Protocol on the Effects of Postnatal Exercises on Musculoskeletal Pain among Postpartum Women

Background: Pregnancy brings a slew of morphological and physiological changes to the body. The gravida must not only nourish the foetus, but also adjust to a new body habit and hormonal changes. These alterations, unsurprisingly, have an impact on the musculoskeletal system, which can lead to a number of issues, such as generalized arthralgias, back pain, separation of the pelvic bones, transient osteoporosis, and tendonitis. Objectives: 1. To assess the pretest and posttest musculoskeletal pain among postpartum women in experimental and control group. 2. To assess the effectiveness of postnatal exercises related to musculoskeletal pain among postpartum women in experimental group. 3. To find association between posttest musculoskeletal pain score among postpartum women with selected demographic variables in experimental and control group. Materials and Methods: Quasi-experimental pretest posttest design is used to assess the effectiveness of postnatal exercises, among postpartum women in selected hospitals of Wardha. 80 sample size taken who fulfils the inclusion criteria, 40 postpartum women for control and 40 for experimental group with non-probability convenience sampling. Expected Results: This study is planned to assess the effectiveness of postnatal exercises to the postpartum women experiencing musculoskeletal pain syndrome. Hence, it is expected to identify the level of pain and may reduce their level of pain. The conclusion will be drawn from the results and will be published in per review journal.

Radiomics and Machine Learning Can Differentiate Transient Osteoporosis from Avascular Necrosis of the Hip

Differentiation between transient osteoporosis (TOH) and avascular necrosis (AVN) of the hip is a longstanding challenge in musculoskeletal radiology. The purpose of this study was to utilize MRI-based radiomics and machine learning (ML) for accurate differentiation between the two entities. A total of 109 hips with TOH and 104 hips with AVN were retrospectively included. Femoral heads and necks with segmented radiomics features were extracted. Three ML classifiers (XGboost, CatBoost and SVM) using 38 relevant radiomics features were trained on 70% and validated on 30% of the dataset. ML performance was compared to two musculoskeletal radiologists, a general radiologist and two radiology residents. XGboost achieved the best performance with an area under the curve (AUC) of 93.7% (95% CI from 87.7 to 99.8%) among ML models. MSK radiologists achieved an AUC of 90.6% (95% CI from 86.7% to 94.5%) and 88.3% (95% CI from 84% to 92.7%), respectively, similar to residents. The general radiologist achieved an AUC of 84.5% (95% CI from 80% to 89%), significantly lower than of XGboost (p = 0.017). In conclusion, radiomics-based ML achieved a performance similar to MSK radiologists and significantly higher compared to general radiologists in differentiating between TOH and AVN.

Transient Osteoporosis

Background: Transient osteoporosis is an uncommon and self-limited clinical syndrome characterized by acute joint pain with evidence of bone marrow edema on MRI. It predominantly affects healthy middle-aged men or women in the third trimester of pregnancy. The hips, knee, foot and ankle are affected in decreasing order of frequency. Pathophysiology is unknown but multiple etiologies such as ischemia, neurogenic compression or impaired venous return have been proposed. Classically, it is unilateral and bilateral in only 20%-40% of cases. It has been reported to periodically involve different joints over time with one report showing the progression to regional migratory osteoporosis in at least 20% of patients. There are no specific biomarkers to aid with diagnosis, MRI shows diffuse bone marrow edema sometimes associated with joint effusion with infrequent subchondral microfractures. Other etiologies to consider for bone marrow edema include osteomyelitis, avascular necrosis, trauma, tumors and inflammatory arthropathy. Transient osteoporosis can be self- limiting however, bisphosphonate use has been associated with shortened recovery time. In our patient given lack of access to his previous records to review and ascertain his previous diagnosis, his diagnosis of record was transient osteoporosis rather than regional migratory osteoporosis. Clinical Case: A 47 yo male presented to clinic with complaint of left ankle pain. Pain initially noted when he tripped and fell one year ago. Initial x-rays did not reveal any fractures. He was unable to weight bear due to pain although he had full range of motion at the ankle with a normal neurological and vascular exam of the foot. Due to persistence of pain, an MRI was done which showed cutaneous edema around the medial and lateral aspects of the ankle, trace tibiotalar joint effusion, marrow edema in the distal tibia and navicular with no acute fracture or definite evidence of avascular necrosis. On further questioning he reported a previous history of hip pain at age 32 and 41 with no preceding trauma. X-rays were negative for fracture and MRI showed marrow edema. Symptoms resolved after a few weeks with possible treatment with Alendronate. With the current presentation biochemical work up including Vitamin D, PTH, 24-hour urine calcium, electrolytes, phosphorus and alkaline phosphatase was unremarkable. Given the marrow edema reported on MRI, absence of fracture, osteochondral lesion or recent trauma transient osteoporosis was diagnosed. Given the duration of symptoms he was treated with Reclast 5mg IV once and reported 80% improvement in ankle pain during follow up 4 weeks later. Conclusion: It is important to identify transient osteoporosis and regional migratory osteoporosis to prevent unnecessary medical or surgical therapy.

Bilateral transient osteoporosis of the hip with unilateral fracture in a 40 years old pregnant woman

Purpose: Some physiological events in women’s life such as pregnancy and lactation can be associated to a condition known as Transient Osteoporosis of the Hip (TOH); if not promptly diagnosed it can lead to significant consequences such as femoral neck fracture. In this paper we describe a case of bilateral TOH, focusing on the importance of early treatment and how it influenced the outcome. Methods: A 40 years old post-delivery woman came to our attention for hip pain and a left femoral neck fracture was diagnosed. Magnetic resonance (MRI) showed bilateral edema of the femoral head. She underwent total hip replacement on the left side; toe-touch weight bearing and pharmacological therapy were prescribed for the right hip. Results: MRI at nine months showed complete regression of the femoral head and neck edema; the patient was clinically asymptomatic. Conclusion: If not promptly diagnosed and treated, TOH can potentially evolve in fracture. Many therapeutic strategies have been suggested since now; we believe that avoiding weight bearing on the involved hip as early as possible is the key to recovery.

Transient osteoporosis of the hip in pregnancy: the orthopaedic management of bilateral neck of femur fractures in the third trimester

Transient osteoporosis of the hip (TOH) is a rare cause of pelvic pain in the third trimester of pregnancy and post partum. Although several cases have been reported in literature, its aetiology is poorly understood. The diagnosis is commonly missed in pregnancy, as the presenting symptoms can be vague, and the risks of radiographic imaging deter clinicians from pursuing investigation. In extreme cases, this pathology presents with neck of femur fractures, with no current guidelines on optimal management. We describe the case of a 24-year-old woman who presented with bilateral neck of femur fractures at 34 weeks gestation. Following an emergency caesarean section, operative management consisted of bilateral closed reduction and internal fixation using dynamic hip screws. Postoperative radiographs demonstrated failure of fixation on the left side, which was revised to a complex primary arthroplasty. This case demonstrates both the diagnostic and management challenges associated with TOH.