Winston Rennie

High impact exercise increased femoral neck bone mineral density in older men: a randomised unilateral intervention.

INTRODUCTION There is little evidence as to whether exercise can increase BMD in older men with no investigation of high impact exercise. Lifestyle changes and individual variability may confound exercise trials but can be minimised using a within-subject unilateral design (exercise leg [EL] vs. control leg [CL]) that has high statistical power. PURPOSE This study investigated the influence of a 12month high impact unilateral exercise intervention on femoral neck BMD in older men. METHODS Fifty, healthy, community-dwelling older men commenced a 12month high impact unilateral exercise intervention which increased to 50 multidirectional hops, 7days a week on one randomly allocated leg. BMD of both femurs was measured using dual energy X-ray absorptiometry (DXA) before and after 12months of exercise, by an observer blind to the leg allocation. Repeated measures ANOVA with post hoc tests was used to detect significant effects of time, leg and interaction. RESULTS Thirty-five men (mean±SD, age 69.9±4.0years) exercised for 12months and intervention adherence was 90.5±9.1% (304±31 sessions completed out of 336 prescribed sessions). Fourteen men did not complete the 12month exercise intervention due to: health problems or injuries unrelated to the intervention (n=9), time commitments (n=2), or discomfort during exercise (n=3), whilst BMD data were missing for one man. Femoral neck BMD, BMC and cross-sectional area all increased in the EL (+0.7, +0.9 and +1.2 % respectively) compared to the CL (-0.9, -0.4 and -1.2%); interaction effect P<0.05. Although the interaction term was not significant (P>0.05), there were significant main effects of time for section modulus (P=0.044) and minimum neck width (P=0.006). Section modulus increased significantly in the EL (P=0.016) but not in the CL (P=0.465); mean change +2.3% and +0.7% respectively, whereas minimum neck width increased significantly in the CL (P=0.004) but not in the EL (P=0.166); mean changes being +0.7% and +0.3% respectively. CONCLUSION A 12month high impact unilateral exercise intervention was feasible and effective for improving femoral neck BMD, BMC and geometry in older men. Carefully targeted high impact exercises may be suitable for incorporation into exercise interventions aimed at preventing fractures in healthy community-dwelling older men.

The Influence of High-Impact Exercise on Cortical and Trabecular Bone Mineral Content and 3D Distribution Across the Proximal Femur in Older Men: A Randomized Controlled Unilateral Intervention

Regular exercisers have lower fracture risk, despite modest effects of exercise on bone mineral content (BMC). Exercise may produce localized cortical and trabecular bone changes that affect bone strength independently of BMC. We previously demonstrated that brief, daily unilateral hopping exercises increased femoral neck BMC in the exercise leg versus the control leg of older men. This study evaluated the effects of these exercises on cortical and trabecular bone and its 3D distribution across the proximal femur, using clinical CT. Fifty healthy men had pelvic CT scans before and after the exercise intervention. We used hip QCT analysis to quantify BMC in traditional regions of interest and estimate biomechanical variables. Cortical bone mapping localized cortical mass surface density and endocortical trabecular density changes across each proximal femur, which involved registration to a canonical proximal femur model. Following statistical parametric mapping, we visualized and quantified statistically significant changes of variables over time in both legs, and significant differences between legs. Thirty‐four men aged mean (SD) 70 (4) years exercised for 12‐months, attending 92% of prescribed sessions. In traditional regions of interest, cortical and trabecular BMC increased over time in both legs. Cortical BMC at the trochanter increased more in the exercise than control leg, whereas femoral neck buckling ratio declined more in the exercise than control leg. Across the entire proximal femur, cortical mass surface density increased significantly with exercise (2.7%; p < 0.001), with larger changes (> 6%) at anterior and posterior aspects of the femoral neck and anterior shaft. Endocortical trabecular density also increased (6.4%; p < 0.001), with localized changes of > 12% at the anterior femoral neck, trochanter, and inferior femoral head. Odd impact exercise increased cortical mass surface density and endocortical trabecular density, at regions that may be important to structural integrity. These exercise‐induced changes were localized rather than being evenly distributed across the proximal femur.

Computed Tomography-Guided Coblation and Cementoplasty of a Painful Acetabular Metastasis: An Effective Palliative Treatment

Percutaneous cementoplasty is an effective palliative treatment for acetabular metastases. Potential problems with this technique include inadequate filling and intra-articular cement leakage, leading to increased hip pain. We present a case of metastatic non-small cell lung cancer in which we illustrate how using radiofrequency coblation prior to cement injection creates a well-defined cavity allowing controlled cement injection limiting cement extrusion. To the best of our knowledge this is the first report in which coblation of an acetabular metastasis prior to cement filling has been performed.

Correlation between trochlear dysplasia and anterior cruciate ligament injury

Purpose. To evaluate the correlation between trochlear dysplasia and anterior cruciate ligament (ACL) injury Methods. Magnetic resonance images (MRIs) of 95 knees in 54 males and 36 females aged 4 to 74 (mean, 28) years who had anterior knee pain and suspected ligamentous injury were reviewed. The MRIs were independently reviewed by 2 musculoskeletal radiologists on 2 occasions. According to the Dejour classification, trochlear dysplasia was classified into types A, B, C, and D. Intra-articular injuries/disorders of the patients included patellofemoral osteoarthritis, chondromalacia patella, meniscal tears, and ligamentous injuries. Intra- and inter-observer variability was calculated. Results. 58 of the knees had trochlear dysplasia, 38 of which were Dejour type A. The intra- and inter-observer variability was good to excellent (Kappa=0.76–1). ACL tear was the most common injury (n=13). No ACL injury occurred in patients without trochlear dysplasia. The odds of having sustained an ACL injury were 8.8 fold greater in Dejour type-A knees than in non–type-A knees (p=0.023). Conclusion. Dejour type-A trochlear dysplasia was associated with ACL injuries.

Wii knee revisited: meniscal injury from 10-pin bowling.

The present report concerns a 23-year-old woman who sustained an injury to her right knee while playing 10-pin bowling on a Nintendo Wii video game console. She presented to our orthopaedic outpatients clinic 3 months later with history and examination findings suggestive of a medial meniscal tear, which was confirmed by MRI scan. She underwent arthroscopic partial medial meniscectomy and made an uneventful recovery.

Correlation between trochlear dysplasia and the notch index.

Purpose. To evaluate the correlation between trochlear dysplasia and the notch index. Methods. Magnetic resonance images (MRI) of 95 knees in 54 male and 36 female patients aged 4 to 74 (mean, 28) years were reviewed by 2 musculoskeletal radiologists. Standard MRI sequences were used. Based on the Dejour classification of trochlear dysplasia, the knees were classified into normal or types A, B, C, and D. A notch index of <0.2 was considered narrow. Normal knees and knees with trochlear dysplasia were compared. Results. 60 of the 95 knees had trochlear dysplasia, of which 39 were Dejour type A, 13 were type B, 7 were type C, and one was type D. Dejour types B, C, and D were combined as non-type A. Inter-observer agreement in assessing the notch index was good (Kappa=0.6). The mean notch indices in normal knees and knees with trochlear dysplasia were comparable (0.161 vs. 0.157, p=0.18), as were in Dejour type A and non-type A knees (0.154 vs. 0.160, p=0.54) and in Dejour types A, B, C, and D knees (0.154 vs. 0.165 vs 0.153 vs. 0.2, p=0.17–0.7). The rate of ACL injuries was similar in patients with normal knees and those with type-A trochlear dysplasia. A low notch index (narrow notch) was not associated with ACL injury. Conclusion. The notch index and trochlear morphology are 2 independent entities. A narrow notch does not imply a shallow trochlear grove.

A rare cause of late-onset cerebellar ataxia: Erdheim-Chester disease.

Non-Langerhans cell histiocytosis is an extremely uncommon, still poorly understood, but frequently fatal, multisystemic disorder occurring most frequently in the fifth or sixth decade of life. Fewer than 400 cases have been reported to date worldwide [1]. This disorder was first reported by Jakob Erdheim and William Chester in 1930 [2] and the name “Erdheim–Chester disease” (ECD) was coined in the 1970s. Bone pain and cardiorespiratory and renal involvement are frequent but associated central nervous system involvement is exceptional in this already rare disease. The prognosis in ECD remains to date poor, with most patients dying within 3 years of diagnosis, although possibly improved with available new therapies which may prolong survival. We here report a patient with a progressive cerebellar presentation of late onset, whose investigations led to an initially unexpected diagnosis of ECD. A 58-year-old man presented with a progressively worsening sense of unsteadiness for 6 months. He developed slurred speech and started having falls. There was no history of any preceding neurological or psychiatric symptoms, diabetes, hypertension or hypercholesterolaemia. He was a non-smoker and did not consume alcohol. There was no family history of neurological problems. Written informed consent was obtained from the patient prior to submission of this report. On initial examination, cognitive function was intact with Mini Mental Score Examination of 30/30. There was mild proptosis, normal visual acuity and visual fields with normal extra ocular movements and pursuits. There was no gazeevoked nystagmus. Cranial nerve functions were normal. Deep tendon reflexes were brisk, with pendular knee jerks. Plantar responses were flexor. Marked limb and trunk cerebellar ataxia was present, with finger-to-nose and heel-toshin dysmetria, base widening and very unsteady gait requiring support. Sensory examination was normal to all modalities including vibration and joint position in the distal lower limbs. There were no extrapyramidal signs. Magnetic resonance imaging (MRI) of the brain demonstrated T2-weighted diffuse white matter hyperintensities in the middle cerebellar peduncle, pons and cerebellum (Fig. 1a). There was patchy contrast enhancement (not shown). No orbital abnormalities were detected. Computed tomography (CT) of thorax, abdomen and pelvis showed retroperitoneal fibrosis, with a “hairy kidney” appearance (Fig. 1c). HIV, hepatitis and syphilis serologies, coeliac screen including anti-gliadin antibodies of IgG and IgA subtypes, autoantibody screen, creatine kinase, tumour markers, white cell enzymes, very long chain fatty acids, alpha-fetoprotein level, serum copper and caeruloplasmin, serum vitamin E, thyroid function tests and angiotensin S. V. Shanmugam :M. Kolappan :Y. A. Rajabally Department of Neurology, University Hospitals of Leicester, Leicester LE5 4PW, UK

Ganglia Arising from the Transverse Acetabular Ligament: A Report of Two Cases

Ganglia arising from the hip are rare. Its diagnosis is difficult owing to the anatomic location. A high index of suspicion and high-resolution imaging is essential to make the diagnosis. Treatment depends on the size, location, and symptoms. This report is of 2 patients with ganglia arising from the transverse acetabular ligament.

Coracoid impingement treated with corrective osteotomy. A case report

Coracoid impingement syndrome is a rare cause of anterior shoulder pain. It is mainly a diagnosis of exclusion after considering the more common subacromial impingement. We describe a case of coracoid impingement and a novel approach to its management: coracoid osteotomy as opposed to the more commonly used technique of coracoplasty. A review of the literature is also presented in relation to this condition. Coracoid osteotomy with internal fixation allows good stability with reliable direct bone-to-bone healing. Coracoid osteotomy is a reliable and a satisfactory alternative to the more commonly-used technique of coracoplasty for the treatment of idiopathic coracoid impingement syndrome.