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Concept: Iliac crest


The term, hip pointer, is applied in the setting of a blunt trauma injury to the iliac crest. It typically occurs in contact and collision sports and can cause significant pain and loss of practice or game time. A direct blow results in subperiosteal edema with hematoma formation within surrounding muscle or soft tissue and bone contusion of the iliac crest. Conservative management with compression, ice, antiinflammatories, and rehabilitation exercises are successful in treating hip pointers. Injection therapy with the use of local anesthetic can be helpful in minimizing pain and increasing function to allow more rapid return to play.

Concepts: Monotonic function, Injuries, Hematoma, C, Iliac crest, Bruise, Pelvis, Function


[Purpose] It has been reported that exercises focusing upon the transversus abdominis (TrA) ameliorate low back pain (LBP). We investigated whether expiratory muscle training (EMT) can promote activity of the TrA to the same degree as the abdominal drawing-in manoeuvre (ADIM) in elderly individuals. [Subjects and Methods] Twenty-one elderly subjects (9 males, 12 females; mean age, 84.9 ± 6.6 years) without LBP symptoms were included. Using ultrasound imaging we measured changes in thickness of the lateral abdominal muscles, TrA, internal oblique muscle (IO), and external oblique muscle (EO) during ADIM and EMT. The load in EMT was set to 15% of maximal expiratory pressure. [Results] TrA showed a significant increase in muscle thickness during ADIM and EMT compared with at rest. A significant increase in muscle thickness was noted for EMT in comparison with ADIM. No significant differences were found for IO and EO. [Conclusion] In elderly people, EMT may be an effective alternative to ADIM for promoting activity of the TrA and can be used as an exercise to maintain TrA function.

Concepts: Abdominal internal oblique muscle, Transversus abdominis muscle, Physical exercise, Abdomen, Iliohypogastric nerve, Muscles of the torso, Abdominal external oblique muscle, Iliac crest


Meniscal cartilage tears are common and predispose to osteoarthritis (OA). Most occur in the avascular portion of the meniscus where current repair techniques usually fail. We described previously the use of undifferentiated autologous mesenchymal stem cells (MSCs) seeded onto a collagen scaffold (MSC/collagen-scaffold) to integrate meniscal tissues in vitro. Our objective was to translate this method into a cell therapy for patients with torn meniscus, with the long-term goal of delaying or preventing the onset of OA. After in vitro optimization, we tested an ovine-MSC/collagen-scaffold in a sheep meniscal cartilage tear model with promising results after 13 weeks, although repair was not sustained over 6 months. We then conducted a single center, prospective, open-label first-in-human safety study of patients with an avascular meniscal tear. Autologous MSCs were isolated from an iliac crest bone marrow biopsy, expanded and seeded into the collagen scaffold. The resulting human-MSC/collagen-scaffold implant was placed into the meniscal tear prior to repair with vertical mattress sutures and the patients were followed for 2 years. Five patients were treated and there was significant clinical improvement on repeated measures analysis. Three were asymptomatic at 24 months with no magnetic resonance imaging evidence of recurrent tear and clinical improvement in knee function scores. Two required subsequent meniscectomy due to retear or nonhealing of the meniscal tear at approximately 15 months after implantation. No other adverse events occurred. We conclude that undifferentiated MSCs could provide a safe way to augment avascular meniscal repair in some patients. Registration: EU Clinical Trials Register, 2010-024162-22. Stem Cells Translational Medicine 2017;6:1237-1248.

Concepts: Magnetic resonance imaging, Knee, Tear of meniscus, Iliac crest, Bone, Mesenchymal stem cell, Stem cell, Bone marrow


Thoracodorsal artery perforator (TAP) flaps without latissimus dorsi muscle - have been used for reconstruction of the extremities, head and neck as free style flaps, and as pedicled flaps for reconstruction of the chest wall and axillary wounds. This retrospective study aimed to analyse the clinical applications and relevant anatomic findings of TAP flaps.

Concepts: Heart, Iliac crest, Subscapular artery, Thoracodorsal nerve, Latissimus dorsi muscle


BACKGROUND: In addition to prosthetic rehabilitation, maxillary defects can also be surgically reconstructed. Soft-tissue reconstruction employs a radial forearm or latissimus dorsi muscle flap, while bony reconstruction can be achieved using a fibula, iliac crest, or scapular flap. Reconstruction using a scapular flap is further divided into two subgroups: the traditional scapular flap with the circumflex scapular artery as the donor vessel and the scapular angle flap with the angular artery originating from the thoracodorsal artery as the donor vessel. MATERIALS AND METHODS: We report on four patients who underwent successful reconstruction with a free scapular angle flap between 2009 and 2011, following maxillary resection due to malignancy. RESULTS: Vertical positioning of the scapular angle flap enables reconstruction of the facial contour, whereas its horizontal alignment and microvascular anastomosis makes a bony reconstruction of the hard palate possible. CONCLUSIONS: The versatility, low rate of donor site morbidity and shape of the scapular angle flap-which resembles that of the hard palate-render it ideal for plastic reconstruction. The suitability of bone quality for dental rehabilitation with implants is a topic of controversial discussion. The scapular angle flap represents an alternative to obturator prosthesis for the reconstruction of maxillary defects ≥ grade I according to Okay et al.

Concepts: Palatal obturator, Reconstruction, Reconstruction era of the United States, Arteries of the upper limb, Thoracodorsal nerve, Subscapular artery, Iliac crest, Latissimus dorsi muscle


BACKGROUND: Ablation of locally advanced head and neck cancers generally results in large composite oro-facial defects. Due to the often-large segment of mandible missing, as well as the need to provide skin coverage and oral lining, reconstructive options are limited. We present our experience in oncologic head and neck reconstruction using chimaeric subscapular system free flaps. METHODS: We performed a retrospective chart review of patients presenting important through-and-through oro-facial defects following ablation of T3, T4a or T4b tumours in two university centres between 2005 and 2011. All defects were reconstructed with a subscapular system free flap that was harvested in a dorsal decubitus position. RESULTS: Sixteen patients (15 M, 1 F; mean age = 60 years) underwent mandibular reconstruction with latissimus dorsi flaps with one or two skin paddles and one bony component based on the angular branch of the thoracodorsal artery. Fifteen patients received adjuvant radiotherapy. We experienced no flap loss. Donor-site complications were minimal, albeit a limitation of shoulder range of motion was found in four patients. Eight patients presented postoperative complications requiring re-intervention. Fourteen patients were able to recommence oral nutrition and their diction returned to normal in all but one. The mean follow-up period was 25 months. Aesthetic results were satisfactory upon atrophy of the latissimus dorsi muscle. CONCLUSIONS: In cases of extensive oro-facial defects involving a large mandibular segment, reconstruction with subscapular system free-tissue transfer is a safe and reliable technique that offers satisfactory functional and aesthetic results.

Concepts: Cancer, Subscapular artery, Oncology, Glenohumeral joint, Thoracodorsal artery, Iliac crest, Thoracodorsal nerve, Latissimus dorsi muscle


BACKGROUND:: Slipping rib syndrome (SRS) is a musculoskeletal cause of severe and recurrent thoracic or abdominal pain. The etiology of SRS is unknown, it seems to arise from costal hypermobility with a tendency of one of the ribs (usually from 8th to 10th but also 11th and 12th have been described) to slip under the superior adjacent rib. Its prevalence is underestimated because SRS is mainly a clinical diagnosis, frequently missed. The critical aspect of the diagnosis is knowledge of the condition itself, which, when lacking, often results in the patient being referred to many different specialists and exposed to unnecessary and costly investigations. The management of the condition includes conservative techniques such as manipulation, localized anesthetic, and steroid or anesthetic nerve block. However, where conservative therapy fails, surgical treatment, with excision of the rib, may be performed. METHODS:: In this paper we describe the case of a patient with persistent and debilitating flank pain who, after many investigations, was diagnosed with SRS. RESULTS:: The usual conservative treatment failed, after which we treated the patient with injections of incobotulinumtoxin A into muscles inserting on the inferior side of the rib cage (quadratus lumborum muscle, muscle transversus abdomini, abdominal external oblique muscle, and recto abdomini) achieving a complete relief from pain. CONCLUSIONS:: To our knowledge botulinum toxin has never been proposed before for the treatment of SRS. We believe that it should be considered as a therapeutic option, especially where other medical treatments have failed or as an intermediate step before surgical intervention.

Concepts: Quadratus lumborum muscle, Human rib cage, Abdomen, Muscles of the torso, Rib, Thorax, Abdominal external oblique muscle, Iliac crest


: Study Design. Retrospective cohort study of 13,927 patients, 820 of whom received iliac crest bone graft (ICBG).Objective. To compare adverse events, length of stay (LOS), and readmission for patients receiving ICBG to those who did not using multivariate analysis to control for potentially confounding factors.Summary of Background Data. The use of ICBG in spinal fusion has been associated with increased surgical time, LOS, and donor site morbidity. Development of expensive bone graft substitutes has been predicated on these issues. Data on the effect of bone graft harvest on LOS and readmission rate is sparse, and multivariate analysis has not been used to control for confounding factors.Methods. Prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) 2010-2012 database was retrospectively reviewed. This includes demographics, comorbidities, surgical data, and hospital and 30-day follow-up outcomes data including adverse events, LOS, and readmission.Results. Only 5.9% of spinal fusions utilize ICBG.Bivariate logistic regression (used for categorical variables) found the ICBG cohort was more likely to have a postoperative blood transfusion (11.6% vs. 5.5%, p<0.001). Bivariate linear regression (used for continuous variables) found the ICBG cohort to have an extended operative time (+36.0 min, p<0.001) and extended LOS (+0.6 days, p<0.001).Multivariate analyses controlling for comorbidities, demographics, and approach determined postoperative blood transfusion (OR 1.5), extended operative time (+ 22.0 min, p<0.001) and LOS (+0.2 days, p = 0.037) to be significantly associated with ICBG use.No other adverse event was significantly associated with ICBG use. Readmission rates were not significantly different.Conclusion. This study used a large national database cohort and identified increased postoperative blood transfusion, extended operative time, and increased LOS as short-term outcomes associated with ICBG on multivariate analysis. Other short-term morbidities were not significantly associated with ICBG. Readmission rates were not affected.

Concepts: Time, Experimental design, Iliac crest, Blood transfusion, Regression analysis, Surgery, Clinical trial, Cohort study


Background: Sport climbing has been increasingly applied as therapy for patients with orthopaedic problems. Results from previous intervention studies have already revealed positive effects, especially for people with back problems, although there is a lack of baseline knowledge regarding the general effects of climbing. The aim of this present study is to investigate the muscle activation of the trunk while performing various static climbing positions at different inclination angles. Subjects/Material and Methods: Thirteen healthy adults without climbing experience were asked to hold three static climbing positions (base position, lifting a hand, lifting a foot) at three different handhold set-ups and six wall inclination angles (0°, 4°, 8°, 12°, 15°, 18°) for 5 seconds each. Bilateral muscle activity of Erector spinae, Multifidus, Latissimus dorsi, Obliquus externus abdominis, Obliquus internus abdominis and Rectus abdominis was measured using surface electromyography. Data were analysed for each muscle and climbing condition separately. Results: Compared to the vertical wall, the muscle activity starts to differ significantly (p ≤ 0.05) from 12° onwards. This inclination angle particularly affects the activity of all muscles when lifting a hand (0.000 ≤ p ≤ 0.048). The oblique abdominal muscles did not show any or little effects when lifting a foot or being in the base position, while all other muscles demonstrate a continuous increase. The EMG data were normalised to the corresponding base position and analysed for each muscle and climbing condition separately. Conclusion: Inclinable climbing walls are an appropriate method to increase muscle activity. Compared to the base position, activation of the oblique abdominal muscles, which are relevant for a stable trunk, is increased only when a hand is lifted. Climbing walls used for therapy should offer variable inclination angles. Further research should concentrate on the development and evaluation of climbing exercises for specific patients (eg people with scoliosis).

Concepts: Muscle, Abdominal internal oblique muscle, Crunch, Abdomen, Muscles of the torso, Abdominal external oblique muscle, Iliac crest, Electromyography


Should the trocar suddenly lose contact with bone during bone marrow aspiration, it may result in visceral injury. The anatomy of the ilium and the structures adjacent to the iliac bone were studied to determine the danger of breach by a trocar introduced into the iliac crest.

Concepts: Bone, Ischium, Acetabulum, Greater pelvis, Ilium, Pelvis, Bone marrow, Iliac crest