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BACKGROUND Fractures in late life are highly consequential for health, services use, and spending. Little is known about trends in extremity fracture hospitalizations among older adults in the United States. DESIGN Retrospective longitudinal cohort study. SETTING The 2003-2017 National Inpatient Sample (NIS), a representative sample of U.S. community hospitals. PARTICIPANTS Hospitalized adults aged 65 and older with a diagnosis of upper or lower extremity fracture. MEASUREMENTS Incidence of extremity fracture hospitalization and mortality, using NIS discharge and trend weights, and population denominators derived from the U.S. Census Bureau. Incidence was reported separately for men and women by age, fracture diagnosis, and injury mechanism. Weighted linear regression was used to test for significant trends over time. RESULTS Incidence of extremity fracture hospitalizations declined in both women (15.7%, p trend

Objective The aim of this study is to analyze the efficacy of open reduction and Herbert screw fixation for coronal fractures of the capitellum via the anterior approach in adolescents. Methods We retrospectively analyzed the clinical and imaging data of 15 adolescents with capitellar fractures who were admitted to our hospital from May 2014 to May 2019. The fracture was reduced through the cubital crease incision via the anterior approach and was internally fixated with Herbert screws. A follow-up was conducted after the operation to examine fracture healing and elbow function. The postoperative functional recovery of patients was evaluated with the Mayo Elbow Performance index (MEPI) and the Broberg-Morrey rating system. Results Patients underwent surgery 3.7 days after injury on average. Intraoperative fracture reduction was satisfactory. No vascular injury or nerve injury occurred. Bony union occurred in an average of 6 weeks after the operation. All adolescents completed a 12- to 36-month follow-up. At the last follow-up, the Mayo Elbow Performance index was considered excellent in 12 patients and good in three patients. The Broberg-Morrey score was considered excellent in 12 patients, good in two patients, and fair in one patient. Conclusion Open reduction with Herbert screw fixation via the anterior approach is a feasible surgical method for the treatment of coronal fractures of the capitellum in adolescents. Levels of evidence Therapeutic, retrospective study-Level IV

To determine whether radiotherapy (RT) can increase pelvic fracture risk in rectal cancer survivors. Rectal cancer patients who underwent curative surgery between 1996 and 2011 in Taiwan were retrospectively studied using the National Health Insurance Research Database (NHIRD) of Taiwan. ICD‐9 Codes 808, 805.4‐805.7, 806.4‐806.7, and 820 (including pelvic, sacrum, lumbar, and femoral neck fracture) were defined as pelvic fracture. Propensity scores for RT, age, and sex were used to perform one‐to‐one matches between the RT and non‐RT group. Risks of pelvic and arm fractures were compared by multivariable Cox regression. Of the 32 689 patients, 7807 (23.9%) received RT, and 1616 suffered from a pelvic fracture (incidence rate: 1.17/100 person‐years). The median time to pelvic fracture was 2.47 years. After matching, 6952 patients each in the RT and non‐RT groups were analyzed. RT was associated with an increased risk of pelvic fractures in the multivariable Cox model (hazard ratio (HR): 1.246, 95% confidence interval (CI): 1.037‐1.495, P = 0.019) but not with arm fractures (HR: 1.013, 95% CI: 0.814‐1.259, P = 0.911). Subgroup analyses revealed that RT was associated with a higher pelvic fracture rate in women (HR: 1.431, 95% CI: 1.117‐1.834) but not in men, and the interaction between sex and RT was significant (P = 0.03). The HR of pelvic fracture increased 2‐4 years after RT (HR: 1.707, 95% CI: 1.150‐2.534, P = 0.008). An increased risk of pelvic fracture is noted in rectal cancer survivors, especially women, who receive RT.

OBJECTIVES We provide descriptions and functional interpretations of 11 >2.0 Ma hominin vertebral and upper limb fossils from Sterkfontein. MATERIALS AND METHODS We employed taphonomic methods to describe postmortem damage observed on the fossils. We used osteometric tools and measurements to generate quantitative descriptions, which were added to qualitative descriptions of the fossils. These observations were then interpreted using published data on the same skeletal elements from extant and extinct hominoid taxa. RESULTS Six of the fossils carry carnivore tooth marks. Two vertebrae show morphologies that are consistent with fully developed lordosis of the lumbar spine, but which are not completely consistent with bipedal loading of the same intensity and/or frequency as reflected in the lumbars of modern humans. A clavicle shows a combination of humanlike and apelike features, the latter of which would have endowed its hominin with good climbing abilities. When combined, analyses of fragmentary radius and ulna fossils yield more ambiguous results. DISCUSSION The new fossil collection presents a mix of bipedal and climbing features. It is unclear whether this mix indicates that all Sterkfontein hominins of >2.0 Ma were terrestrial bipeds who retained adaptations for climbing or whether the collection samples two differently adapted, coeval hominins, Australopithecus africanus and Australopithecus prometheus, both of which are represented at Sterkfontein by skull remains. Regardless, the significant frequency of tooth-marked fossils in the sample might indicate that predation was a selection pressure that maintained climbing adaptations in at least some Sterkfontein hominins of this period.

Background The phenotypic features of SHOX deficiency (SHOX-D) are highly variable and can be very mild, especially in young children. The aim of this retrospective study was to evaluate auxological and radiological indicators that could be predictive of SHOX-D in children. Methods Molecular analysis of the SHOX gene was performed in 296 subjects with growth impairment or skeletal disproportion, without alternative diagnosis. Auxological variables and radiographs of the hand, wrist and forearm were evaluated. Results SHOX mutations (88% inherited, 12% de novo) were identified in 52 subjects. The most predictive auxological indicators of SHOX-D were an increased sitting height/height ratio and a decreased arm span/height ratio. The convexity of distal radial metaphysis at X-ray, not yet reported in literature, was also found to be predictive of SHOX-D. In young children, stratification of data by bone age also highlighted ulnar tilt, lucency of the ulnar border of the distal radius and enlarged radius as the radiological signs most related to SHOX-D . Conclusions In this study, the analysis of auxological and radiological indicators in SHOX-D children allowed to identify an additional early radiological sign and underlines the importance of family auxological evaluation.

Background/aim: The goal of this study was to compare differences in hand and wrist shapes and to evaluate these according to growth and allometry in children on radiographs related to bone age. Materials and methods: The study included 263 males and 189 females. A total of 452 left hand and wrist radiographs were retrospectively collected. Standard anatomical landmarks marked on radiographs. Results: There were seen to be significant differences in comparisons of hand and wrist shapes according to sex (P = 0.009). The most suitable model in the growth models was seen as the Gompertz growth model for both females and males (model P < 0.001). For the relationship between shape and size to evaluate allometry, significant models were obtained in females (model P = 0.017, MSE = 0.0002) and in males (model P < 0.001, MSE = 0.0002). In our study, the difference between the sexes was found mostly in the radiocarpal region. It was observed that the deformation of the carpal bones started in the distal row carpal bones. Conclusion: Significant differences were found in hand and wrist shapes according to sex. Models for growth and allometry of hand and wrist shapes were found to be significant in children.

Objectives: Transgender individuals submitted to hormone or surgical treatment may have alterations in their bone metabolism as these elements are important players in bone remodeling. We aimed to study bone mineral density (BMD) and body composition in transwomen undergoing cross-sex hormonal treatment (CSHT) from Brazil for over 3 years, comparing them with female and male controls. Methods: 93 individuals (31 transwomen, 31 females and 31 males paired for age and body mass index) were studied for bone mass, and body composition by densitometry (by DXA). Epidemiological and clinical data were collected through direct questioning. Results: Low bone mass (T score ≤2) was found in 12.9% of transwomen; in 3.2% of females and 3.3% of males. Transwomen individuals had lower spine Z score (0.26 ± 1.42 vs 0.50 ± 1.19) and femur Z score (−0.41 ± 0.95 vs 0.29 ± 1.04) than females. They had lower total femur Z score than males (−0.41 ± 0.95 vs 0.20 ± 0.83). Lean mass values correlated positively with total femur BMD (ρ = 0.40; 95% confidence interval = 0.009–0.68; p = 0.04) and BMD in femoral neck (ρ = 0.48; 95% confidence interval = 0.11–0.74; p = 0.01) but neither the type of therapy received nor the time that they were used, impacted bone mass. Conclusion: Low BMD is found frequently in transwomen and it is correlated with lean body mass. Advances in knowledge: There are few studies of the effects of hormone therapy on the bones and muscles of transwomen. This study demonstrated that significant changes occur, and that the population studied needs greater care in musculoskeletal health.

The major upper limb skeletal elements (scapulae, humeri, ulnae and radii) are frequently utilized for sex determination and stature estimation. Consequently, in forensic cases that involve commingled remains, it is crucial to reassociate the aforementioned bones and attribute them to the right individual. The aim of the present study is to develop simple and multiple regression equations for sorting commingled human skeletal elements of the upper limb. In that context, ten common anthropological linear measurements of the articular surfaces of scapulae, humeri, ulnae, and radii were performed on 222 adult skeletons from the Athens Collection. The functions developed for sorting adjoining bones presented a strong positive linear relationship (r = 0.69–0.93, p < 0.05). The values of the determination coefficient statistics (r2 = 0.47–0.86) were found to be high and those of the standard errors of the estimate were found to be low (SEE = 0.88–1.61). Blind tests indicated that when metric and morphoscopic sorting techniques are combined, a reliable sorting of the skeletal elements of the upper limbs is possible.

Objectives: To describe peripheral long bone material and structural differences in youth at risk of secondary osteoporosis across disease-specific profiles. Methods: Upper- and lower limbs of children and adolescents were scanned at 4% distal and 66% mid-shaft sites using peripheral Quantitative Computed Tomography sub-categorised as (1) increased risk of secondary osteoporosis (neuromuscular disorders; chronic diseases; endocrine diseases; inborn errors of metabolism; iatrogenic conditions), (2) low motor competence and (3) non-affected controls. Results: Children with disease-specific profiles showed a range of bone deficits compared to the control group with these predominantly indicated for neuromuscular disorders, chronic diseases and low motor competence. Deficits between upper arm and lower leg long bone parameters were different for disease-specific profiles compared to the control group. Endocortical radius, muscle area, and mid-cortical ring density were not significantly different for any disease-specific profile compared to the control group for any bone sites. Conclusions: Neuromuscular disorders, chronic diseases and low motor competence have a strong correlation to bone health for appendicular bone parameters in youth, suggesting a critical mechanical loading influence which may differ specific to disease profile. As mechanical loading effects are observed in regional bone analyses, targeted exercise interventions to improve bone strength should be implemented to examine if this is effective in reducing the risk of secondary osteoporosis in youth.

OBJECTIVE To determine risk factors for osteomyelitis in US military personnel with combat-related, extremity long bone (humerus, radius, and ulna) open fractures. DESIGN Retrospective observational case-control study. SETTING US military regional hospital in Germany and tertiary care military hospitals in the United States (2003-2009). PATIENTS/PARTICIPANTS Sixty-four patients with open upper extremity fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Ninety-six patients with open upper extremity fractures who did not meet osteomyelitis diagnostic criteria were included as controls. INTERVENTION Not applicable. MAIN OUTCOME MEASUREMENTS Multivariable odds ratios (ORs; 95% confidence interval [CI]). RESULTS Among patients with surgical implants, osteomyelitis cases had longer time to definitive orthopaedic surgery compared with controls (median: 26 vs. 11 days; P < 0.001); however, there was no significant difference with timing of radiographic union. Being injured between 2003 and 2006, use of antibiotic beads, Gustilo-Anderson [GA] fracture classification (highest with GA-IIIb: [OR: 22.20; CI: 3.60-136.95]), and Orthopaedic Trauma Association Open Fracture Classification skin variable (highest with extensive degloving [OR: 15.61; CI: 3.25-74.86]) were independently associated with osteomyelitis risk. Initial stabilization occurring outside of the combat zone was associated with reduced risk of osteomyelitis. CONCLUSIONS Open upper extremity fractures with severe soft-tissue damage have the highest risk of developing osteomyelitis. The associations with injuries sustained 2003-2006 and location of initial stabilization are likely from evolving trauma system recommendations and practice patterns during the timeframe. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

AimsAdjuvant treatment after intralesional curettage for atypical cartilaginous tumours (ACTs) of long bones is widely accepted for extending surgical margins. However, evaluating the isolated effect of adjuvant treatment is difficult, and it is unclear whether not using such adjuvants provides poor oncological outcomes. Hence, we analyzed whether intralesional curettage without cryosurgery or chemical adjuvants provides poor oncological outcomes in patients with an ACT.Patients and MethodsA total of 24 patients (nine men, 15 women) (mean age 45 years; 18 to 62) were treated for ACTs of long bones and followed up for a median of 66 months (interquartile range 50 to 84). All patients were treated with extensive manual curettage and limited burring. Bone cement and grafts were used to fill bone defects in 16 and eight patients, respectively. No chemical adjuvants or cryosurgery were used.ResultsNo local recurrence was detectable on plain radiographs and MRI or CT images. At the last follow-up, there were no distant metastases or disease-specific deaths. No procedure-related complications or postoperative fractures developed.ConclusionIntralesional curettage without cryosurgery or chemical adjuvants may provide excellent oncological outcomes for patients with ACTs of long bones, without the risk of complications related to adjuvant use. Our investigation suggests thorough curettage alone is a reasonable treatment option for ACT. However, we acknowledge the limited size of our investigation warrants a multicentre collaborative study to confirm our findings. Cite this article: Bone Joint J 2018;100-B:256–61.

The close association between muscle and bone is broadly intuitive; however, details of the covariation between the two has not been comprehensively studied. Without quantitative understanding of how muscle anatomy influences bone shape, it is difficult to draw conclusions of the significance of many morphological traits of the skeleton. In this study, we investigated these relationships in the Quenda (Isoodon fusciventer), a scratch-digging marsupial. We quantified the relationships between forelimb muscle anatomy and bone shape for animals representing a range of body masses (124-1,952 g) using two-block partial least square analyses. Muscle anatomy was quantified as muscle mass and physiological cross-sectional area (PCSA), and we used two morphometric methods to characterize bone shape: seven indices of linear bone proportions, and landmarks analysis. Bone shape was significantly correlated with body mass, reflecting allometric bone growth. Of the seven bone indices, only shoulder moment index (SMI) and ulna robustness index (URI) showed a significant covariation with muscle anatomy. Stronger relationships between muscle anatomy and forelimb bone shape were found using the landmark coordinates: muscle mass and PCSA were correlated with the geometric shape of the scapula, humerus, and third metacarpal, but to a lesser extent with shape of the ulna. Overall, our data show that landmark coordinates are more sensitive than bone indices to capturing shape changes evident throughout ontogeny, and is therefore a more appropriate method to investigate covariation with forelimb muscle anatomy. Single-species studies investigating ontogeny require refined methods to accurately develop understanding of the important relationships between muscle force generation and bone shape remodeling. Landmark analyses provide such a method.

The sleep quality of patients with osteosarcoma (OS) was poorly understood. We aimed to evaluate the prevalence of sleep dysfunction in adolescent patients with OS using the Pittsburgh Sleep Quality Index (PSQI) and to further investigate the psychometric properties of the PSQI in this cohort of patients. Fifty four adolescent patients with OS who underwent chemotherapy treatment in our clinic centre were included. Sleep quality was assessed with the Chinese PSQI. Cronbach's alpha was calculated to evaluate the internal consistency. The confirmatory factor analysis (CFA) was used to determine the fitness of a two-factor structure. Sleep disturbance was observed in 57.4% (31/54) of the patients. Patients with the presence of metastasis or more than 2 cycles of chemotherapy were found to have remarkably higher median global score. The overall Cronbach's alpha was 0.87. The CFA showed an overall comparative fit index of 0.97, a root mean square error of approximation of 0.06 and a standardised root mean square residual of 0.07 respectively. PSQI was a reliable instrument to evaluate the sleep quality of adolescent patients with OS. Over half of the patients may experience sleep disturbance during the treatment. Early psychological interventions were recommended to improve the sleep quality of the patients.

The Chartered Society of Forensic Sciences South Africa has one of the highest murder rates in the world, which is associated with an increasing number of unidentified individuals. Forensic anthropologists can assist in these cases to reduce the number of potential victims the remains may belong to. Sex estimation potentially decreases the number of possible victims by half. The mixed ancestry population in South Africa is the second largest group of people; however, there remains a paucity of data and population-specific methods for sex estimation in this group. The aim of this study was to assess the potential for metrices obtained around the nutrient foramen and the maximum length of upper limb long bones to estimate sex in mixed ancestry South Africans using discriminant function analysis. A total of 328 humeri, radii and ulnae from individuals of mixed ancestry were analysed. Sex was correctly classified with an average classification accuracy of 84.3% in the humeri, 88.3% for radii and 83.5% for the ulnae. Total length was the single best predictor of sex; the combination of total length with dimensions related to the nutrient foramen produced high classification accuracies in the current study. Overall, sexual dimorphism was observed in mixed ancestry South Africans upper limb long bones. The findings of this study further emphasise the need for population-specific standards of sexing in an attempt to improve current methods of forensic identification of descendants.

Background: Sufficient data on outcome of patients with clinically and radiologically aggressive enchondromas and atypical cartilaginous tumors (ACT) is lacking. We therefore analyzed both conservatively and surgically treated patients with lesions, which were not distinguishable between benign enchondroma and low-grade malignant ACT based upon clinical and radiologic appearance. Methods: The series included 228 consecutive cases with a follow-up > 24 months to assess radiological, histological, and clinical outcome including recurrences and complications. Pain, satisfaction, functional limitations, and the musculoskeletal tumor society (MSTS) score were evaluated to judge both function and emotional acceptance at final follow-up. Results: Follow-up took place at a mean of 82 (median 75) months. The 228 patients all had comparable clinical and radiological findings. Of these, 153 patients were treated conservatively, while the other 75 patients underwent intralesional curettage. Besides clinical and radiological aggressiveness, most lesions were histologically judged as benign enchondromas. 9 cases were determined to be ACT, while the remaining 7 cases had indeterminate histology. After surgery, three patients developed a recurrence, and a further seven had complications of which six were related to osteosynthesis. Both groups had excellent and almost equal MSTS scores of 96 and 97%, respectively, but significantly less functional limitations were found in the non-surgery group. Further sub-analyses were performed to reduce selection bias. Sub-analysis of histologically diagnosed enchondromas in the surgery group found more pain, less function, and worse MSTS score compared to the non-surgery group. Sub-analysis of smaller lesions ( 4.4 cm: MSTS score: 94.0% versus 97.3%, p = 0.007; pain 2.3 versus 0.8, p = 0.001). The majority of lesions treated surgically was filled with polymethylmethacrylate bone-cement, while the remainder was filled with cancellous-bone, without significant difference in clinical outcome. Conclusion: Feasibility of intralesional curettage strategies for symptomatic benign to low-grade malignant chondrogenic tumors was supported. Surgery, however, did not prove superior compared to conservative clinical and radiological observation. Due to the low risk of transformation into higher-grade tumors and better functional results, more lesions might just be observed if continuous follow-up is assured.

Objectives The aim of this work is to study age, sex, and population variations in epiphyseal fusion and persistence of the epiphyseal line in the appendicular skeleton of two identified modern (19th-20th c.) adult skeletal samples, using a specifically designed macroscopic scoring method. The use of epiphyseal closure and persistence of the epiphyseal line as an adult-age marker is also discussed. Materials and methods This study examined 981 adult skeletons of both sexes from two identified modern (20th c.) skeletal samples from the Sassari Collection (Museum of Anthropology, University of Bologna, Italy) and the Coleccao de Esqueletos Identificados (Museum of Anthropology, University of Coimbra, Portugal). Our scoring method considers a five-degree scale, from nonfusion (Degree 0) to complete fusion (Degree 4). In addition, the persistence of the epiphyseal line, a feature that is not commonly collected during routine anthropological analyses, is taken into account here as Degree 3. Results Intra- and interobserver errors of 1.2% and 5.2%, respectively, were found, suggesting a good reproducibility of this scoring method. Some sites show variable degrees of epiphyseal fusion still in adult skeletons (e.g., secondary center of ossification of the clavicle, iliac crest, ischial tuberosity, distal epiphysis of the radius and ulna). Conclusions Population differences have been observed, showing a delay in the complete epiphyseal closure for the Sassari sample compared to the Coimbra sample. Degree 3 seems to be a good adult-age indicator for individuals less than 35-year-old.

Skeletal and dental data for subadult analyses obtained from dry bones or various types of medical images, such as computed tomography (CT) scans or conventional radiographs/x-rays, should be consistent and repeatable to ensure method applicability across modalities and support combining study samples. The present study evaluates observer agreement of epiphyseal fusion and dental development stages obtained on CT scans of a U.S. sample and the consistency of epiphyseal fusion stages between CT scans and projected scan radiographs/scout images (U.S. CT sample), and between dry bones and conventional x-rays (Colombian osteological sample). Results show that both intra- and interobserver agreements of scores on CT scans were high (intra: mean Cohen’s kappa = 0.757–0.939, inter: mean Cohen’s kappa = 0.773–0.836). Agreements were lower for dental data (intra: mean Cohen’s kappa = 0.757, inter: mean Cohen’s kappa = 0.773–0.0.820) compared to epiphyseal fusion data (intra: mean Cohen’s kappa = 0.939, inter: mean Cohen’s kappa = 0.807–0.836). Consistency of epiphyseal fusion stages was higher between dry bones and conventional x-rays than between CT scans and scout images (mean Cohen’s kappa = 0.708–0.824 and 0.726–0.738, respectively). Differences rarely surpassed a one-stage value between observers or modalities. The complexity of some ossification patterns and superimposition had a greater negative impact on agreement and consistency rates than observer experience. Results suggest ordinal subadult skeletal data can be collected and combined across modalities.

Various age estimation techniques have been utilised in Australia to evaluate the age of individuals who do not have documentation to determine legal majority/culpability. These age estimation techniques rely on the assessment of skeletal development as visualised in radiographs, CT scans, MRI or ultrasound modalities, and subsequent comparison to reference standards. These standards are not always population specific and are thus known to be less accurate when applied outside of the original reference sample, leading to potential ethical implications. Therefore, the present study aims to: (i) explore the variation in developmental trajectories between the established Tanner-Whitehouse (TW) age estimation standards and a Western Australian population; and (ii) develop specific hand-wrist age estimation standards for the latter population. The present study examines digital anterior-posterior hand-wrist radiographs of 360 individuals 0 to 24.9 years of age, equally represented by sex. Each radiograph was assessed using the RUS, Carpal and 20-bone methods of Tanner et al. The standard error of the estimate (SEE) was calculated for each method (range: ♀ SEE ±0.4-11.5 years; ♂ SEE ±0.9-10.1 years). The most accurate method was TW3 RUS for females and the TW2 Carpal system for males. The 50th centile skeletal maturity scores for each year age group were plotted against average chronological age to produce polynomial regression standards with a demonstrated accuracy of (♀ SEE ±0.09-3.46 years; ♂ SEE ±0.02-3.42 years) for females and males, respectively. The standards presented here can be used in future forensic investigations that require age estimation of hand-wrist bones in a Western Australian population, however, they are not appropriate for establishing age of majority (18 years), as skeletal maturity was attained on average earlier than 15 years of age in both sexes for all three systems examined.

Areal bone mineral density (aBMD) is the most common estimate of bone mass, incorporated in the World Health Organization definition of osteoporosis. However, aBMD depends on not only the amount of mineral but also the bone size. The estimated postmenopausal decline in aBMD could because of this be influenced by changes in bone size.We measured bone mineral content (BMC; mg), aBMD (mg/cm2), and bone width (mm) by single-photon absorptiometry at the cortical site of the forearm in a population-based sample of 105 Caucasian women. We conducted 12 measurements during a 28-yr period from mean 5 yr (range: 2-9) before menopause to mean 24 yr (range: 18-28) after menopause. We calculated individual slopes for changes in the periods before menopause, 0

An accurate and precise estimate of stature can be very useful in the analysis of human remains in forensic cases. A problem with many stature estimation methods is that an unknown individual must first be assigned to a specific group before a method can be applied. Group membership has been defined by sex, age, year of birth, race, ancestry, continental origin, nationality or a combination of these criteria. Univariate and multivariate sex-specific and generic equations are presented here that do not require an unknown individual to be assigned to a group before stature is estimated. The equations were developed using linear regression with a sample (n=244) from the Terry Collection and tested using independent samples from the Forensic Anthropology Databank (n=136) and the Lisbon Collection (n=85). Tests with these independent samples show that (1) the femur provides the best univariate results; (2) the best multivariate equation includes the humerus, femur and tibia lengths; (3) a generic equation that does not require an unknown to first be assigned to a given category provides the best results most often; (4) a population-specific equation does not provide better results for estimating stature; (5) sex-specific equations can provide slightly better results in some cases; however, estimating the wrong sex can have a negative impact on precision and accuracy. With these equations, stature can be estimated independently of age at death, sex or group membership.

Ipiutak (100BCE-500CE) and Tigara (1200 - 1700CE) are two populations from Point Hope, Alaska. As commonly observed in forager communities, it may be expected males and females to have been involved in markedly different daily activities. Nevertheless, activity-related sexual dimorphism in these populations has been scarcely studied. Using humeral diaphyseal cross-sectional properties and forearm rotational efficiency, which are activity-dependent characteristics, we aim to assess differences between sexes and discuss what activities could have triggered them. Our results suggest that in Ipiutak males and females did not differ meaningfully in their cross-sectional properties. Conversely, in Tigara males had a greater rigidity of the entire humeral diaphysis than females, which suggests the existence of greater relative activity levels and more physically demanding tasks, possibly related to hunting activities. Concerning the differences between sexes in the forearm rotational efficiency, in Tigara females rotational efficiency in elbow flexion is maximal in a more supinated position than in males, which leads to an improvement of efficiency in those stages related to manipulation, and so improves the manipulative capacities of the upper limb. These differences in efficiency are caused by a more proximally oriented humeral medial epicondyle in females, which is thus confirmed to be a good feature to assess differences in labor. Therefore females in Tigara probably performed in a daily basis household activities, such as hide processing and other manipulative labors. In Ipiutak, the analysis of forearm rotational efficiency did not reveal differences between sexes. Overall, the results suggest that division of labor in Ipiutak was not as marked as in Tigara, where upper limb skeletal structure supports the idea that both sexes were involved in different daily activities. Nevertheless, the generalized lack of results in Ipiutak could be due to the small sample size, and thus interpretations should be considered with caution.

Author(s): Becker, Sara K | Abstract: OBJECTIVES:Studies of osteoarthritis (OA) in human skeletal remains can come with scalar problems. If OA measurement is noted as present or absent in one joint, like the elbow, results may not identify specific articular pathology data and the sample size may be insufficient to address research questions. If calculated on a per data point basis (i.e., each articular surface within a joint), results may prove too data heavy to comprehensively understand arthritic changes, or one individual with multiple positive scores may skew results and violate the data independence required for statistical tests. The objective of this article is to show that the statistical methodology Generalized Estimating Equations (GEE) can solve scalar issues in bioarchaeological studies. MATERIALS AND METHODS:Using GEE, a population-averaged statistical model, 1,195 adults from the core and one colony of the prehistoric Tiwanaku state (AD 500-1,100) were evaluated bilaterally for OA on the seven articular surfaces of the elbow joint. RESULTS:GEE linked the articular surfaces within each individual specimen, permitting the largest possible unbiased dataset, and showed significant differences between core and colony Tiwanaku peoples in the overall elbow joint, while also pinpointing specific articular surfaces with OA. Data groupings by sex and age at death also demonstrated significant variation. A pattern of elbow rotation noted for core Tiwanaku people may indicate a specific pattern of movement. DISCUSSION:GEE is effective and should be encouraged in bioarchaeological studies as a way to address scalar issues and to retain all pathology information.

Aims A single-centre prospective randomized trial was conducted to investigate whether a less intensive follow-up protocol would not be inferior to a conventional follow-up protocol, in terms of overall survival, in patients who have undergone surgery for sarcoma of the limb. Initial short-term results were published in 2014. Patients and Methods The primary objective was to show non-inferiority of a chest radiograph (CXR) group compared with a CT scan group, and of a less frequent (six-monthly) group than a more frequent (three-monthly) group, in two-by-two comparison. The primary outcome was overall survival and the secondary outcome was a recurrence-free survival. Five-year survival was compared between the CXR and CT scan groups and between the three-monthly and six-monthly groups. Of 500 patients who were enrolled, 476 were available for follow-up. Survival analyses were performed on a per-protocol basis (n = 412). Results The updated results recorded 12 (2.4%) local recurrences, 182 (36.8%) metastases, and 56 (11.3%) combined (local + metastases) recurrence at a median follow-up of 81 months (60 to 118). Of 68 local recurrences, 60 (88%) were identified by the patients themselves. The six-monthly regime (overall survival (OS) 54%, recurrence-free survival (RFS) 46%) did not lead to a worse survival and was not inferior to the three-monthly regime (OS 55%, RFS 47%) in terms of detecting recurrence. Although CT scans (OS 53%, RFS 54%) detected pulmonary metastasis earlier, it did not lead to a better survival compared with CXR (OS 56%, RFS 59%). Conclusion The overall survival of patients who are treated for a sarcoma of the limb is not inferior to those followed up with a less intensive regimen than a more intensive protocol, in terms of frequency of visits and mode of imaging. CXR at six-monthly intervals and patient education about examination of the site of the surgery will detect most recurrences without deleterious effects on the eventual outcome. Cite this article: Bone Joint J 2018;100-B:262–8.

Biological reconstruction is a useful option for reconstruction following bone sarcoma resection in children. The mid-term functional and radiological outcomes of biological reconstructions after resection of bone sarcomas in children are presented in this study. Eighteen patients [average age 12.5 years (range 4-22 years)] with primary sarcomas of long bones underwent wide surgical resection and biological reconstruction. The bone defects were managed by intercalary (n=14), osteoarticular (n=3) reconstructions and arthrodesis (n=1) with a vascularized fibular graft (VFG). VFG was combined with a massive allograft in seven lower extremity reconstructions. The average follow-up was 45.7 months (range 25-78 months). Graft union and graft hypertrophy was observed in 17 (94.4%) of 18 patients at 12 months. The VFG-allograft osteointegration rate was 100% at 24 months. The average final follow-up Musculoskeletal Tumor Society (MSTS) scores for lower and upper extremity reconstructions were 79.7% (range 66.6-90%) and 80.9% (range 53.3-100%), respectively. Four (22.2%) complications, including nonunion (n=1), implant failure (n=1), infection (n=1) and skin necrosis (n=1), required reoperation. The disease relapsed in three (16.6%) patients. Defect size and VFG length did not correlate with MSTS scores and radiological parameters (P>0.05). Biological reconstruction with VFG can provide permanent stability and progressively increasing functional and radiological results. Copyright (C) 2015 Wolters Kluwer Health, Inc. All rights reserved.

Background Chondroblastoma is a rare benign cartilage tumor that commonly occurs in children and adolescents. This study was designed to review the epidemiologic characteristics and outcomes of surgical management in a large series of patients with extremity chondroblastoma. Methods We performed a multicenter retrospective analysis of 199 patients with extremity chondroblastoma. Clinical data, radiographic images, histological findings, treatment, and outcome were analyzed. Results There were 145 male patients and fifty-four female patients with a mean age of 18.0 years. The most commonly involved bone was the proximal part of the tibia (fifty-five patients [27.6%]), followed by the proximal part of the femur (fifty-two patients [26.1%]) and the distal part of the femur (thirty-eight patients [19.1%]). Prior to presentation, 73.4% (146 of 199 patients) experienced pain. The mean duration of pain and other symptoms was 8.7 months. The physis was open in 25.7%, it was closing in 22.2%, and it was closed in 52.1% of the patients at the time of presentation. One hundred and twenty-six patients had at least twenty-four months of follow-up; their mean follow-up duration was 62.1 months (range, twenty-four to 190 months). Initial treatment was curettage for 119 patients (94.4%) and en bloc resection for seven patients (5.6%). The local recurrence rate was 5.0% after curettage and 0% after resection. The only significant factor related to recurrence was the location of the lesion in the proximal part of the humerus (p = 0.001). Conclusions Chondroblastoma occurs most frequently in the proximal part of the tibia and the proximal part of the femur with significant male predilection. In this series, recurrence was most frequent in the proximal part of the humerus. Our results suggest that curettage and bone-grafting provide favorable local control and satisfactory functional outcome for patients with this disease. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES In this study, we explore whether ground reaction forces recorded during horizontal walking co-vary with the shape of the long bones of the forelimb in strepsirrhines. To do so, we quantify (1) the shape of the shaft and articular surfaces of each long bone of the forelimb, (2) the peak vertical, mediolateral, and horizontal ground reaction forces applied by the forelimb during arboreal locomotion, and (3) the relationship between the shape of the forelimb and peak forces. MATERIALS AND METHODS Geometric morphometric approaches were used to quantify the shape of the bones. Kinetic data were collected during horizontal arboreal walking in eight species of strepsirrhines that show variation in habitual substrate use and morphology of the forelimb. These data were then used to explore the links between locomotor behavior, morphology, and mechanics using co-variation analyses in a phylogenetic framework. RESULTS Our results show significant differences between slow quadrupedal climbers (lorises), vertical clinger and leapers (sifaka), and active arboreal quadrupeds (ring-tailed lemur, ruffed lemur) in both ground reaction forces and the shape of the long bones of the forelimb, with the propulsive and medially directed peak forces having the highest impact on the shape of the humerus. Co-variation between long bone shape and ground reaction forces was detected in both the humerus and ulna even when accounting for differences in body mass. DISCUSSION These results demonstrate the importance of considering limb-loading beyond just peak vertical force, or substrate reaction force. A re-evaluation of osseous morphology and functional interpretations is necessary in light of these findings.

South Africa has had an increase in rates of crime, interpersonal violence and homicide since the introduction of democracy in 1994. Forensic osteological standards was lacking for South Africans of different population groups necessitating the generation of new standards for forensic identification of individuals from skeletal remains. For these reasons, there is a concerted demand for methods of identifying skeletal remains with sex being amongst the most important of the biological characteristics required. The nutrient foramen has been used to estimate sex in lower limb long bones with much accuracy but this has not been demonstrated in the upper limb long bones. The aim of this study was to develop osteometric standards for sex estimation from measurements around the nutrient foramen of the arm and forearm bones of South Africans of different population affinities. A total of 660 bones consisting of humeri, radii and ulnae of black South Africans and white South Africans were assessed for sex estimation using dimensions related to the nutrient foramen. Sex was correctly classified with a range of 84–85% for the humerus and 83–88% for the arm bones. The study showed that length measurements were more sexually dimorphic than width dimensions in South Africans, as length was consistently selected as the best predictor of sex in all bones. However, the average accuracy increased when length was used in combination with measurements related to the nutrient foramen. In conclusion, the dimensions of upper limb long bones that are directly related to the nutrient foramen are sexually dimorphic and are useful in the estimation of sex in South Africans, with the highest accuracy shown in the white South African population group.

Objectives The locomotor and manipulative abilities of australopithecines are highly debated in the paleoanthropological context. Australopithecus afarensis and Australopithecus sediba likely engaged in arboreal locomotion and, especially the latter, in certain activities implying manipulation. Nevertheless, their degree of arboreality and the relevance of their manipulative skills remain unclear. Here we calculate the pronation efficiency of the forearm (Erot) in these taxa to explore their arboreal and manipulative capabilities using a biomechanical approach. Materials and methods Three-dimensional humeral images and upper limb measurements of A.L. 288-1 (Au. afarensis) and MH2 (Au. sediba) were used to calculate Erot using a previously described biomechanical model. Results Maximal Erot in elbow flexion occurs in a rather supinated position of the forearm in Au. afarensis, similarly to Pan troglodytes. In elbow extension, maximal Erot in this fossil taxon occurs in the same forearm position as in Pongo spp. In Au. sediba the forearm positions where Erot is maximal are largely coincident with those for Hylobatidae. Conclusions The pattern in Au. afarensis suggests relevant arboreal capabilities, which would include vertical climbing, although it is suggestive of poorer manipulative skills than in modern humans. The similarity between Au. sediba and Hylobatidae is difficult to interpret, but the differences between Au. sediba and Au. afarensis suggest that the capacity to rotate the forearm followed different evolutionary processes in these australopithecine species. Although functional inferences from the upper limb are complex, the observed differences between both taxa point to the existence of two distinct anatomical models.

To review our 10-year experience with percutaneous long bone cementoplasty (PLBC) in poor surgical patients. Fifty-one patients were included. Primary endpoints were pain and functional outcomes one month following PLBC. A secondary endpoint dealt with factors predicting cement leakage. Delayed adverse events and overall survival (OS) were also investigated. Sixty-six lesions were treated. Local pain relief at 1-month occurred in 59/66 lesions (89.4 %); pain improvement was significantly more common for lesions of the upper limb (p

Sex estimation is the first biological attribute needed for personal identification from mutilated and amputated limbs or body parts in medical-legal autopsies. Populations have different sizes and proportions that affect the anthropometric assessment of sex. Relatively few published works assess the accuracy of sex estimation from soft tissue measurements of upper limb parts, except for the hand and its components, but these studies involve a limited range of global populations. The current study aimed to assess the degree of sexual dimorphism in upper limb measurements and the accuracy of using these measurements for sex estimation in a contemporary adult Sudanese population. The upper arm length, ulnar length, wrist breadth, hand length, and hand breadth of 240 right-handed Sudanese subjects (120 males and 120 females) aged between 25 and 30 years were measured by international anthropometric standards. Demarking points, sexual dimorphism indices and discriminant functions were developed from 200 subjects (100 males and 100 females) who composed the study group. All variables were sexually dimorphic. The ulnar length, wrist breadth and hand breadth significantly contributed to sex estimation. Forearm dimensions showed a higher accuracy for sex estimation than hand dimensions. Cross-validated sex classification accuracy ranged between 78.5% and 89.5%. The reliability of these standards was assessed in a test sample of 20 males and 20 females, and the results showed accuracy between 77.5% and 90%. This study provides new forensic standards for sex estimation from upper limb measurements of Sudanese adults.

Age at death in immature human skeletal remains has been estimated from the diaphyseal length of the long bones, but few studies have actually been designed specifically for the purpose of age estimation and those which have, show important caveats. This study uses regression and classical calibration to model the relationship between age and diaphyseal length of the six long bones, in a sample of 184 known sex and age individuals (72 females and 112 males), younger than 13 years of age, selected from Portuguese and English skeletal collections. Age estimation models based on classical calibration were obtained for each of the six long bones, and separately for each sex and for the sexes combined, and also for the entire sample and when it is subdivided into two subsamples at the age of 2 years. Comparisons between inverse and classical calibration show there is a systematic bias in age estimations obtained from inverse calibration. In the classical calibration models, the length of the femur provides the most accurate estimates of age. Age estimates are more accurate for the male subsample and for individuals under the age of 2 years. These results and a test of previously published methods caution against inverse calibration as a technique for developing age estimation methods even from the immature skeleton. Age estimation methods developed using cemetery collections of identified human skeletons should not be uncritically applied to present-day populations from the same region since many populations have experienced dramatic secular trends in growth and adult height over the last century.

OBJECTIVE To determine if the length of fetal long bones (LB) at mid-trimester ultrasound is predictive of small-for-gestational-age (SGA) newborns at term delivery. METHODS Retrospective evaluation of 6,781 women between 18 and 24 weeks' gestation at Magee-Womens Hospital (MWH). Gestational age (GA) was confirmed by first- or second-trimester ultrasound and patient's last menstrual period. Data were accrued from the institutional database at MWH. LB measurements were normalized to GA at the time of the ultrasound. The ratio was correlated with the probability of delivering an SGA newborn at term. RESULTS In all, 583 women were identified with an SGA newborn (8.6%). LB-to-GA ratios were associated with the probability of delivering an SGA newborn at term (p < 0.001). There was no single LB that proved to be superior in predicting an SGA newborn. CONCLUSION There is a significant association between LB-to-GA ratio at midtrimester and the probability of SGA at term.

Consistency of dual-energy X-ray absorptiometry (DXA) scan results is critical for data integrity. For pediatric subjects, the extent to which cross-calibration of DXA scanners alleviates model-to-model scanner differences is unclear. In the current study, DXA bone outcomes were compared for same-day measurements performed using different scanners, cross-calibrated to alleviate discrepancies (Hologic; Discovery A [DISCO] and QDR 4500W [QDR]). Interscanner differences were evaluated in approximately 130 females aged 8-24 yr. Scans were performed in a single session on both QDR and DISCO scanners to compare projected area, bone mineral content, and areal bone mineral density (BMD) outputs for the whole body (total, subhead, head, arm, and leg), forearm (1/3 and ultradistal radius), lumbar spine (vertebra L3 and L1-L4), and proximal femur (femoral neck). Paired t tests evaluated interscanner differences; concordance correlation coefficients (CCCs) evaluated interscanner correlations. Root mean square error coefficients of variation were compared to same-day duplicate DISCO scan root mean square error coefficients of variation for approximately 30 adult females. Deming regression equations were generated for conversion of QDR to DISCO results and vice versa. Interscanner correlations were very high (95% confidence interval for CCC 0.90), for all outcomes except for femoral neck area and subhead area (95% confidence interval for CCC = 0.83-0.94, 0.57-073). However, QDR values were systematically lower than Discovery values (p 0.05), except for head area, head bone mineral content, head BMD, ultradistal BMD (QDR Discovery, p ≤ 0.05) and L1-L4 area, L3 area, and femoral neck BMD (no differences). Most Bland-Altman and Deming regression plots indicated good interscanner agreement, with little systematic variation based on bone or body size. In pediatric and young adult females, subtle but systematic differences were noted between scans obtained on DISCO and QDR scanners, despite cross-calibration, such that most outcomes are systematically higher for DISCO than for QDR. The use of conversion equations is warranted.

Secular change in height has been extensively investigated, but size and shape of the postcranial skeleton much less so. The availability of large, documented collections of nineteenth- and twentieth-century skeletons makes it possible to examine changes in skeletal structure over the past 150 years. We examined secular changes in long bone lengths and proportions, their allometric relationship to stature, and crosssectional properties of long bone shafts. Bone measurements and stature were organized into 10-year birth cohorts, ranging from 1840 to 1989. Variation among cohorts was tested by one-way ANOVA, and secular trend was examined visually by plotting mean measurements by birth decade. Allometry was examined by regressing log bone lengths onto log stature, using least squares regression. Allometry was also examined using the geometric mean of log bone lengths as the size variable. All bone lengths and stature showed positive secular change. Stature and the distal long bones showed the most pronounced changes. Proportions also changed, as revealed by the brachial and crural indices. Both indices increased, but the brachial index change was the most pronounced. Allometric relationships suggest that brachial index changes result from positive allometry of the radius and negative allometry of the humerus. Similar but less marked allometric relationships were found in the tibia and femur. Long bone shaft properties changed in the following ways: femur midshafts and tibia shafts at the nutrient foramen became more mediolaterally narrowed, and the femur became more mediolaterally thickened at the subtrochanteric level, approaching platymeria. All major long bones became more gracile. These remarkable changes in the postcranial skeleton are a response to the unparalleled changes in the environment in which modern Americans now live. Changes in growth resulting from plentiful and secure nutrition, reduced disease load, and marked reduction in bone loading from reduced activity levels are mainly responsible.

The estimation of gestational age (GA) in fetal human remains is important in forensic settings, particularly to assess fetal viability, in addition to often being the only biological profile parameter that can be assessed with some accuracy for non-adults. The length of long bone diaphysis is one of the most frequently used methods for fetal age estimation. The main objective of this study was to present a simple and objective method for estimating GA based on the measurements of the diaphysis of the femur, tibia, fibula, humerus, ulna, and radius. Conventional least squares regression equations (classical and inverse calibration approaches) and quick reference tables were generated. A supplementary objective was to compare the performance of the new formulae against previously published models. The sample comprised 257 fetuses (136 females and 121 males) with known GA (between 12 and 40 weeks) and was selected based on clinical and pathological information. All measurements were performed on radiographic images acquired in anonymous clinical autopsy records from spontaneous and therapeutic abortions in two Portuguese hospitals. The proposed technique is straightforward and reproducible. The models for the GA estimation are exceedingly accurate and unbiased. Comparisons between inverse and classical calibration show that both perform exceptionally well, with high accuracy and low bias. Also, the newly developed equations generally outperform earlier methods of GA estimation in forensic contexts. Quick reference tables for each long bone are now available. The obtained models for the estimation of gestational age are of great applicability in forensic contexts.

Calcanei are the most common sites for bony spurs. Although calcaneal enthesophytes have been extensively researched, many unknowns remain. Whether biological factors, such as age, weight and genetics, play a greater role in calcaneal spur etiology than activity is still unknown.The current study examines 121 adults from a prehistoric hunter-gatherer population to aid in understanding bony spur etiology.Calcaneal spurs are scored as present or absent on the dorsal or plantar side; they are analyzed in regards to their relationships with age, sex, osteoarthritis, cortical index, femoral head breadth and muscle markers.Dorsal and plantar spurs frequencies increase with age (chi-squares=16.90, 7.268, Ps0.05, respectively). Dorsal spurs were more frequent than plantar spurs (chi-square=38.000; P0.0001). There is a positive relationship with calcaneal spurs and upper limb and lower limb osteoarthritis (chi-squares=5.587, 7.640, Ps0.05, respectively).The data presented support that dorsal spurs are in part the result of activities, but plantar spurs may be a more modern phenomena resulting from long periods of standing and excess weight.

Summary Bone mineral content (BMC) is known to be greater in the dominant arm after the age of 8 years. We studied a group of children and found that BMC sidedness gradually increased up to the age of 6 years and then remained stable into late adolescence. Introduction Bone mineral content (BMC) exhibits sided- ness in the arms after the age of 8 years, but it is not known whether BMC is greater in the dominant arm from birth or whether lateralization develops in early childhood. To ad- dress this, we examined bone mineral status in relation to handedness and age. Methods Subjects (N0158) were children recently initiating glucocorticoids for underlying disease (leukemia 43 %, rheumatic conditions 39 %, nephrotic syndrome 18 %). Handedness was determined by questionnaire and BMC by dual-energy X-ray absorptiometry. Results Median age was 7.2 years (range, 1.5 to 17.0 years), 49 % was male, and the spine BMD Z-score was −0.9 (SD, 1.3). By linear regression, BMC sidedness in the arms was significantly related to age (r00.294, p00.0005). Break- point analysis revealed two lines with a knot at 6.0 years (95 % CI, 4.5-7.5 years). The formula for the first line was: dominant:nondominant arm BMC ratio00.029×age (in years)+0.850 (r00.323, p00.017). The slope of the second line was not different from 0 (p00.332), while the slopes for the two lines were significantly different (p00.027). Conclusions These results show that arm BMC sidedness in this patient group develops up to age 6 years and then remains stable into late adolescence. This temporal profile is consistent with mechanical stimulation of the skeleton in response to asymmetrical muscle use as handedness becomes manifest.

Objective: A site-specific bone loading index was developed to predict post-menarcheal arm bone mass, geometry, areal density and non-bone lean mass using organized activity records. Methods: Two cohorts of post-menarcheal girls (A= 55, B= 48) met analysis inclusion criteria: 1) Whole body and non-dominant radius DXA scans +1.0 to +2.6 years post-menarche; 2) detailed, organized activity records available for 36 months prior to the focal DXA scan; 3) accompanying anthropometric data. DXA non-dominant arm and radius regions of interest (1/3, Ultradistal (UD)) were evaluated. An arm bone loading index (arm totBLI) was developed and refined to describe >50 activities. Separate regression analyses for Cohorts A&B tested explanatory value of arm totBLI for DXA outcomes, accounting for gynecological age, height and whole body non-bone lean mass. Results: In both cohorts, arm totBLI reflecting 3 years of peri-menarcheal activity exposure exhibited strong explanatory value for post-menarcheal radius and arm outcomes (squared semi-partial r =0.07-0.34, p

We present the first report of the development of characteristic radiologic appearances of long bones during the first year of life in an infant with type V osteogenesis imperfecta (OI). We show the evolution of metaphyseal abnormalities from a rickets-like appearance to the classically described dense metaphyseal bands. These abnormalities suggest that the underlying defect in type V OI may involve a molecule common to both bone and cartilage that is involved in the regulation of growth plate development and metadiaphyseal ossification. Our findings provide new insights into skeletal development in type V OI and potentially yield useful clues to the identity of the defect underpinning the condition.

Background: There is scarce information regarding osteoarticular tuberculosis of the elbow in children, even in countries where tuberculosis is endemic. We report our experience with ten patients who were managed nonoperatively. Methods: We retrospectively assessed ten children with elbow tuberculosis with regard to their presentation, diagnosis, management, response to standard antitubercular drugs, and outcome at the completion of antitubercular therapy. All patients were managed nonoperatively with splinting for as long as six weeks, followed by mobilization along with multidrug antitubercular medication for twelve months. Results: Swelling of the elbow that did not respond to initial treatment was the most common cause for referral to our clinic. The proximal ulnar metaphysis was most commonly involved. The average duration of follow-up was twenty-six months. The average time for healing of draining sinuses was twelve weeks (range, four to fourteen weeks). Lytic lesions, including coke-like sequestrum, healed radiographically at an average of 7.4 months (range, six to nine months). Range of motion improved with treatment, but some motion restriction always persisted, depending on the extent of joint destruction. Conclusions: In the Indian subcontinent, the presentation of elbow tuberculosis is usually exudative with abscess formation, and the disease is fairly advanced at the time of diagnosis. An “ice cream scoop” appearance of the proximal part of the ulna in children should raise suspicion for tuberculosis. Elbow tuberculosis in children can be treated adequately with use of nonoperative means, regardless of the extent of osseous destruction, with a good outcome. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

To determine if gestational age (GA) at the time of ultrasound impacts the positive predictive value of shortened femur and humerus lengths (FL, HL) for trisomy 21 (T21).Sonograms from 14 to 21 and 6/7 weeks' gestation were collected over a 28 month period. Multiple gestations or fetuses with major structural anomalies were excluded. Biometric data and GA were obtained; the expected HL (or FL): observed HL (or FL) ratios were calculated using two regression formulas (Benacerraf and Nyberg). A HL ratio0.90 and a FL ratio0.91 were considered shortened. T21 fetuses were identified through database and chart review. Positive predictive values (PPV) for T21 of the shortened bone ratios were determined, then stratified by GA.Of the 2606 ultrasounds, 8.9% and 18.9% of fetuses had shortened HL and FL ratios, respectively, using the Benacerraf formula. Shortened ratios were noted significantly less commonly (2.3 and 4.4%, respectively, P0.001 for each) using the Nyberg formula. With either formula, abnormal bone ratios were more frequently documented with a GA less than 17 weeks (P0.001). There were 17 T21 pregnancies.GA and formula selection influence the performance of long bone ratios as soft markers for T21 in the second trimester.

Studies that investigate the relationships between the main elbow flexion crease and the underlying osseous anatomy are lacking. The relationship between the flexion skin crease and osseous anatomy of the elbow joint was studied. Markers were placed along the main flexion skin crease of both elbows in 50 healthy volunteers. Measurements were expressed in millimeters of perpendicular distance from each skin crease to the osseous structures of the elbow joint including medial and lateral epicondyles, tip of the olecranon, and radial head. The mean perpendicular distances between the elbow crease from osseous structures were found to be as follows: from medial epicondyle, 6.93 mm; from lateral epicondyle, −0.25 mm; from olecranon, 9.97 mm; and from radial head, −21.97 mm. There was no statistical significant difference between the dominant versus non-dominant hand. The association between the main flexion elbow crease and the bony structures observed in this study seems to support that the elbow crease can be a useful surface anatomy landmark and expected to aid in the placement of surgical incisions.

To investigate the non-weight-bearing effect of trunk fat mass (composed of visceral and subcutaneous fat mass) and peripheral fat mass (subcutaneous fat mass alone) on bone mineral density (BMD) in pre- and post-menopausal women.The subjects were 412 pre-menopausal women, 20-50 years of age and 228 post-menopausal women, 50-75 years of age. Age, years since menopause (YSM), height, body weight, and body mass index were recorded. Trunk, peripheral (extremities), left arm (non-weight-bearing site), lean mass, and BMD were measured by dual-energy X-ray absorptiometry.In pre-menopausal women, the amount of trunk fat mass was 6.8+/-4.1 kg, which was significantly lower than the amount of peripheral fat mass (11.6+/-3.8 kg, p0.001). Although trunk fat mass was positively correlated with arm BMD on Pearson's correlation test, arm lean mass was the only significant predictor of BMD on multiple regression analysis. In post-menopausal women, the amount of trunk fat mass (8.7+/-3.6 kg) was also significantly lower than the peripheral fat mass (10.3+/-3.4 kg, p0.001). On multiple regression analysis, however, trunk fat mass, but not arm lean mass, was the significant predictor of BMD. In both groups, peripheral fat mass was not correlated with left arm BMD.The effect of adipocyte-derived biochemical factors on BMD may differ with menopausal status and the sites of adipocyte deposition.

Twenty five adult chimpanzee skeletons (Pan troglodytes verus) of known age and sex (15 females, 10 males) from a long-term study site in Taï National Park, Cote d'Ivoire present new data on variation. These skeletons provide a rare opportunity to measure the cranium and postcranium from the same individuals. We compare measurements and indices of the Taï sample with those of relatively complete Pan troglodytes schweinfurthii skeletons from Gombe National Park, Tanzania. Measurements of Pan paniscus are included as an outside comparison. The Taï and Gombe samples are analyzed by sex; combined sex samples are compared between the two groups, and the two sexes to each other. Taï females and males do not differ in most long bone lengths or in pelvic dimensions, but do differ significantly in cranial capacity, facial measurements, clavicle length, scapular breadth, and femur length. Gombe females and males differ significantly in some facial measurements and in scapular breadth. In combined sex samples, Taï individuals have lower cranial capacity, longer palate and mandible, and greater dimensions in the trunk and limb lengths. Taï females account for most of the variation; males differ from each other only in greater length of humerus and femur. The Taï skeletons provide new data for assessing individual variation and sexual dimorphism within and between populations and species. The combination of cranial and postcranial data provides a clearer picture of chimpanzee intraspecific and interspecific variation than can be gained from either data set alone.

Vascularised bone graft is a well accepted technique when dealing with long defects. Its role in refractory nonunion, in small defects and in the growing patient is rarely discussed. In this paper the authors review the different alternatives to deal with bone defects in the upper extremity. The indications of vascularised corticoperiosteal graft for solving small defects harbouring refractory nonunion, and the use of vascularised bone phalanx and metatarsal for complex - but small - defects in the fingers is presented. The ability of the bone to grow and remodel when a living epiphysis is included, and to maintain the cartilage viability when a composite osteochondral graft is transferred are also discussed.

Successful management of osteosarcoma with limb salvage surgery is a challenging problem in the developing world. We report our early results with low-cost chemotherapy (without methotrexate) and low-cost limb salvage surgery. We prospectively collected data for 135 patients with histologically proven high-grade osteosarcoma of the extremities given neoadjuvant chemotherapy and treated with limb salvage surgery between January 2000 and February 2004. A locally designed and fabricated stainless steel customized megaprosthesis was used in 78 patients. Disease status and function was evaluated at followup ranging from 24 to 72 months. Followup data were available for 120 of the 135 patients. There were eight infections, four prosthesis breakages and three loosenings. Eighteen patients had local recurrence; 17 of these patients also developed lung metastases. Seventy-three patients (61%) were disease-free at followup. The group of 34 patients with 100% necrosis had better disease-free survival (79%). According to a modified Enneking system, the average functional score was 25.5 of 30 (85%) for the lower extremity and 20 of 30 (66%) for the shoulder. Our preliminary results suggest osteosarcoma can be managed well in a developing country in a cost-effective way. Limb salvage surgery has now become the standard of care.

In malignant surface tumors, hemicortical excision in select cases may allow adequate margins with better function. We treated 10 of 22 malignant surface tumors with hemicortical excision and reconstruction from January 2000 to June 2003. There were eight conventional parosteal osteosarcomas, one high-grade surface osteosarcoma, and one surface chondrosarcoma. Six tumors occurred in the femur, two in the tibia and one each in the humerus and radius. Defects were reconstructed with allograft (five), fibula autograft (three), or autogenous iliac crest (two). Internal fixation as suitable was used. Margins were reported uninvolved in all cases. At followup ranging from 40 months to 61 months we observed no local recurrence. Using the MSTS scoring system, six patients had a maximum possible score of 30; the other four had a score of 29. None developed distant metastasis. Though a longer followup is ideal, in selected cases hemicortical excision appears a reasonable procedure that obviates joint replacement. Biological reconstruction with bone could help reduce the incidence of subsequent revision surgery that would likely occur in cases treated initially with conventional excision and replacement with megaprostheses or circumferential intercalary allografts.

The vascularised corticoperiosteal graft was introduced by Sakai and Doi, in 1991, as a means to achieve bony union under unfavourable conditions. We present our experience with this vascularised graft, taken from the femoral condyle, in six patients with difficult non-unions (5) or other bony problems (1) in the upper limb. In five cases, a long bone defect—two humeral, two ulnar and one radial—was involved. All had had between three and seven previous operations. Two of the non-unions were secondary to infection. The others had had conventional grafting on two or three previous occasions each. In the sixth case, a corticoperiosteal graft was used to promote healing in a combined carpometacarpal and intercarpal dislocation with a very poor bed. All of the grafts survived without complications and all of the bones healed radiologically in less than three months. Three patients achieved a normal range of motion and two obtained a functional range of motion with only slight limitations. The carpometacarpal arthrodesis was healed soundly at five weeks.