Comparison of various treatment modalities for the management of bone marrow edema syndrome/transient osteoporosis in men and non-pregnant women: a systematic review

Transient osteoporosis (TO) or bone marrow edema syndrome (BMES) is a self-limited clinical condition, which affects middle-aged men and women. It can be treated with miscellaneous conservative and surgical measures, which are analyzed in this systematic review.

INTRODUCTION

BMES/TO is a transient clinical entity, which can be treated with various therapeutic modalities. The aim of our study was to assess the efficacy of different therapeutic options for the alleviation of pain and reduction of bone marrow edema (BME) in patients with BMES/TO, as well as to propose a therapeutic algorithm.

METHODS

PubMed, Scopus, Cochrane, and Google Scholar were searched. Eligibility and extraction of studies were conducted by two authors. Methodological quality assessment was carried out with the modified Delphi technique, Methodological Index for Non-Randomized Studies (MINORS) criteria, and Cochrane Collaboration's risk of bias tool. Outcomes that were compared were time of pain resolution, VAS pain scores, and BME regression on magnetic resonance imaging (MRI).

RESULTS

A total of 36 articles (880 patients) were included. Bisphosphonates had higher efficiency in less than 1-month outcomes on pain resolution compared with core decompression (CD), while iloprost was more efficient at 1-3 months compared with bisphosphonates and CD. At 3-6 months, all three of the aforementioned showed equal results on pain resolution, and at a period of 6-12 months, CD and extracorporeal shockwave therapy (ESWT) showed excellent results followed by bisphosphonates and the conservative group (CG) consisting of non-steroidal anti-inflammatory drugs (NSAIDs) and/or analgesics and/or restricted weight bearing. On MRI at 1-3 months, bisphosphonates, iloprost, and CD had relatively the same outcomes on BME resolution, with the least promising being the CG. At 3-6 months, CD seemed to have achieved the best results on the resolution of BME, followed by ESWT, CG, and bisphosphonates group. At 6-12 months, ESWT had the best outcomes compared with the conservative, bisphosphonates, and iloprost groups.

CONCLUSION

BMES/TO has been treated with many non-standardized measures due to the low number of highly reliable studies. Current literature shows promising results with regard to the reduction of the clinical course of BMES/TO, but further large multicenter randomized controlled trials, as well as standardized radiological and clinical scores, are warranted to acquire evidence-based recommendations on the therapeutic algorithm.

Cubonavicular Coalition in a Middle-Aged Woman: A Case Report

Cubonavicular coalition is a rare type of tarsal coalition that can be described as osseous or nonosseous (fibrous, cartilaginous, or fibrocartilaginous). Typically, it manifests symptoms during adolescence, as it presents with pain at the Mid-hindfoot and with decreased range of motion at the midtarsal joints, hindfoot valgus deformity, or peroneal spasm. Here, we present a rare case of cubonavicular coalition in a middle-aged woman with atypical presentation and a review of the literature. We conclude that this abnormality should be taken into account in the differential diagnosis of mid-hindfoot pain, even in middle-aged adults.

Bilateral Medial Epicondyle Fracture Without Elbow Dislocation in a High-Level Adolescent Gymnast Athlete: A Rare Case

Isolated medial epicondyle fracture constitutes a common fracture in children's and adolescent's elbow and is highly associated with an elbow dislocation. Cases with bilateral medial epicondyle fracture with concomitant elbow dislocation have been previously described in literature, while cases without an associated elbow dislocation are lacking. In this article, a bilateral medial epicondyle fracture without elbow dislocation in an adolescent high-level gymnast athlete is reported. To the best of the authors' knowledge, this is the first case report in literature regarding such an extremely rare traumatic elbow injury.

Closed posterolateral elbow dislocation without fracture leading to complete brachial artery rupture

Traumatic vascular injury of the brachial artery by closed posterolateral complete elbow dislocation, without fracture is an unusual injury. Based on clinical and radiological evidence, emergency treatment is necessary.

We present a case of complete brachial artery rupture, with a clot resulting from a closed posterolateral elbow dislocation, without fracture. We report the early assessment and operative treatment.

A brachial artery injury due to a closed elbow dislocation, without fracture is uncommon. The diagnosis poses a dilemma and the operation is a challenge. It is addressed by Orthopaedic and Vascular team.

Extreme stiff knee recurvatum following manipulation under anesthesia and botulinum neurotoxin injection

In this article we report a case of stiff, neglected extreme recurvatum knee deformity in a 17-year-old female. This is the first reported case in the literature of an acquired ligamentous stiff extreme knee recurvatum following manipulation under anesthesia and botulinum neurotoxin injection. Μodified Judet quadricepsplasty combined with Ilizarov external hinged frame fixation was implemented. This dual technique can be considered as a rational approach for such an extreme deformity as it stabilizes, progressively corrects, and prevents recurrence. A patellar tendon rupture caused by the increasing tension of the extensor mechanism following the correction was treated successfully using a cadaveric Achilles tendon allograft.

Neglected Stiff Equinocavus Foot Deformity Treated with Cole Osteotomy, Combined with External Ilizarov Hinged Frame Fixation, Soft-Tissue Release, and Achilles Tendon Lengthening: A Case Report

Stiff equinocavus foot deformities are challenging clinical entities that may be treated with osteotomies and extensive soft-tissue release. The most common causes of such lesions are neglected trauma and Charcot-Marie-Tooth disease; other causes include burns, neurologic diseases, and compartment leg syndrome. Conventional treatments, including extensive soft-tissue release, osteotomies, and arthrodesis combined with or without internal splinting, may result in severe complications such as neurovascular or soft-tissue damage and shortening of the foot. The Ilizarov technique may be superior to the traditional approach, because it allows surgeons to apply gradual and titrated correction of individual components of complex deformities and results in minimal surgical morbidity without shortening of the foot. This is the first case report in the literature describing the simultaneous use of Cole osteotomy, combined with external Ilizarov hinged frame fixation, soft-tissue release, and Achilles tendon lengthening for the treatment of an extreme neglected stiff equinocavus foot deformity.

The efficacy and safety of bisphosphonates in patients with bone marrow edema syndrome/transient osteoporosis: A systematic literature review

Background

The purpose of our systematic literature review study was to critically analyze all current data including time to achieve pain relief and resolution of bone marrow edema (BME) on magnetic resonance imaging (MRI) in patients with bone marrow edema syndrome (BMES) when using bisphosphonates.

Methods

A systematic review was performed to address studies which concerned the efficacy and safety of bisphosphonates in patients with BMES. A systematic search was conducted by two investigators using databases including Pubmed and Scopus.

Results

Nine studies were included between July 2002 and June 2019 with a total of 187 patients out of whom 150 had been treated with bisphosphonates. Mean age of patients was 44,14 (mean ranges 34.9-54.0), 113 males and 54 females (excluding one study which did not mention ages). Five studies described the outcomes from MRI on follow-up (42 out of 78 patients achieved resolution with time ranging from 3 to 12 months with a mean of 3.85 months) and eight studies described the outcomes regarding pain resolution (128 out of 140 achieved resolution with mean time 4.20 months, ranging from 0.7 months to 12 months). Adverse events related to the administration of bisphosphonates included flue-like symptoms in 6 patients, musculoskeletal pain in 1 patient, arthralgias and fever in 9 patients.

Conclusions

The outcome of this systematic review indicated that the effect of bisphosphonates on pain relief and on regression of BME on MRI is controversial, but due to the low level of evidence of the included studies, no definite conclusions can be acquired and no evidence based recommendation could be given.

Bone marrow edema syndrome/transient osteoporosis of the hip joint and management with the utilization of hyperbaric oxygen therapy

Transient osteoporosis of hip (TOH) is a self-limited condition that affects young and middle aged women or men. The clinical manifestation is characterized by sudden or gradual onset of pain that is exacerbated on weight-bearing and at night. The treatment of TOH is either conservative or surgical. Conservative regimens include restriction of weight-bearing, pharmacological agents such as prostacyclin analogues (iloprost), non-steroid anti-inflammatory drugs (NSAIDs), extracorporeal shock wave and hyperbaric oxygen therapy (HBOT). Surgical intervention includes drilling or core decompression. The aim of this article is to review the clinical entity of TOH (clinical presentation, pathophysiology, diagnosis) and to further discuss the off-label utilization of HBOT as an alternative treatment regimen in patients suffering from TOH that fail to respond to other conservative methods.

Surgical modalities for the management of bone marrow edema of the knee joint

Background

Bone marrow edema (BME) is a radiological term which can be found in many conditions with varied pathogenesis and histopathological images. It usually presents with pain in the affected joint and is diagnosed with MRI. Subchondroplasty (SCP) and core decompression (CD) are the surgical methods that are available to achieve pain relief and functional improvement. Both surgical methods have their own indications and are used depending on the patient's history. The aim of this literature review article is to discuss the surgical modalities for the management of bone marrow edema focusing on the knee joint. Such topic which analyzes both surgical methods for treatment of bone marrow edema of the knee joint has never been described in a review article before.

Materials and methods

For the purpose of our manuscript we thoroughly searched electronic databases such as Pubmed and Medline to acquire the appropriate material for our review paper. Only English articles were used in this review. In our study we included every article that had described the surgical management of BME of the knee by CD and SCP. In the discussion we included 18 studies (9 CD and 9 SCP) with a total number of patients equal to 397, while 206/397 had undergone surgical intervention (169 underwent SCP and 37 CD).

Results

Follow-up of 180 patients out of 206 were available for our review. A total number of 166 patients (92.2%) were successfully treated. Specifically, 29 (100%) patients were treated by CD and 137 (90.7%) by SCP. In a study, 10 patients who underwent SCP for BME secondary to advanced osteoarthritis (OA) yielded poor results. In other studies, pain persistency was observed in 2 patients, 1 patient had postoperative infection and another patient eventually underwent total knee arthroplasty (TKA). 70% prevention of TKA was achieved by SCP in a study of 66 patients with BME secondary to advanced OA. Thus, a total number of 166 patients were considered as clinical success and 14 patients as clinical failure.

Conclusions

The included studies that have been published referred to the surgical methods of CD or SCP for the management of BME of the knee but none of that summarizes all current studies on both methods. Those studies seem that CD is a surgical technique that is proposed to perform in patients without findings of OA that usually fail to respond to conservative treatment. On the other hand, the option of SCP technique is carried out in patients with varied stage of OA associated with subchondral BME. Both methods aim to reduce the pain and to improve function in the setting of subchondral BME. Nevertheless it is not clear in literature which method is the best according to the criteria of the use. This literature review shows a lack of standardized guidelines with respect to diagnosis and surgical treatment.

Percutaneous repair of the Achilles tendon rupture in athletic population

AIMS

This review was designed in order to study the percutaneous repair of Achilles tendon rupture in athletic population. We present a comprehensive description of clinical, functional outcomes, complications, with emphasis on patients' level, and time of return to sports.

METHODS

We proceeded to a systematic search of Medline (PubMED), Cochrane, and Scopus databases using keywords "Achilles Tendon", "Percutaneous Repair", "Percutaneous suturing", "Subcutaneous repair", "Subcutaneous suturing", "Athletes", and "Athletic" to identify articles or abstracts written in English.

RESULTS

Thirteen studies, including 670 patients, could be identified. A variety of percutaneous repair techniques were performed. Re-rupture rate was very low. The most frequent complication was sural nerve damage. Average functional outcomes were satisfying. Up to 91.4% continued practicing sports after surgery. Furthermore, 78-84% returned to the same or higher sports level. Average time of return was 18 weeks in 9 studies.

CONCLUSION

Percutaneous repair of Achilles tendon rupture is an excellent perspective for athletic population. Low re-rupture rate and impressing level of return to sports allow athletes to continue their recreational activities or careers.

Carpus translocation into the ipsilateral ulna for distal radius recurrence giant cell tumour: A case report and literature review

Giant cell tumour is a frequent benign neoplasm. It is characterized by local aggressive behaviour and frequent recurrence. The most common localization is the distal femur followed by proximal tibia (40%). The distal radius is the next place (10%). The recurrence in the distal radius in primary cases is reported 10%, in recurrent cases is almost 30% and depends to the kind and the stage of the tumour at the time of treatment. Multiple options have been reported for treatment of Campanacci III giant-cell tumour (GCT) of the distal radius after resection. Actually the treatment of recurrence remains a real dilemma. Several reconstructive options (e.g. resection arthroplasty, prosthetic replacement, arthrodesis, ulnar translocation, centralization of the carpus over the remaining ulna, use of vascularized or nonvascularized fibular graft, with or without, arthrodesis, have been described up to date. We present a case of recurrence of GCT of distal radius after curettage, where we selected the centralization of the ulna into the carpus as a salvage procedure with satisfactory results. The procedure provides a valid option for the management of recurrent GCTs of distal radius offering excellent cosmetic and acceptable functional result.

Functional bracing of humeral shaft fractures. A review of clinical studies

Functional bracing has been widely accepted as the gold standard for treating humeral shaft fractures conservatively. We conducted a literature review to verify the efficacy of this treatment method. Sixteen case series and two comparative studies fulfilled the criteria set. Analysis of these clinical studies showed that humeral shaft fractures when treated with functional bracing heal in an average of 10.7 weeks. Union rate is high (94.5%). Statistical analysis showed that proximal third fractures and AO type A fractures have a higher non-union rate although this is not statistical significant. Residual deformity and joint stiffness are considered the main drawbacks of conservative treatment. Angulation--usually varus--rarely exceeded 10 degrees, while full shoulder and elbow motion was achieved in 80% and 85% of the patients, respectively. Nevertheless, in the few studies that subjective parameters such as functional scores, pain and quality of life were assessed results were not so promising.

Bilateral transient bone marrow edema or transient osteoporosis of the knee in pregnancy

Transient osteoporosis or transient bone marrow edema is an uncommon self-limiting condition of unknown etiology. The most commonly affected joint is the hip, followed by the knee, ankle, and the foot. Simultaneous involvement of both hips has been reported exclusively in pregnant women. Bilateral knee involvement during pregnancy seems to be extremely rare. We present a case of bilateral transient bone marrow knee edema during pregnancy with complete resolution of symptoms and radiological findings after 10 months.

Total Dislocation of the Talus without a Fracture. Open or Closed Treatment? Report of Two Cases and Review of the Literature

Complete dislocation of the talus not accompanied by a fracture is a very rare injury. The injury is encountered as a closed one even more rarely. Reviewing the literature we found that proposed treatments for total talus dislocation varied from primary talectomy or arthodesis (to avoid complications) to closed reduction and an under knee cast. Most importantly, there was no agreement among authors about the method of reduction (open/closed). We report our experience with two cases of closed total talus dislocation not accompanied by a fracture, and review the literature to retrieve evidence on whether a closed or open treatment should be preferred for this type of injury.

Tuberculous spondylitis in patients with end-stage renal disease undergoing chronic hemodialysis therapy

Tuberculosis of the spine is not rare in immunocompromised patients and particularly in those with end-stage renal disease (ESRD). Furthermore, the possible vascular compromise of the spinal cord in patients with diabetic nephropathy may result in symptoms of neurological involvement that could lead to deterioration and paralysis. We report a series of 4 patients with ESRD undergoing dialysis that developed tuberculous spondylitis of the thoracic spine. Diabetic nephropathy was the primary cause for chronic kidney disease in 2 patients; 3 of these patients were treated conservatively with anti-tuberculous medication and orthotic splints and were cured. The fourth patient with diabetes mellitus and clinically evident signs and symptoms of severe vascular insufficiency has additionally developed incomplete paraplegia. A complete sensory recovery and partial recovery of the hip flexors and abductors within 3 months occurred, following decompression of the spine and drainage of the abscess, in combination with long-term anti-tuberculous treatment and spinal orthosis.

Meniscal bucket handle tears: a retrospective study of arthroscopy and the relation to MRI

In this study, we aim to evaluate the arthroscopic findings of meniscal bucket handle tears and to correlate them with the proposed MR imaging signs of meniscal bucket handle tears suggested in the literature. Thirty-six patients who had a diagnosis of bucket handle tear in arthroscopy, in either medial or lateral meniscus, were included in our study (32 males and 4 females). Meniscal tears were evaluated in arthroscopy according to Dandy's classification. The MRIs were retrospectively analyzed regarding the following findings: absence of bow tie sign, presence of double posterior cruciate ligament (PCL) sign, double anterior horn sign, flipped meniscus sign, disproportional posterior horn sign, and fragment within the intercondylar region. Locked types I and II fragment of medial meniscus and half-length, whole-width and whole length-half-width fragment of lateral meniscus in arthroscopy were basically correlated with fragment within the intercondylar notch and absent bow tie signs in MRI. We did not find the double PCL sign in any of the patients with a lateral meniscal bucket handle tear. The most common signs in MR images of meniscal bucket handle tears were the fragment in the notch sign and the absent bow tie sign. They were observed with equal frequency of 88.8%. The presence of double PCL sign, double anterior horn sign, flipped meniscus sign, disproportional posterior horn sign were less common (41.66, 33, 25, and 27.7%, respectively). We conclude that the presence of at least two of the six MRI signs should be regarded as highly suggestive for bucket handle tears of menisci.