined focused electromagnetic (Storz Ultra, Storz Medical AG, Tägerwillen, CH) and focused electrohydraulic (MTS, Konstanz, Germany) ESWT in a fractioned fashion plus EMTT (Storz Magnetolith, Tägerwillen, CH) in five consecutive weekly sessions while allowing the patient to fully weight bear. The follow-up WBCT after six weeks revealed a near to total healing of the delayed union and being pain-free. Notably, combination therapy with focused ESWT and EMTT did not result in early closure of the calcaneal epiphysis. We conclude that combined focused electromagnetic and electrohydraulic ESWT and EMTT facilitate bony healing in adolescent calcaneal apophyseal fractures without any adverse effects on the open physis. Evidence level IV (case report).

Bone Age Determination of Epiphyseal Fusion at Knee Joint and Its Correlation with Chronological Age.

Background and Objectives: Bone age determination is a valuable method for forensic and disaster identifications of unknown human remains, as well as for medical and surgical procedural purposes. This retrospective research study aimed to determine the age based on epiphyseal fusion stages and investigate differences related to gender. Materials and Methods: X-rays of the knee were collected from medical imaging centers in hospitals in the south of Jordan and examined by two observers who determined the bone epiphyseal phase of closure for the femur, tibia, and fibula bone ends close to the knee based on a three-stage classification. Results: The main results revealed that females showed earlier epiphyseal union (Stage II) at the lower end of the femur and the upper ends of the tibia and fibula compared to males. In males, the start of complete union (Stage III) at knee bones was seen at the age of 17-18 years, while in females, it was seen at the age of 16-17 years. Additionally, knee bones showed complete union in 100% of males and females in the age groups 21-22 years and 20-21 years, respectively. Although females showed an earlier start and end of epiphyseal complete union than males, analysis of collected data showed no significant age differences between males and females at the three stages of epiphyseal union of the knee bones. Conclusions: Findings of the radiographic analysis of bone epiphyseal fusion at the knee joint are a helpful method for chronological age determination. This study supports the gender and ethnicity variation among different geographical locations. Studies with a high sample number would be needed to validate our findings.

Terminology of the growing bone: A historical study.

Division of the growing long bone into individual basic parts, that is, diaphysis, metaphysis, physes and epiphyses, has become generally accepted and used. However, the origin of these terms is almost unknown. Therefore, we have analyzed the literature in order to identify their sources. The terms epiphysis and apophysis have been used since the time of Hippokrates, although with different meanings. During the time of Galen, the term apophysis was used to describe all types of bone processes, and epiphyses denoted articular ends. The term diaphysis denoting the middle cylindrical part of the long bone was used for the first time by Heister in 1717. The first to use the term metaphysis was Theodor Kocher in his books on gunshot wounds and on bone inflammation of 1895. On the basis of Kocher's study, Lexer published a radiological study of the vascular supply to bones in which he defined metaphyseal blood vessels as a separate group supplying a particular part of the long bone. The epiphyseal growth plate had no particular name from the time of its first description in 1836. During the second half of 19th century, this structure acquired different names. The term "physis" was therefore introduced in 1964 by the American radiologist Rubin in order to label the growth structure between metaphysis and epiphysis clearly. One year later, the term physis also appeared in the radiological literature, and during the following decades it spread in the orthopedic literature.

Static Plantar Pressure under Different Conditions in Children with Surgically Treated Unilateral Slipped Capital Femoral Epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is the most common hip disease during infancy and adolescence. Our study aimed to analyze static plantar pressure in children with surgically treated unilateral SCFE. METHODS: Twenty-two children with right SCFE with in situ fixation with one percutaneous screw were assessed by PoData plantar pressure analysis under three different conditions (open eyes, eyes closed, and head retroflexed). RESULTS: The total foot loading was significantly higher on the unaffected limb compared with the affected one for all the three testing conditions (p < 0.05). When assessing the differences between testing conditions, there were no significant differences for the right and left foot loadings, or for the three sites of weight distribution, except for the right fifth metatarsal head (lower loading in eyes-closed condition in comparison to eyes open, p = 0.0068), left fifth metatarsal head (increased loading in head-retroflexed condition in comparison to eyes open, p = 0.0209), and left heel (lower loading in head-retroflexed condition in comparison to eyes open, p = 0.0293). CONCLUSION: Even after a successful surgical procedure, differences in foot loading can impact the postural static activities in different conditions (natural eyes-open, eyes-closed, or head-retroflexed posture).

Displaced Distal Fibular Epiphysis in a Child: A Clinical and Radiological Evaluation of a Rare Injury Hidden From the Initial Radiological Examination.

Fractures of the lateral malleolus are common in children. Isolated lesions of the distal fibula physis commonly comprise nondisplaced or minimally displaced fractures. An isolated, completely displaced epiphysiolisthesis of the distal fibula is an extremely rare lesion. This study introduces the case of an 11-year-old boy presenting an extremely rare lesion of an isolated, completely displaced distal fibular epiphysis that was difficult to diagnose on X-ray. Initial radiographic examination of the injured ankle showed normal configuration of the tibia and fibula on AP projection, with soft tissue swelling of the lateral malleolus. On the lateral projection, the talus completely covered the distal fibular epiphysis, and particular attention was required to reveal the complete displacement of the distal fibular epiphysis. A CT scan confirmed the diagnosis of an isolated, completely displaced distal fibular epiphysiolisthesis. The patient was treated with a closed reduction and made an uneventful recovery. This report highlights the importance of accurate clinical and radiological assessment of an isolated, completely displaced, distal fibular epiphysiolisthesis.

Delayed slipped capital femoral epiphysis after orif for subtrochanteric femur fracture.

INTRODUCTION AND IMPORTANCE: Slipped capital femoral epiphysis (SCFE) is a common phenomenon of the proximal femur in adolescents with an unclear etiology. It is more common in boys than girls and there does seem to be some predilection to race, weight, and age (Lehmann et al., 2006 [7]). CASE PRESENTATION: We reported a 13-year-old boy who presented with unilateral SCFE following subtrochanteric left femur fracture, which was fixed by blade plate 6 monthes before the SCFE. The SCFE fixed by two cannulated screw. We aim to discuss the possible link between the surgical technique used for proximal femur fractures and the delayed onset of SCFE. CLINICAL DISCUSSION: Slipped capital femoral epiphysis (SCFE) after treatment of subtrochanteric fracture can be caused by inadequate treatment of the fracture. Orthopedic surgeons should be aware of this complication so that they can promptly recognize this complication and treat it urgently (Chinoy et al., 2020). CONCLUSION: Slipped capital femoral epiphysis (SCFE) after treatment of subtrochanteric fracture is a very rare condition, that it can be prevented by proper reduction and fixation of the fracture using appropriate osteosynthesis material.

MR-based Bony 3D models enable radiation-free preoperative patient-specific analysis and 3D printing for SCFE patients.

Objectives: Slipped capital femoral epiphyses (SCFE) is a common pediatric hip disease with the risk of osteoarthritis and impingement deformities, and 3D models could be useful for patient-specific analysis. Therefore, magnetic resonance imaging (MRI) bone segmentation and feasibility of 3D printing and of 3D ROM simulation using MRI-based 3D models were investigated. Methods: A retrospective study involving 22 symptomatic patients (22 hips) with SCFE was performed. All patients underwent preoperative hip MR with pelvic coronal high-resolution images (T1 images). Slice thickness was 0.8-1.2 mm. Mean age was 12 ± 2 years (59% male patients). All patients underwent surgical treatment. Semi-automatic MRI-based bone segmentation with manual corrections and 3D printing of plastic 3D models was performed. Virtual 3D models were tested for computer-assisted 3D ROM simulation of patients with knee images and were compared to asymptomatic contralateral hips with unilateral SCFE (15 hips, control group). Results: MRI-based bone segmentation was feasible (all patients, 100%, in 4.5 h, mean 272 ± 52 min). Three-dimensional printing of plastic 3D models was feasible (all patients, 100%) and was considered helpful for deformity analysis by the treating surgeons for severe and moderate SCFE. Three-dimensional ROM simulation showed significantly (p < 0.001) decreased flexion (48 ± 40°) and IR in 90° of flexion (-14 ± 21°, IRF-90°) for severe SCFE patients with MRI compared to control group (122 ± 9° and 36 ± 11°). Slip angle improved significantly (p < 0.001) from preoperative 54 ± 15° to postoperative 4 ± 2°. Conclusion: MRI-based 3D models were feasible for SCFE patients. Three-dimensional models could be useful for severe SCFE patients for preoperative 3D printing and deformity analysis and for ROM simulation. This could aid for patient-specific diagnosis, treatment decisions, and preoperative planning. MRI-based 3D models are radiation-free and could be used instead of CT-based 3D models in the future.

Vara Deformity and Subluxed Humeral Heads: An Unusual Sign in Pseudohypoparathyroidism.

Pseudohypoparathyroidism is a rare disorder characterized by end-organ resistance to intact parathyroid hormone (PTH) and concomitant laboratory findings of hypocalcemia and hyperphosphatemia. Radiologic evidence of the disease may manifest as a variety of bone abnormalities. This case describes an 11-year-old female with a history of repaired bilateral slipped capital femoral epiphysis who presented with a limited range of motion of the bilateral upper extremities. Laboratory findings were consistent with pseudohypoparathyroidism. Radiographs revealed subchondral resorption of bilateral clavicular heads and multiple ribs and band lucencies of proximal humeral metaphyses, along with vara deformity and inferior subluxation of the humeral heads. This presentation adds to the spectrum of potential radiographic manifestations of pseudohypoparathyroidism.

Revascularization of a Necrotic Femoral Head in Severely Slipped Capital Femoral Epiphysis With a Modified Dunn Procedure: A Case Report.

Avascular necrosis, a serious slipped capital femoral epiphysis (SCFE) complication, is difficult to treat. We report a rare case of revascularization of the necrotic femoral head in a 12-year-old male patient with a severe SCFE (posterior tilting angle, 87°). We performed the modified Dunn procedure (MDP), followed by long-term unloading therapy. Blood flow to the epiphysis had partially resumed 2.3 years postoperatively. At the final 4.5-year follow-up, blood flow had been restored, leading to epiphyseal closure without significant femoral head deformity or hip pain. The patient could walk unassisted, with a flexion range of 120°. These findings support the use of the MDP with long-term unloading therapy as a potential treatment option for severe SCFE.

The clinical value of preoperative 3D planning and 3D surgical guides for Imhäuser osteotomy in slipped capital femoral epipysis: a retrospective study.

BACKGROUND: Accurate repositioning of the femoral head in patients with Slipped Capital Femoral Epiphysis (SCFE) undergoing Imhäuser osteotomy is very challenging. The objective of this study is to determine if preoperative 3D planning and a 3D-printed surgical guide improve the accuracy of the placement of the femoral head. METHODS: This retrospective study compared outcome parameters of patients who underwent a classic Imhäuser osteotomy from 2009 to 2013 with those who underwent an Imhäuser osteotomy using 3D preoperative planning and 3D-printed surgical guides from 2014 to 2021. The primary endpoint was improvement in Range of Motion (ROM) of the hip. Secondary outcomes were radiographic improvement (Southwick angle), patient-reported clinical outcomes regarding hip and psychosocial complaints assessed with two questionnaires and duration of surgery. RESULTS: In the 14 patients of the 3D group radiographic improvement was slightly greater and duration of surgery was slightly shorter than in the 7 patients of the classis Imhäuser group. No difference was found in the ROM, and patient reported clinical outcomes were slightly less favourable. CONCLUSIONS: Surprisingly we didn't find a significant difference between the two groups. Further research on the use of 3D planning an 3D-printed surgical guides is needed. TRIAL REGISTRATION: Approval for this study was obtained of the local ethics committees of both hospitals.

Exploring the lack of articular ends at the Middle Pleistocene site of Qesem Cave, Israel.

Biased skeletal part representation is a key element for making inferences about transport decisions, carcass procurement, and use patterns in anthropogenic accumulations. In the absence of destructive taphonomic processes, it is often assumed that the abundance of different anatomical portions represents selective transport and discard patterns of human groups. Because body parts may be transported for specific products such as meat, marrow or grease, a pattern that usually attracts attention in many archaeological sites is the low proportions of appendicular epiphyses. Here we present the case of faunal assemblages from the lower stratigraphic sequence of Qesem Cave, Israel, dated to ca. 430 to 300 ka. All bone accumulations are characterized by a biased skeletal profile including mainly long-limb bones and a virtual absence of epiphyses. The assemblages also show density-mediated attrition not linked to fossil-diagenetic processes, a targeted specific destruction to the most greasy articular ends and an almost total absence of carnivore intervention. Our goal here is to explore the processes that entail the destruction of appendicular epiphyses at Qesem Cave, as well as propose viable hypotheses to explain their underrepresentation on-site. Our results shed light on the domestic activities linked to the processing of bones at the site and support the importance of animal grease in the caloric intake of Middle Pleistocene humans.

Bone age assessment based on different MRI modalities of the proximal humerus epiphysis: the comparisons of T1WI, T2WI, and PDWI.

Bone age assessment (BAA) is crucial in various fields, including legal proceedings, athletic competitions, and clinical medicine. However, the use of X-ray methods for age estimation without medical indication is subject to ethical debate, especially in forensic and athletic fields. The application of magnetic resonance imaging (MRI) with non-ionizing radiation can overcome this limitation in BAA. This study aimed to compare the application value of several MRI modalities of proximal humeral in BAA. A total of 468 patients with shoulder MRIs were retrospectively collected from a Chinese Han population aged 12-30 years (259 males and 209 females) for training and testing, including T1 weighted MRI (T1WI), T2 weighted MRI (T2WI), and Proton density weighted MRI (PDWI). Optimal regression models were established for age estimation, yielding mean absolute error (MAE) values below 2.0 years. The MAE values of T1WI were the lowest, with 1.700 years in males and 1.798 years in females. The area under the curve (AUC) and accuracy values of different MRI modalities of 16-year and 18-year thresholds were all around 0.9. For the 18-year threshold, T1WI outperformed T2WI and PDWI. In conclusion, the three MRI modalities of the proximal humerus can serve as reliable indicators for age assessment, while the T1WI performed better in age assessment and classification.

Does Prophylactic Pinning Affect the Proximal Femur Morphology in Slipped Capital Femoral Epiphysis?

Background: The role of prophylactic pinning of the contralateral hip in unilateral SCFE is well established in patients with risk factors for developing contralateral slip. The effect of prophylactic pinning on the growth and morphology of the hip is not well documented in the literature. We aimed to study the effect of prophylactic pinning on the residual growth and morphology of the proximal femur. Materials & Methods: The institutional database was searched for all unilateral SCFE cases for the period 2011 to 2020. A total of 171 unilateral SCFE cases were identified. All the radiographs were scanned and those patients who had follow-up X-rays till skeletal maturity were included in the study. Prophylactic pinning was performed using 6.5 mm fully threaded cancellous screws in supine position on a radiolucent table. The following radiological parameters were measured on the post-operative X-rays and at skeletal maturity: (i) neck length (NL), (ii) neck-shaft angle (NSA), (iii) femoral offset (FO), (iv) articulo-trochanteric distance (ATD) and (iv) tip-apex distance (TAD) by two different observers. Results: The mean age of the cohort was 13.7 years. ATD decreased from the mean value of 25.67 mm in post-operative radiographs to 20.84 mm in final follow-up radiographs. The NL, FO, and TAD were found to be increasing with age with mean final follow-up values of 55.35 mm, 41.41 mm, and 6.19 mm respectively compared to post-operative mean values of 50.95 mm, 37.4 mm, and 4.69 mm. There was no significant change in the neck-shaft angle. The mean post-operative NSA was 132.9° and it was 131.8° at final follow-up radiographs. Conclusion: Prophylactic pinning in unilateral SCFE does not stop the growth of the proximal femur completely. The ATD decreases in all the patients with prophylactic screw fixation probably due to the discrepancy in growth between the trochanteric apophysis and proximal femoral physis. The clinical effects of this subtle change in the morphology of the proximal femur need further investigation. Level of Evidence: Level IV Case series.