In 14 rabbits we determined the origin of the cells effecting healing of the tendon of supraspinatus inserted into a bony trough. After two weeks both the cellularity of the underlying bone and the thickness of the subacromial bursa were significantly increased in the operated compared with the control shoulders. The cellularity of the stump of the tendon, however, was significantly decreased in the operated shoulders. In this model, both the underlying bone and the subacromial bursa but not the stump of the tendon contributed to the process of repair. We conclude that the medial stump should be debrided judiciously but that cutting back to bleeding tissue is not necessary during repair of the rotator cuff. Moreover, great care should be taken to preserve the subacromial bursa since it seems to play an important role in the healing process

Quantitative polarised light microscopy was applied to sections of unfixed, undecalcified bone taken at operation from patients with two types of proximal femoral fracture, subcapital and trochanteric. Specimens were also taken from the equivalent sites in otherwise normal subjects at autopsy, and from various other sites of traumatic fractures; these two latter groups acted as controls. Analysis of the 57 specimens disclosed changes in the nature of the bone at the site of subcapital fractures, namely the presence of relatively large crystals of hydroxyapatite and a change in the molecular orientation, but not total content, of the acidic proteoglycans of the bone matrix. Our results have confirmed and extended the findings of others on subcapital fractures, and have also shown very similar changes in the trochanteric fractures. It thus appears that the bony changes in the two types of proximal femoral fracture are not as different as has been suggested

We describe an unusual case of a postoperative bone cyst resulting from a retained fragment of surgical glove. We highlight some of the problems associated with gloves and suggest ways of safeguarding against similar complications

Radiopaque solutions and suspensions introduced into cancellous bone in the extremities of the cadaver are rapidly removed into the venous system through regional superficial or deep veins. The experiments described in this communication confirm the simplicity of methods of introduction of fluids into cancellous bone and justify further observations on their clinical application for the technique of phiebography

We evaluated the efficacy of Escherichia coli-derived recombinant human bone morphogenetic protein-2 (E-BMP-2) in a mini-pig model of spinal anterior interbody fusion. A total of 14 male mini-pigs underwent three-level anterior lumbar interbody fusion using polyether etherketone (PEEK) cages containing porous hydroxyapatite (HA). Four groups of cages were prepared: 1) control (n = 10 segments); 2) 50 μg E-BMP-2 (n = 9); 3) 200 μg E-BMP-2 (n = 10); and 4) 800 μg E-BMP-2 (n = 9). At eight weeks after surgery the mini-pigs were killed and the specimens were evaluated by gross inspection and manual palpation, radiological evaluation including plain radiographs and micro-CT scans, and histological analysis. Rates of fusion within PEEK cages and overall union rates were calculated, and bone formation outside vertebrae was evaluated. One animal died post-operatively and was excluded, and one section was lost and also excluded, leaving 38 sites for assessment. This rate of fusion within cages was 30.0% (three of ten) in the control group, 44.4% (four of nine) in the 50 μg E-BMP-2 group, 60.0% (six of ten) in the 200 μg E-BMP-2 group, and 77.8% (seven of nine) in the 800 μg E-BMP-2 group. Fusion rate was significantly increased by the addition of E-BMP-2 and with increasing E-BMP-2 dose (p = 0.046). In a mini-pig spinal anterior interbody fusion model using porous HA as a carrier, the implantation of E-BMP-2-loaded PEEK cages improved the fusion rate compared with PEEK cages alone, an effect that was significantly increased with increasing E-BMP-2 dosage. Cite this article: Bone Joint J 2013;95-B:217–23

To ascertain whether patients with Colles’ fracture should be investigated for osteoporosis and the risk of future fractures, we measured the bone mineral density of the distal radius of the other arm in 31 women patients and compared the results with those of a control group of 289 normal women. We divided the patients into two groups, those younger than 66 years and those older. In 25 patients we found values for bone mineral density which were lower than one standard deviation below the mean value for their age. Younger patients had a deficit greater than that expected for their ages. We believe that women with Colles’ fracture should be evaluated routinely for osteoporosis, particularly if they are under 66 years of age

A clay containing hydroxyapatite (HA) was developed for use as a filling material between an uncemented implant and bone. It consists of 55% HA granules greater than 0.1 mm in size with a homogeneous pore distribution and a porosity of 35% to 48% in a saline solution of sodium alginate (6%). Ti-6A1-4V alloy rods with smooth surfaces were implanted into the distal medullary canal of one osteotomised tibia of 32 Japanese white rabbits. Sixteen rods were inserted with HA clay and 16 without the clay to act as a control group. Six of each group were killed at one week and ten at 12 weeks postoperatively. The pull-out strength of the implants with HA clay was significantly greater at 12 weeks (p < 0.05), as was the percentage of the area of the new bone (p < 0.05). The study suggests that HA clay has an osteoconductive property, allowing adequate bone fixation across a gap at an early stage. The use of HA clay to enhance the early stability of uncemented components may help to improve the functional outcome of total joint arthroplasty

We used single-photon absorptiometry to assess the forearm bones after the removal of internal fixation plates in 14 patients. We found convincing evidence of cortical atrophy in only one patient, in whom the plates had been removed prematurely after only 16 months. It is suggested that such plates should be retained for at least 21 months, to allow bone density to return to its prefracture level. The recommendations of the AO/ASIF group are supported

We retrospectively compared the outcome after the treatment of giant cell tumours of bone either with curettage alone or with adjuvant cementation. Between 1975 and 2008, 330 patients with a giant cell tumour were treated primarily by intralesional curettage, with 84 (25%) receiving adjuvant bone cement in the cavity. The local recurrence rate for curettage alone was 29.7% (73 of 246) compared with 14.3% (12 of 84) for curettage and cementation (p = 0.001). On multivariate analysis both the stage of disease and use of cement were independent significant factors associated with local recurrence. The use of cement was associated with a higher risk of the subsequent need for joint replacement. In patients without local recurrence, 18.1% (13 of 72) of those with cement needed a subsequent joint replacement compared to 2.3% (4 of 173) of those without cement (p = 0.001). In patients who developed local recurrence, 75.0% (9 of 12) of those with previous cementation required a joint replacement, compared with 45.2% (33 of 73) of those without cement (p = 0.044)

We performed a prospective, randomised study on 110 patients more than 50 years old with fractures of the distal radius to compare the outcome of conservative treatment with that using remodellable bone cement (Norian skeletal repair system, SRS) and immobilisation in a cast for two weeks. Patients treated with SRS had less pain and earlier restoration of movement and grip strength. The results at one year were satisfactory in 81.54% of the SRS patients and 55.55% of the control group. The rates of malunion were 18.2% and 41.8%, respectively. There was a significant relationship between the functional and radiological results. Soft-tissue extrusion was present initially in 69.1% of the SRS patients; most deposits disappeared progressively, but persisted in 32.73% at one year. We conclude that the injection of a remodellable bone cement into the trabecular defect of fractures of the distal radius provides a better clinical and radiological result than conventional treatment

Heterotopic ossification occurring after the use of commercially available bone morphogenetic proteins has not been widely reported. We describe four cases of heterotopic ossification in patients treated with either recombinant bone morphogenetic protein 2 or recombinant bone morphogenetic protein 7. We found that while some patients were asymptomatic, heterotopic ossification which had occurred around a joint often required operative excision with good results

1. Some physical properties of living and dead bone have been studied in rats; most of these are interrelated and ultimately depend upon the composition of the tissue. 2. Dead bone, remaining within the body, does not take up measurable amounts of mineral from the tissue fluid but retains its original physical properties of radiographic density, specific gravity, strength and composition. 3. The altered radiographic density of avascular bone seen in clinical practice is almost certainly relative unless there has been concomitant appositional new bone formation. 4. Some other explanation must be sought for the finding that dead bone takes up significant amounts of bone-seeking isotopes in radioactive tracer studies

We reviewed 32 children after the treatment of simple bone cysts by intralesional injections of methyl-prednisolone acetate. The age of the child and the activity and size of the cyst did not significantly affect the radiological outcome. The earliest time at which the radiological response could be reliably determined was three months. After a median period of review of five years, four (13%) cysts had healed, 20 (62%) cysts were partially visible but sclerotic, four (12.5%) were still visible but opaque and four (12.5%) were clearly visible. The healed and partially visible but sclerotic cysts were classified as having satisfactory radiological healing. This was observed in 13 of 32 cysts (41%) after the first injection, in eight of 21 (38%) after the second injection, but in relatively few of the remaining cysts after subsequent injections. A satisfactory symptomatic outcome was achieved in all of the 18 children with humeral cysts and in the one child with a fibular cyst irrespective of the radiological outcome, but only in nine (67%) of the 13 children with femoral or tibial lesions, in whom the cysts were healed or sclerotic. The remaining four children had exertional bone pain and repeated fractures of their femoral or tibial cysts which were incompletely healed with sclerosis in one and opacities in three. We conclude that the healing response to intralesional corticosteroids is unpredictable and usually incomplete even after multiple injections. The failure rate in weight-bearing bones is too high

There has been an increase in the incidence of bone and joint tuberculosis (BJTB) in The Netherlands and we have carried out an epidemiological study in order to find an explanation for this increase. Data from 1993 to 2000 from The Netherlands Tuberculosis Register (NTR) were used. In 1993 there was a total of 52 patients with BJTB. This figure increased gradually to 80 in 1999 before decreasing to 61 in 2000. There was a total of 12 447 patients with tuberculosis; BJTB was found in 532, accounting for 4.3% of all cases and 10.6% of all extrapulmonary cases. Localisation in the spine occurred in 56%. Certain immigrants, in particular from Somalia, were more likely to have BJTB than other immigrants or the native Dutch population. Increased age and female gender were associated with BJTB. Only 15% of BJTB patients also suffered from pulmonary tuberculosis. The usual long delay in the diagnosis of BJTB may be shortened if physicians are more aware of tuberculosis

We have performed a form of lunate replacement arthroplasty, which included excision of the lunate and insertion of a vascularised radial bone flap wrapped in pronator quadratus, for stage IIIB or stage IV Kienböck’s disease, in 41 patients who have been followed up for more than three years. All patients reported an improvement in their symptoms, and 20 of the 41 became free of pain after the operation. Extension and flexion of the wrist were increased by a mean of 9° and 6°, respectively (p < 0.05). The radioscaphoid angle and the carpal height ratio were not significantly changed and only minimal deterioration was observed due to degenerative change. The size, density or location of the inserted bone did not change with time. A vascularised radial bone flap wrapped in pronator quadratus can be a reliable treatment option for advanced Kienböck’s disease, when the pedicled bone and muscle envelope acts as a stable spacer for the excised lunate

The clinical, radiographic and pathological features of eighty-eight cases of histologically verified intra-osseous ganglia in eighty-three patients are described. All were located in the subchondral bone adjacent to a joint and most frequently involved the hip, the ankle (medial malleolus), the knee and the carpal bones. Forty-seven of the eighty-three patients were male and all the patients were between fourteen and seventy-three years of age, with an average age of forty-one years. There are two fundamental types of intra-osseous ganglia, one apparently arising by penetration of juxta-osseous ganglion into the underlying bone, a mechanism proved in fourteen of our eighty-eight cases (16 per cent); in the remaining seventy-four cases, the ganglion cyst was primarily intra-osseous ("idiopathic"). The initial cause of the intramedullary mucoid degeneration is discussed. We believe that mechanical stress and repeated minor trauma near the surface of the bone may lead to intramedullary vascular disturbance with consequent foci of aseptic bone necrosis. The revitalisation of these areas causes fibroblastic proliferation, followed by mucoid degeneration of the connective tissue, possibly due to some unknown local factor. Curettage or excision is usually effective, and recurrence (only four cases) is exceptional

The management of chronic osteomyelitis requires the excision of necrotic and infected material followed by the prolonged administration of antibiotics. Sequestrectomy may be required before an involucrum has formed, resulting in a longitudinal bone defect. This can be difficult to fill. Vascularised grafts are complicated by a high rate of recurrent infection and thrombosis. We have managed defects of long bones in children after sequestrectomy by the use of non-vascularised fibular grafts harvested subperiosteally and held by an intramedullary Kirschner wire. Eight children underwent this procedure. In six the tibia was involved and in one each the humerus and radius. One patient was lost to follow-up. Six grafts united at both ends within 12 weeks. The seventh developed an infected nonunion distally which united after further debridement. One patient required a further sequestrectomy which did not compromise union. We have found this to be a straightforward technique with reliable results and were able to salvage the limb in all the seven patients who were reviewed

1. Sections were cut from the third metacarpal, the radius, the femur and the third lumbar vertebra of thirty-four male and twenty-one female cadavera. The mineral content of these different specimens was measured by ashing and the relationships between the quantity of bone mineral present at these sites were examined. 2. In the females the whole bone density and mineral/unit length at both the midshaft metacarpal and the midshaft radius correlated significantly with the whole bone density at all the other sites. 3. In the males these correlations were much less significant and no significant correlation was found between the whole bone density of either the metacarpal midshaft or the radial midshaft and that of the third lumbar vertebra or the distal femur, although a highly significant correlation was found between those of the distal femur and the lumbar vertebra. 4. It is suggested that in women, measurements of either mineral/unit length or whole bone density of both the midshaft metacarpal and radius provide useful information on the whole bone densities at other sites throughout the skeleton. This work was supported by the Scottish Hospital Endowments Research Trust, the National Fund for Research into Crippling Diseases and G. D. Searle and Co. Ltd., High Wycombe

1. The incidence of osteogenic sarcoma, chondrosarcoma and Ewing's sarcoma in relation to age, sex and site is analysed in a study of 832 malignant primary bone tumours diagnosed in Sweden in 1958-68. The results are compared with those in other series. 2. The adolescent incidence peak for osteogenic sarcoma is caused by tumours localised to the long bones of the lower limb. The peak incidence occurs at a mean age of twelve years for girls and sixteen years for boys and is associated with the maximum growth velocity for the adolescent growth spurt. 3. Ewing's sarcoma, showing no sex difference with regard to its incidence peak, seems not to be associated with bone growth. 4. In the adult, the incidence of osteogenic sarcoma parallels that of chondrosarcoma, thus showing a successive increase with increasing age. In Sweden, where Paget's disease is uncommon, the incidence of osteogenic sarcoma over the age of thirty is only one-third of that during adolescence. 5. In osteogenic sarcoma and chondrosarcoma but not in Ewing's sarcoma, the characteristic predominance of males over females is valid only for localisations to the long bones of the lower limb, the pelvis and the spinal column and not for other sites. Internal factors such as age, sex, bone growth and maturation and also weight-bearing seems to be of importance in modifying the response of the tissue to a causative external factor, like a common virus

1. Five cases of pigmented villonodular synovitis with associated lesions within bone are recorded, two in the hip, two in the knee and one in the elbow. 2. The mode of formation of these intraosseous lesions is explained and methods of treatment are discussed