Osteonecrosis risk after steroids-related treatment of COVID-19 is not negligible: A cross sectional study

BACKGROUND & AIMS

During the pandemic, steroids use at various dosages and durations for the treatment of COVID-19 patients, especially in hospitalized patients, was a common and effective strategy. However, steroid administration is associated with osteonecrosis as an adverse event. The aim of the study was to examine the prevalence of skeleton osteonecrosis in COVID-19 patients treated with or without steroids.

METHODS

Eighty randomly selected hospitalized COVID-19 patients were analyzed, of which 40 were managed with a published protocol including steroids and 40 did not receive steroids. Demographics and laboratory measurements including white blood cells count, C-reactive protein and ferritin were retrieved from the medical records. All patients underwent magnetic resonance imaging of the hips, shoulders, and knees. Subsequently, all patients were clinically examined and Oxford hip score (OHS) and EuroQol- 5 Dimension (EQ-5D-5 L) were documented.

RESULTS

Three patients (3/40; 7.5 %) treated with steroids were diagnosed with femoral head osteonecrosis. None of the patients in the non-steroid-treated group developed osteonecrosis. There were no differences between the two groups regarding OHS and EQ-5D-5 L. Patients with osteonecrosis had higher ferritin levels, received higher doses of corticosteroids (median dose 2200 mg), and had longer hospitalization.

CONCLUSIONS

COVID-19-related therapy with steroids resulted in lower prevalence of osteonecrosis than that previously recorded in patients with severe acute respiratory syndrome caused by coronavirus-type-1. However, this risk seems not negligible and therefore, high clinical suspicion for early diagnosis is warranted, given the fact that a great proportion of hospitalized patients received steroids during the COVID-19 pandemic.

Bilateral Femoral Neck Pseudarthrosis in an Adolescent Girl With Congenital Spondyloepiphyseal Dysplasia. The Treatment Journey: A Case Report

CASE

We describe the surgical management of a girl with dwarfism and congenital spondyloepiphyseal dysplasia, who presented in adolescence with coxa vara and bilateral pseudarthrosis between the femoral neck and the diaphysis, with asymmetric distal migration at both sites and leg length discrepancy. The patient at 16 years underwent valgus osteotomy in situ and femoral neck fixation in the left hip. The right hip was operated 19 months later.

CONCLUSION

Hip dysplasia is common in spondyloepiphyseal dysplasia, but a debilitating nontraumatic bilateral pseudarthrosis at the base of the femoral neck has not been previously reported. Valgus corrective osteotomies of the femur in situ led to union and allowed the patient to walk.

MiR-217 Regulates SIRT1 Expression and Promotes Inflammatory and Apoptotic Responses in Osteoarthritis

Previous studies have reported miR-217 uregulation in age-related pathologies. We investigated the impact of miR-217-5p on sirtuin 1 (SIRT1) regulation in human osteoarthritic (OA) chondrocytes. MiR-217 target enrichment analyses were performed using three public databases, Gene Ontology and Kyoto Encyclopedia of Genes and Genomes. MiR-217-5p expression levels were quantified in normal and OA chondrocytes. SIRT1 expression levels, nuclear factor kappa-B p65 subunit (NF-κBp65) and p53 acetylation levels, and expression levels of OA-related pro-inflammatory markers [tumor necrosis factor α (TNFα), interleukin 1β (IL-1β), IL-6], pro-apoptotic markers [Bax, pro-caspase 3, cleaved caspase 3] and matrix regulators [matrix metalloproteinase (MMP)-1, MMP-13, MMP-9, Collagen 2 (COL2A1), Aggrecan (ACAN)] were evaluated in miR-217 mimic-treated and/or miR-217 inhibitor-treated OA chondrocytes, with/without subsequent treatment with siRNA against SIRT1 (siSIRT1). MiR-217-5p was upregulated in OA chondrocytes, while target prediction/enrichment analyses revealed SIRT1 as miR-217 target-gene. Deacetylation of NF-κBp65 and p53 in miR-217 inhibitor-treated OA chondrocytes was reversed by siSIRT1 treatment. MiR-217 inhibitor-treated OA chondrocytes showed increased COL2A1, ACAN and decreased IL-1β, IL-6, TNFα, Bax, cleaved caspase 3 and MMPs expression levels, which were reversed following miR-217 inhibitor/siSIRT1 treatment. Our findings highlight the impact of miR-217-5p on SIRT1 downregulation contributing to OA pathogenesis.

Revision total hip arthroplasty for aseptic loosening compared with primary total hip arthroplasty for osteoarthritis: long-term clinical, functional and quality of life outcome data

PURPOSE

The aim of this study was the comparative assessment of long-term clinical (subjective and objective), functional and quality of life outcome data between primary and revision THA.

METHODS

122 patients (130 hips) who underwent cementless revision THA of both components (TMT cup, Wagner SL stem, Zimmer Biomet) for aseptic loosening only (Group A) were compared to a matched group of 100 patients (100 hips) who underwent cementless primary THA for osteoarthritis (Synergy stem, R3 cup, Smith & Nephew) (Group B). Outcomes were evaluated with survival analysis curves, Harris Hip Score (HHS), WOMAC, Oxford Hip Score (OHS), Short-Form Health Survey (SF-12) and EQ-5D-5L scales. Mobility was assessed with walking speed, Timed Up And Go Test (TUG), Parker Mobility Score, Lower Extremity Functional Scale (LEFS) and UCLA scores.

RESULTS

At a mean follow-up of 11.1 (8-17) years a cumulative success rate of 96% (95% CI, 96-99%) in Group A and 98% (95% CI, 97-99%) in Group B with operation for any reason as an endpoint was recorded. Statistically significant differences between groups were developed for WOMAC (Mann-Whitney U-test, p = 0.014), OHS (Mann-Whitney U-test, p = 0.020) and physical component of SF-12 scores (Mann-Whitney U-test, p = 0.029) only. Group A had less improvement in function as compared with group B. In Group A, in multiple regression analysis, patients' cognition (p = 0.001), BMI (p = 0.007) and pain (p = 0.022) were found to be independent factors influencing functional recovery (WOMAC). Similarly, pain (p = 0.03) was found to influence quality of life (EQ-5D-5).

CONCLUSIONS

In the long term, revision THA shows satisfactory but inferior clinical, functional, and quality of life outcomes when compared to primary THA. Residual pain, BMI and cognitive impairment independently affect functional outcomes.

Solitary Radio-Opaque Lesion of Wrist (Tumoral Calcinosis) Disappears Spontaneously After Causing Acute Carpal Tunnel Syndrome: A Case Report

CASE

We describe the case of a 53-year-old male patient with a history of acute carpal tunnel syndrome (CTS) provoked by a radio-opaque mass on the palmar side of the wrist. Although the mass disappeared in new radiographs 6 weeks later without any intervention apart from the carpal tunnel release, excisional biopsy was conducted on the residue, revealing tumoral calcinosis.

CONCLUSION

Both acute CTS and spontaneous resolution are clinical manifestations of this rare condition on suspicion of which biopsy can be avoided by following a "wait and see" strategy.

Diffuse pigmented villonodular synovitis of the knee joint: 3-year follow-up of a case report

Pigmented villonodular synovitis (PVNS) is a proliferative, recurrent and locally invasive disease of the synovium. The symptoms of the disorder are not typical and thus it is very often misdiagnosed. Most of the times, magnetic resonance imaging presents the nodular model of development and sets the basis for the diagnosis. The final diagnosis will be set by the pathological evaluation of the lesion's biopsy. PVNS may be localized (nodule with a clear boundary with/without presence of single pedicle) or diffuse (extensive involvement of the adjacent nerves and vessels). Depending on the extension of the PVNS, a different management approach is performed, lesion excision vs. resection, followed by radiotherapy respectively. We report a case of diffuse PVNS in the knee joint, treated with surgical excision and adjuvant radiotherapy as well as follow-up imaging after a time period of 3 years.

Clinical, functional and radiographic outcomes after revision total hip arthroplasty with tapered fluted modular or non-modular stems: a systematic review

PURPOSE

The aim of the study was to systematically evaluate clinical outcomes of tapered fluted stems, either monoblock or modular, in revision total hip arthroplasty.

METHODS

PubMed, EMBASE and Web of Science and Cochrane databases were systematically searched by 2 researchers. Clinical studies reporting primarily on survival and re-revision rates, and secondarily on subsidence, dislocation, intraoperative fractures, periprosthetic fractures and infection were included. 2 investigators assessed the quality of the studies.

RESULTS

46 studies were included in this review, reporting on 4601 stem revisions. The pooled re-revision rate was 5.1% and long-term survival ranged from 75% to 98.5%. No differences were observed between monoblock and modular stems regarding re-revision rate, dislocation rate, periprosthetic fracture rate or infection rates. Monoblock stems exhibited more subsidence and modular stems displayed more intraoperative fractures.

CONCLUSIONS

Satisfactory results can be obtained with the use of tapered fluted end-bearing stems. Monoblock stems offer the same clinical results as modular stems.

Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome

Purpose

This is a retrospective cohort study of type C distal humeral fractures (AO classification system) aimed at evaluating the effectiveness of current operative treatment options.

Materials and methods

Thirty-seven patients with type C distal humeral fractures, treated operatively from January 2002 to September 2016, were retrospectively studied. Thirty-two were eligible for inclusion. Patients were treated by open reduction using the posterior approach, olecranon osteotomy and parallel-plate two-column internal fixation. Patients were evaluated for fracture healing, functional outcomes and complications (infection, ulnar neuropathy, heterotopic ossification and need for implant removal). Restoration of the normal anatomy was defined by measuring carrying angle, posterior angulation and intercondylar distance of distal humerus.

Results

The mean follow-up time was 8.7 years [range 2–15.5 years, standard deviation (SD) = 3.96]. Mean time to fracture union was 8 weeks for 29 patients (90.6%) (range, 6–10 weeks). In nine cases, there was malunion of varied importance (28.1%). There was one case with postoperative ulnar neuropathy and one case with deep infection. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score and mean Mayo Elbow Performance Score (MEPS) were 20 (range 0–49) and 83.3 (range 25–100), respectively.

Conclusion

In complex distal humerus fractures, the posterior approach with olecranon osteotomy and parallel plating of two columns, after anatomic reconstruction of the articular segment, is a prerequisite for successful elbow function.

How to cite this article

Athanaselis ED, Komnos G, Deligeorgis D, et al. Double Plating in Type C Distal Humerus Fractures: Current Treatment Options and Factors that Affect the Outcome. Strategies Trauma Limb Reconstr 2022;17(1):7–13.

Spaghetti wrist: Transverse injury, axial incision, layered microsurgical reconstruction

INTRODUCTION

Among various patterns of complex injuries of the wrist and forearm, "spaghetti wrist" refers to an extensive volar forearm laceration, in which several of the 12 tendons, 2 major nerves and 2 major arteries are transected, leading to lifelong disability and psychological, social and economic consequences. The aim of the study is to emphasize the keynote principles for the management of these injuries through retrospective review of a large group of patients treated by a team of experienced hand surgeons.

MATERIAL-METHODS

Data were retrospectively obtained for 61 patients (49 males and 12 females with average age of 34.7 years) treated for spaghetti wrist lacerations and followed for a minimum period of two years, in two accredited Orthopaedic / Hand-Upper Extremity Surgery and Microsurgery Departments in Greece. All patients were treated within 16 hours of injury and underwent primary, layered reconstruction of all injured structures through an axial forearm exposure.

RESULTS

The most frequent mechanism of injury was glass-related lacerations. Overall, 541 structures were reconstructed, of which 417 were tendons, 76 nerves, and 48 arteries. An average of 8.86 structures were injured per patient, including 6.83 tendons, 1.24 nerves, and 0.79 arteries. The majority of the patients (28/61) had ≥10 structures injured (45.9%), while 32.7% (20/61) and 21.3% (13/61) of patients had 6-9 and 3-5 injured structures respectively. Almost 80% (49/61) of patients had excellent/good grading in all six tests used for the functional assessment post-operatively.

DISCUSSION

Spaghetti wrist injuries usually occur in a transverse wound pattern and necessitate timely and definitive operative reconstruction of all injured structures in layers, through an axial approach, by experienced hand surgeons to maximize outcome and to avoid complications. The most important prognostic factor of functional recovery is not the number of transected tendons, but the involvement of ulnar and/or median nerve injury.

Mortality, functional outcomes and quality of life after hip fractures complicated by infection: a case control study

Introduction: Infection is a detrimental complication of operatively treated hip fractures. The objective of this retrospective case-control study was to evaluate the mortality, the physical function and the quality of life of hip fractures complicated with infection and determine risk factors for deep infection in hip fractures. Patients and methods: All patients with hip fractures (31A and 31B OTA/AO) that were operatively managed over a 10-year period that subsequently developed deep infection were included in the study. Thirty-nine patients met the inclusion criteria. These patients were compared with a matched control group of 198 patients without infection. Minimum follow-up was 1 year. Mortality, Barthel index score, EQ-5D-5L, Parker mobility score and visual analogue scale (VAS) pain score were compared between groups. Results: Mortality at 1 month was 20.5 % and 43 % at 1 year. Half of the infections were acute and 28 % were polymicrobial. Mortality was greater in the infection group (43 % vs. 16.5 %, p < 0.0014 ), and Barthel index was inferior in the infection group (14 vs. 18, p < 0.0017 ) compared to control group. Logistic regression analysis revealed that time from admission to surgery was a negative factor that predisposed to infection. Conclusions: Patients complicated with infection after a hip fracture have higher mortality and inferior functional results. Delay from admission to surgery predisposes to infection.

The effect of zoledronic acid and high-dose vitamin D on function after hip fractures. A prospective cohort study

PURPOSE

Hip fractures are associated with functional decline and increased mortality. The aim of this study was to investigate the effect of zoledronic acid and high-dose vitamin D on function and mortality after hip fractures.

PATIENTS AND METHODS

Forty-five patients received zoledronic acid and high dose of vitamin D during hospitalization after fracture management. These patients were compared with a control group of 46 patients. Pre- and postoperative prospectively collected data including ASA score, Charlson comorbidity score, presence of dementia, Vitamin D, and the Barthel index were available. Final follow-up was performed after one year. Primary outcome was patients' function at final follow-up as measured with Barthel index score. Secondary outcomes included mortality, assessment of pain, and complications.

RESULTS

Barthel index score at final follow-up was decreased in both groups. There was no significant difference in Barthel index between the two groups (15.5 ± 5.0 vs 15.8 ± 5.8, p = 0.850). However, the Barthel index in the control group decreased beyond the smallest detectable change (3 points). Mortality was statistically different between groups (8.8% vs 28.2%, p = 0.047). Complications and pain at final follow-up were not different between groups. Multivariate analysis revealed that preoperative Barthel index and Charlson comorbidity score independently affected function at final follow-up. Logistic regression analysis disclosed that not receiving active treatment and complications were associated with increased mortality.

CONCLUSIONS

Medical treatment after surgical management of hip fractures results in reduced mortality and lessens the functional decline associated with these fractures.

A Challenging Case of Extraordinary - Long standing Forearm Non-union Treated with Extensive Debridement, Locking Plates, and Bone Grafting. Technical Considerations in Multiple-operated, Neglected Non-unions

Introduction:

Forearm non-unions pose a significant treatment challenge to orthopedic surgeons. Repetitive treatment failures can lead to a devastating situation for the patient. Forearm function influences both elbow and wrist proper function.

Case Report:

A functionless hand is presented, describing a longstanding non-union, treated with multiple surgeries before. A thorough debridement with respect to blood supply and local biology are of major importance before applying the locking plates along with the use of bone-graft. The reconstruction of the forearm converted a functionless arm to a fully functioning arm and the patient returned eventually to her previous activities.

Conclusion:

Fixation with locking plates combined with the use of autograft can lead to very satisfactory results even in extraordinary cases, especially when attention is paid to local anatomy and blood supply.

Primary Paraspinal Hydatid Cyst in a Patient Presenting with Low Back Pain: A Case Report

CASE

A 54-year-old man presented with low back pain and low-grade fever. Palpation revealed a focal mass of the lumbar region. Radiographs were normal, but magnetic resonance imaging demonstrated a multicystic mass at the level of L2-L4. The initial diagnosis of a hydatid cyst was confirmed after surgical excision.

CONCLUSION

Although primary paraspinal hydatidosis is rare, physicians should be aware of it when dealing with patients suffering from low back pain combined with red-flag symptoms. Especially in rural regions or areas where populations live in close proximity to host animals, primary paraspinal hydatidosis should be included in the differential diagnosis.

Factors predisposing to thrombosis after major joint arthroplasty

BACKGROUND

Total joint arthroplasty is one of the most common options for end stage osteoarthritis of major joints. However, we must take into account that thrombosis after hip/knee arthroplasty may be related to mutations in genes encoding for blood coagulation factors and immune reactions to anticoagulants [heparin-induced thrombocytopenia (HIT)/thrombosis]. Identifying and characterizing genetic risk should help to develop diagnostic strategies or modify anticoagulant options in the search for etiological mechanisms that cause thrombophilia following major orthopedic surgery.

AIM

To evaluate the impact of patients’ coagulation profiles and to study specific pharmacologic factors in the development of post-arthroplasty thrombosis.

METHODS

In 212 (51 male and 161 female) patients that underwent primary total hip arthroplasty (100) or total knee arthroplasty (112) due to osteoarthritis during a period of 1 year, platelet counts and anti-platelet factor 4 (PF4)/heparin antibodies were evaluated pre/postoperatively, and antithrombin III, methylenetetrahydrofolate reductase, factor V and prothrombin gene mutations were evaluated preoperatively. In a minimum follow-up of 3 years, 196 patients receiving either low-molecular-weight heparins (173) or fondaparinux (23) were monitored for the development of thrombocytopenia, anti-PF4/heparin antibodies, HIT, and thrombosis.

RESULTS

Of 196 patients, 32 developed thrombocytopenia (nonsignificant correlation between anticoagulant type and thrombocytopenia, P = 0134.) and 18 developed anti-PF4/heparin antibodies (12/173 for low-molecular-weight heparins and 6/23 for fondaparinux; significant correlation between anticoagulant type and appearance of antibodies, P = 0.005). Odds of antibody emergence: 8.2% greater in patients receiving fondaparinux than low-molecular-weight heparins. Gene mutations in factor II or V (two heterozygotes for both factor V and II) were identified in 15 of 196 patients. Abnormal low protein C and/or S levels were found in 3 of 196 (1.5%) patients, while all patients had normal levels of von Willebrand factor, lupus anticoagulant, and antithrombin III. Four patients developed HIT (insignificant correlation between thrombocytopenia and antibodies) and five developed thrombosis (two had positive antibodies and two were heterozygotes for both factor II & V mutations). Thrombosis was not significantly correlated to platelet counts or HIT. The correlation of thrombosis to antibodies, factor II, factor V was P = 0.076, P = 0.043, P = 0.013, respectively.

CONCLUSION

Screening of coagulation profile, instead of platelet monitoring, is probably the safest way to minimize the risk of post-arthroplasty thrombosis. In addition, fondaparinux can lead to the formation of anti-PF4/heparin antibodies or HIT.

Tips to secure healing at the free vascularised fibular graft-to-host bone junction

The most commonly used vascularized bone graft in Orthopedics for difficult reconstructive problems requiring biological augmentation properties is the fibula. It provides immediate structure and with a patent pedicle, increases blood flow at the recipient site, promoting healing and hypertrophy in response to mechanical stress. The vascular supply from the nutrient branch and the periosteal vessels allows a variety of graft harvesting configurations for a broad spectrum of reconstructive challenges. We present the details on how to optimize healing and graft incorporation at the junction sites.

Genesis 1 posterior cruciate-retaining total knee arthroplasty with asymmetric tibial tray: An 18-to-26-year long-term clinical outcome study

BACKGROUND

To present the long-term clinical and radiological outcomes of the Genesis I posterior cruciate-retaining total knee arthroplasty (TKA) (Smith & Nephew Orthopaedics, Memphis, TN, USA) (one of the first designed with an asymmetric tibial tray).

METHODS

Prospectively collected data from 117 cemented TKAs performed on 95 patients were evaluated using this design, with a mean follow-up of 21.5 years (range, 18-26). Failures, complication rates, and clinical (both subjective and objective) and radiological outcomes were assessed for all patients.

RESULTS

Seven failures occurred (wear and structural failure of the polyethylene insert) and six revision surgeries were performed at a mean of 10 years (range, three to 14) from the index operation. No revision of either the femoral or tibial components for aseptic loosening was performed. Survivorship analysis showed a cumulative success rate of 93.53% (95% CI, 92.75-94.32%) at 20 and 25 years, with revision for any reason as an end point. All patients showed a statistically significant improvement (P = 0.001) in the Knee Society and Oxford knee rating scores.

CONCLUSIONS

This study demonstrated satisfactory long-term clinical outcomes for this TKA design, with revisions being related to polyethylene wear structural failure.

Better knee function after surgical repair of acute quadriceps tendon rupture in comparison to acute patellar tendon rupture

INTRODUCTION

The purpose of this study was to determine if there is a difference in knee function between patients with quadriceps tendon rupture and patellar tendon rupture after acute surgical repair. Our hypothesis was that knee function would be similar between the two groups.

METHODS

The study population included 24 patients; 13 patients suffered from quadriceps tendon rupture and 11 patients from patellar tendon rupture. All patients underwent acute surgical repair using heavy non-absorbable trans-osseous sutures; another non-absorbable suture, passed through both retinaculum and around the repaired tendon to augment the repair. Clinical evaluation was performed using the Lysholm, Kujala, and VAS scoring systems. In addition, radiographic evaluation to evaluate patellar height and patello-femoral joint arthritis using Iwano's classification was performed.

RESULTS

The average follow-up time was 70.5 months. All patients in the quadriceps tendon group had full range of knee motion while 3 patients (27%) in the patellar tendon group had reduced knee flexion. Patients in the quadriceps tendon group had a significantly higher Kujala score in comparison to the patellar tendon group (88 vs. 73 p=0.033). No significant differences were identified between the two groups according to the Lysholm scoring system. Patients in the quadriceps tendon group had significantly less pain according to VAS scale (1.2 vs. 3.5 p=0.012). Radiographic evaluation revealed that two patients from each group showed signs of grade II patello-femoral joint arthritis according to Iwano's classification.

CONCLUSION

Acute surgical repair of quadriceps tendon ruptures provides better knee function, in comparison to the surgical restoration of patellar tendon rupture.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Satisfactory functional and radiological outcomes can be expected in young patients under 45 years old after open wedge high tibial osteotomy in a long-term follow-up

PURPOSE

To report the long-term outcomes of medial open wedge high tibial osteotomy (MOWHTO) for the treatment of medial compartment knee osteoarthritis in patients younger than 45 years old. It was hypothesized that the correction of knee alignment would result in preservation of knee function in a long-term follow-up.

METHODS

Patients under 45 years old, who underwent MOWHTO for symptomatic medial compartment knee osteoarthritis between 2001 and 2005 were retrospectively reviewed after a minimum of 10 years. The osteotomy was performed utilizing a locking plate without the use of bone graft. Patients were evaluated pre- and postoperatively using the International Knee Documentation Committee Score, the Oxford Knee Score, the Knee injury Osteoarthritis Outcome Score and the Short Form-12 Score. Standardized standing whole-limb radiographs were also obtained to assess mechanical tibiofemoral angle (mTFA) and the grade of osteoarthritis.

RESULTS

A total of 20 patients (18 males, 2 females, mean age 35.4 years) with a mean follow-up of 12.3 years were included in the study. During the follow-up period, one patient required conversion to total knee replacement (95% survival rate). All clinical outcome scores (IKDC, KOOS, OKS, and SF-12) significantly improved postoperatively (p < 0.05), with no significant deterioration over time. Preoperative varus alignment with an mTFA of - 5.8 ± 2.4° was corrected to 2.5 ± 1.9° immediately after surgery (p < 0.05), and remained 2.2 ± 1.7° at the last follow-up. Furthermore, no significant radiographic progression of osteoarthritis was observed.

CONCLUSIONS

MWOHTO with a locking plate is an effective joint preservation method to treat medial compartment OA in active patients less than 45 years. Clinical and radiological results are satisfactory and the survival rate is 95%, 12 years after the procedure.

LEVEL OF EVIDENCE

Level IV therapeutic, retrospective, cohort study.

Treatment outcomes for infected juxta-articular knee nonunions

PURPOSE

This retrospective case series assessed the results of a treatment protocol for patients with infected para-articular knee nonunions. The aim was to demonstrate that knee function and quality-of-life (QoL) can be improved.

CASE SERIES

Between January 2001 and December 2011, eleven patients with septic proximal tibial nonunion and seven with septic distal femoral nonunion were managed at our institution. The treatment protocol included extensive debridement, skeletal stabilization, culture-specific antibiotic administration, and soft-tissue and bone-deficit reconstruction. Knee function was evaluated with the Knee Society Score (KSS) while the Knee injury and Osteoarthritis Outcome Score (KOOS) and SF-12 were used for QoL assessment at a mean follow-up of 37.2 (range: 12-149) months. Seventeen nonunions healed at a mean of 21.9 weeks. One patient needed above knee amputation. Knee Society function and knee scores were improved significantly, from 16.7 and 33.8, to 75.0 and 84.9 respectively (p <0.001). KOOS outcome and SF-12 physical and mental components scores confirmed the QoL improvement.

CONCLUSIONS

Staged management can improve QoL and functional knee outcome. HIPPOKRATIA 2018, 22(4): 183-187.

Quality of life and psychological consequences in elderly patients after a hip fracture: a review

Fractures due to fragility of the bone around the hip joint have become a major public health issue, presenting with an increasing incidence due to the growth of the elderly population. The purpose of this review was to evaluate the impact of hip fractures on the quality of life (QoL), health status (HS), functioning, and psychological parameters, and factors influencing the outcome and the appropriate interventions for improvement of elderly patients. A systematic electronic search of the relevant literature was carried out using the CINAHL, Cochrane, EMBASE, Medline (OvidSP), and PubMed databases spanning the time period from their establishment up to January 2017. Forty-nine randomized controlled trials or prospective cohort studies reporting the QoL and psychological outcomes were assessed by using standardized questionnaires. Patients with a hip fracture who were older than 65 years, were included in the analysis. In the majority of elderly patients, the hip fracture seriously affected physical and mental functioning and exerted a severe impact on their HS and health-related QoL (HRQoL). Moreover, most of the patients did not return to prefracture levels of performance regarding both the parameters. The levels of mental, physical, and nutritional status, prior to the fracture, comorbidity, and female gender, in addition to the postoperative pain, complications, and the length of hospital stay, were the factors associated with the outcome. Psychosocial factors and symptoms of depression could increase pain severity and emotional distress. For the displaced femoral neck fractures, the treatment with total hip arthroplasty or hemiarthroplasty, when compared to the treatment with internal fixation, provided a better functional outcome. Supportive rehabilitation programs, complemented by psychotherapy and nutritional supplementation prior to and after surgery, provided beneficial effects on the HS and the psychosocial dimension of the more debilitated patients’ lives. Lack of consensus concerning the most appropriate HRQoL questionnaires to screen and identify those patients with more difficulties in the psychosocial functions, demonstrates the necessity for further research to assess the newer outcome measurement tools, which might improve our understanding for better care of patients with hip fractures.

Management of septic arthritis after arthroscopic anterior cruciate ligament reconstruction using a standard surgical protocol

BACKGROUND

To report the incidence of septic arthritis after anterior cruciate ligament (ACL) reconstruction and management of this complication using a specific treatment protocol.

METHODS

All primary ACL reconstructions performed in our institution between January 2002 and January 2014 were included in this study. Time to presentation, clinical symptoms, and culture results of all infected patients were analyzed. According to our protocol, an arthroscopic debridement and irrigation of the knee joint was performed immediately after a diagnosis of infection was made. In case of recurrence, knee irrigation with hardware and graft removal and later re-implantation was performed. Patients were evaluated with the Lysholm knee score, International Knee Documentation Committee (IKDC) Form, KT 1000 arthrometer and radiographic evaluation.

RESULTS

Postoperative septic arthritis occurred in seven of 1242 patients (0.56%). After initial arthroscopic debridement, infection recurred in six out of seven cases (85%). Graft and hardware removal was performed in these patients. Graft re-implantation was performed in four patients at an average five months after infection. At the final follow-up (mean 6.3years) all patients had full range of motion, while in patients with graft re-implantation the mean Lysholm score was 92, and the mean IKDC score was 87. Radiographs demonstrated that three patients had normal knees and one patient had a grade one, knee arthritis according to Kellgren-Lawrence classification.

CONCLUSIONS

Management of septic arthritis after ACL reconstruction using a specific surgical protocol which includes graft removal in case of infection recurrence with later re-implantation, can provide good and excellent results.

LEVEL OF EVIDENCE

Level IV, case series.

Global Forum: The Burden of Bone and Joint Infections: A Growing Demand for More Resources

The rate and severity of septic complications following joint replacement surgery and the incidence of posttraumatic infections are projected to increase at a faster pace because of a tendency to operate on high-risk patients, including older patients, patients with diabetes, and patients who are immunocompromised or have comorbidities. Musculoskeletal infections are devastating adverse events that may become life-threatening conditions. They create an additional burden on total health-care expenditures, and can lead to functional impairment, long-lasting disability, or even permanent handicap, with the inevitable social and economic burdens. The scientific community should take a more active role to draw public attention to the plight of hundreds of thousands of people across the globe who experience complications, become disabled, and, in some cases, die, and it should highlight what could be achieved if the global community takes decisive steps to improve access, early detection, and appropriate care. However, mitigating the adverse personal, clinical, and socioeconomic effects of these conditions requires increasing financial resources provided by both governments and funding organizations. Furthermore, a targeted action plan from the providers and the professional societies should be put in place so that the burden created by bone and joint infections is included in the agenda for global health-care priorities.

Articular cartilage status 2 years after arthroscopic ACL reconstruction in patients with or without concomitant meniscal surgery: evaluation with 3.0T MR imaging

PURPOSE

To assess articular cartilage changes in the knee joint as detected on 3.0T MR imaging after 2-year follow-up in patients who underwent arthroscopic anterior cruciate ligament reconstruction (ACLR) with or without concomitant meniscal surgery.

METHODS

A total of twenty-nine patients (mean age 30.3 ± 10 years), who underwent arthroscopic ACLR, received clinical and imaging follow-up at an average of 27.8 ± 4.8 months after surgery. Our patients were divided into two subgroups: eighteen patients with additional meniscal injuries at the time of arthroscopic ACLR who underwent meniscal surgery and eleven patients with intact menisci. The cartilage status of all knees at the time of arthroscopic ACLR was recorded. All patients underwent an MRI scan preoperatively and at follow-up with the same imaging protocol. Cartilage status of all knee compartments was evaluated at the time of follow-up by MR imaging and the ICRS classification.

RESULTS

Deterioration of the cartilage status was found at all knee compartments of our study group, with respect to the number of cartilage defects. The cartilage of the lateral femoral condyle (LFC) was most severely affected, followed by patellar and medial femoral condyle (MFC) cartilage. A statistically significant relation was found between surgery of the medial meniscus and the development of new cartilage defects in LFC (p = 0.01) and MFC (p = 0.03) after adjusting for the site of meniscal surgery. The cartilage of LFC and the status of the medial meniscus were also found to be significantly related (p = 0.04). Partial meniscectomy was found to be associated with an increased incidence of new cartilage defects when compared to either meniscal repair or absence of meniscal surgery, although it was not statistically significant.

CONCLUSION

Development of new cartilage lesions was evident after 2-year follow-up in patients with arthroscopic ACLR as detected by MR imaging. There was a multicompartmental pattern of cartilage involvement, and the lateral compartment was most severely affected. Partial meniscectomy at the time of arthroscopic ACLR could be suggested as an additional risk factor for the progression of chondral lesions.

LEVEL OF EVIDENCE

Prospective comparative study, Level II.

Heterotopic ossification after the use of recombinant human bone morphogenetic protein-7

AIM

To present the incidence of heterotopic ossification after the use of recombinant human bone morphogenetic protein-7 (rhBMP-7) for the treatment of nonunions.

METHODS

Bone morphogenetic proteins (BMPs) promote bone formation by auto-induction. Recombinant human BMP-7 in combination with bone grafts was used in 84 patients for the treatment of long bone nonunions. All patients were evaluated radiographicaly for the development of heterotopic ossification during the standard assessment for the nonunion healing. In all patients (80.9%) with radiographic signs of heterotopic ossification, a CT scan was performed. Nonunion site palpation and ROM evaluation of the adjacent joints were also carried out. Factors related to the patient (age, gender), the nonunion (location, size, chronicity, number of previous procedures, infection, surrounding tissues condition) and the surgical procedure (graft and fixation type, amount of rhBMP-7) were correlated with the development of heterotopic ossification and statistical analysis with Pearsons χ² test was performed.

RESULTS

Eighty point nine percent of the nonunions treated with rhBMP-7, healed with no need for further procedures. Heterotopic bone formation occurred in 15 of 84 patients (17.8%) and it was apparent in the routine radiological evaluation of the nonunion site, in a mean time of 5.5 mo after the rhBMP-7 application (range 3-12). The heterotopic ossification was located at the femur in 8 cases, at the tibia in 6, and at the humerus in οne patient. In 4 patients a palpable mass was present and only in one patient, with a para-articular knee nonunion treated with rhBMP-7, the size of heterotopic ossification affected the knee range of motion. All the patients with heterotopic ossification were male. Statistical analysis proved that patient’s gender was the only important factor for the development of heterotopic ossification (P = 0.007).

CONCLUSION

Heterotopic ossification after the use of rhBMP-7 in nonunions was common but it did not compromise the final clinical outcome in most cases, and affected only male patients.

Histological and biochemical evidence related to the collagen quality in torn rotator cuff tendons

This study investigates the histological background of torn rotator cuff tendons, evaluates the stability of newly synthesized collagen by measuring the hydro-xyproline content and attempts to correlate these findings with the clinical outcome after reconstruction of the rotator cuff. Sixty-one patients underwent reconstruction for a -rotator cuff tear. They were evaluated preoperatively with the Constant-Murley score, MRI and ultrasound. Biopsy samples were taken from chronic rotator cuff tears and histological analysis was performed. Hydroxyprolin presence was evaluated in various -tissues. Mean follow-up was 46 months. Histological analysis revealed collagen fragmentation and thinning (90.2% of patients), myxoid degeneration (88%), hyaline degeneration (50.8%), chondroid metaplasia (44.3%), calcification (24.7%), fatty infiltration (20.4%) and vascular proliferation (62.3%). Hydroxyproline was under-represented in newly synthesized collagen in 57% of patients. In the majority of the patients with a low hydroxyproline/collagen ratio the histological findings were abnormal. None of the findings was related to the clinical outcome with a statistical significance. Histological and biochemical findings reflected the poor quality of the tendon. The good clinical outcome did not depend on the histological or biochemical findings but rather on the meticulous surgical reconstruction and physical therapy.

Molecular changes indicative of cartilage degeneration and osteoarthritis development in patients with anterior cruciate ligament injury

BACKGROUND

Anterior cruciate ligament (ACL) tear is considered a risk factor for osteoarthritis development. The purpose of our study was to investigate the expression levels of the apoptotic enzyme caspase 3, pro-inflammatory cytokines interleukin-1β (IL-1β) and interleukin-6 (IL-6) and degrading enzyme matrix metalloproteinase 13 (MMP-13), all indicative of cartilage degeneration and osteoarthritis development in patients' chondrocytes after ACL rupture.

METHODS

We investigated the correlation between grade of cartilage degradation and time from injury or patients' age. IL-1β, IL-6 and MMP-13 mRNA expression levels were investigated in normal (n = 4) and chondrocytes from patients with ACL rupture (n = 33) using real-time polymerase chain reaction (PCR). Moreover, MMP-13 and caspase-3 protein expression levels were evaluated by western blot analysis. Trend analysis and correlation coefficient were performed to derive the relations between gene expression (MMP13, IL-6, IL-1β) and grading of cartilage defects and between gene expression (MMP13, IL-6, IL-1β) and patients' age, respectively.

RESULTS

Correlations were established between grade of cartilage degradation and time from injury. MMP-13, IL-6, IL-1β and caspase 3 expression levels were significantly upregulated in chondrocytes from ACL-deficient knee compared to normal. Among the patients with ACL-deficient knees, a significant upregulation of MMP-13 was observed in patients with ACL-rupture > 18 months from the time of injury to arthroscopy compared to patients with ACL-injury up to 18 months, whereas IL-6 and IL-1β expression was higher in chondrocytes from patients with more than 10 months ACL injury compared to those that underwent surgery within the first 10 months after injury. Νο association was observed between IL-1β, IL-6 and MMP-13 expression levels and cartilage defects or patients' age.

CONCLUSION

Our results showed that increased levels of apoptotic, inflammatory and catabolic factors in chondrocytes are associated with time from injury and could contribute to cartilage degradation and osteoarthritis development after ACL rupture.

Patient-reported quality of life after primary major joint arthroplasty: a prospective comparison of hip and knee arthroplasty

Background

To investigate and compare the impact of primary hip (THA) and knee (TKA) arthroplasty on quality of life in patients with osteoarthritis, to determine patients’ satisfaction with total joint arthroplasty, and to detect the effect of patients’ demographic and clinical characteristics on outcome.

Methods

Three hundred seventy eight (378) patients with hip (174) and knee (204) osteoarthritis undergoing total joint arthroplasty (174 THA-204 TKA) were assessed pre- and post-operatively (6 weeks, 3, 6, and 12 months) using the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and Centre for Epidemiological Studies Depression Scale (CES-D10). The patients’ satisfaction with the results of total joint arthroplasty was also assessed. Differences were analyzed using general linear model for repeated measures.

Results

The one-year response rate was 97 % for THA and 90 % for TKA. WOMAC and CES-D10 scores improved significantly after one year for both THA and TKA (P < 0.0001). The improvement in WOMAC total score was significantly greater for TKA patients (P < 0.0001 at 12 months). WOMAC pain and stiffness improved earlier for THA (6 weeks), while TKA had equivalent improvements at 3 and 6 months respectively. Both THA/TKA displayed significant improvement of WOMAC function at 3 months but TKA had greater improvement. Age, body mass index, residence, education and social support were not significant predictors of quality of life after total joint arthroplasty. One year postoperatively 88 % of patients were satisfied.

Conclusions

WOMAC and CES-D10 improved significantly one year postoperatively. Although pain and stiffness improved earlier in THA, functional improvement was inferior in THA compared to TKA.

RhBMP-7 for the treatment of nonunion of fractures of long bones

We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients' quality of life was estimated using the Short Form (SF) 12 score. A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year. Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union.

Operative management of humeral nonunions. Factors that influence the outcome

The purpose of this study is to present the outcome of surgically treated humeral nonunions and find factors that affect the outcome. Forty-two patients with humeral nonunions (30 shaft, 7 proximal and 5 distal) were reviewed in a prospective manner. Treatment was based on a specific algorithm. Demographics, time to union, range of motion, functional outcome and complications were recorded and analysed.

RESULTS

Mean follow-up was 78 months and mean time to union was 4.3 months. Infection was associated with delayed union of the pseudarthrosis, while range of motion was negatively affected by the location (proximal) and the AO type of the initial fracture. Complication rate was 17%.

CONCLUSION

The surgical management of humeral nonunions yields a favourable outcome with reduced rate of complications. Infection prolonged healing time, while proximal location of the nonunion and the type B or C fracture according to AO/OTA classification adversely affected range of motion.

Scaphocapitate Fracture: Two Cases with Follow-Up over 5 Years

Background Combined scaphoid and capitate fractures of the wrist are rare entities, and delayed diagnosis is frequent. Scaphocapitate fractures may be associated with reversal of the capitate head 90° or 180° (Fenton syndrome). Different treatment options have been proposed, with variable results. Case Description We report two cases of scaphocapitate fractures of the wrist, diagnosed 3 and 15 days after the injury. The first patient suffered from Fenton syndrome, a combined displaced fracture of the waist of the scaphoid with 180° reversal of capitate head. The second patient had combined fractures of the scaphoid, capitate, and distal radius. In both our cases, anatomic reduction and internal fixation were achieved, resulting in union of all fractures. The long-term results, after 5.5 and 7 years respectively, were very satisfactory, both clinically and radiographically, without signs of avascular necrosis of the head of the capitate or the scaphoid. Literature Review Few reports of scaphocapitate fractures were found in literature. Mechanism of injury, treatment, and outcomes of the reported cases in correlation to our cases are discussed. Clinical Relevance Given the high rate of complications of scaphocapitate fractures, long-term follow-up is important to assess the natural history of the wrist joint after such injuries. The restoration of normal anatomic relationships can lead to a successful long-term functional outcome despite the severity of the injury.

Dynamic Effect of Quadriceps Muscle Activation on Anterior Tibial Translation After Single-Bundle and Double-Bundle Anterior Cruciate Ligament Reconstruction

PURPOSE

To examine differences in anterior tibial translation in 3 groups: single-bundle anterior cruciate ligament (ACL)-reconstructed, double-bundle ACL-reconstructed, and ACL-intact knees under gradual dynamic quadriceps muscle activation.

METHODS

Thirty male patients underwent successful single-bundle (n = 15) and double-bundle (n = 15) ACL reconstructions; 15 healthy controls were included in the study. Anterior tibial translation was assessed at 30° of knee flexion in the resting position (0% quadriceps activation) and under 50% and 100% of maximum quadriceps concentric contraction using an isokinetic dynamometer with the KT-2000 arthrometer securely attached to the participants' knees.

RESULTS

The 2 ACL-reconstructed groups were similar regarding International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Score (KOOS), Tegner, and Lysholm scores and preliminary isokinetic evaluation (P = .38). Quadriceps activation significantly affected anterior tibial translation (P = .001, α = 0.98). In all 3 study groups, anterior tibial translation was significantly higher under 100% quadriceps activation compared with 0% contraction (P = .01) and 50% quadriceps activation (P = .047). There were no between-group differences in anterior tibial translation with 0%, 50%, or 100% quadriceps activation (P = .46).

CONCLUSIONS

Under quadriceps muscle activation, anteroposterior knee laxity in ACL-intact and ACL-reconstructed knees is gradually increased. Single-bundle and double-bundle ACL-reconstructed knees show a similar increase in anterior tibial translation under gradual quadriceps contraction. When comparing different ACL reconstruction techniques in the experimental setting, dynamic, in addition to static, testing is advised to reach a comprehensive assessment of anteroposterior knee stability.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

DNA methylation regulates sclerostin (SOST) expression in osteoarthritic chondrocytes by bone morphogenetic protein 2 (BMP-2) induced changes in Smads binding affinity to the CpG region of SOST promoter

Introduction

Sclerostin (SOST), a soluble antagonist of Wnt signaling, is expressed in chondrocytes and contributes to chondrocytes’ hypertrophic differentiation; however its role in osteoarthritis (OA) pathogenesis is not well known. Based on our previous findings on the interaction between Wnt/β-catenin pathway and BMP-2 in OA, we aimed to investigate the role of DNA methylation and BMP-2 on SOST’s expression in OA chondrocytes.

Methods

SOST mRNA and protein expression levels were investigated using real-time polymerase chain reaction (PCR) and Western blot, respectively. The methylation status of SOST promoter was analysed using methylation-specific PCR (MSP), quantitative methylation-specific PCR (qMSP) and bisulfite sequencing analysis. The effect of BMP-2 and 5’-Aza-2-deoxycytidine (5-AzadC) on SOST’s expression levels were investigated and Smad1/5/8 binding to SOST promoter was assessed by Chromatin Immunoprecipitation (ChΙP).

Results

We observed that SOST’s expression was upregulated in OA chondrocytes compared to normal. Moreover, we found that the CpG region of SOST promoter was hypomethylated in OA chondrocytes and 5-AzadC treatment in normal chondrocytes resulted in decreased SOST methylation, whereas its expression was upregulated. BMP-2 treatment in 5-AzadC-treated normal chondrocytes resulted in SOST upregulation, which was mediated through Smad 1/5/8 binding on the CpG region of SOST promoter.

Conclusions

We report novel findings that DNA methylation regulates SOST’s expression in OA, by changing Smad 1/5/8 binding affinity to SOST promoter, providing evidence that changes in DNA methylation pattern could underlie changes in genes’ expression observed in OA.

MicroRNA-33a regulates cholesterol synthesis and cholesterol efflux-related genes in osteoarthritic chondrocytes

Introduction

Several studies have shown that osteoarthritis (OA) is strongly associated with metabolism-related disorders, highlighting OA as the fifth component of the metabolic syndrome (MetS). On the basis of our previous findings on dysregulation of cholesterol homeostasis in OA, we were prompted to investigate whether microRNA-33a (miR-33a), one of the master regulators of cholesterol and fatty acid metabolism, plays a key role in OA pathogenesis.

Methods

Articular cartilage samples were obtained from 14 patients with primary OA undergoing total knee replacement surgery. Normal cartilage was obtained from nine individuals undergoing fracture repair surgery. Bioinformatics analysis was used to identify miR-33a target genes. miR-33a and sterol regulatory element-binding protein 2 (SREBP-2) expression levels were investigated using real-time PCR, and their expression was also assessed after treatment with transforming growth factor-β1 (TGF-β1) in cultured chondrocytes. Akt phosphorylation after treatment with both TGF-β1 and miR-33a inhibitor or TGF-β1 and miR-33a mimic was assessed by Western blot analysis. Furthermore, we evaluated the effect of miR-33a mimic and miR-33a inhibitor on Smad7, a negative regulator of TGF-β signaling, on cholesterol efflux-related genes, ATP-binding cassette transporter A1 (ABCA1), apolipoprotein A1 (ApoA1) and liver X receptors (LXRα and LXRβ), as well as on matrix metalloproteinase-13 (MMP-13), using real-time PCR.

Results

We found that the expression of miR-33a and its host gene SREBP-2 was significantly elevated in OA chondrocytes compared with normal chondrocytes. Treatment of cultured chondrocytes with TGF-β1 resulted in increased expression of both miR-33a and SREBP-2, as well as in rapid induction of Akt phosphorylation, whereas TGF-β-induced Akt phosphorylation was enhanced by miR-33a and suppressed by inhibition of miR-33a, as a possible consequence of Smad7 regulation by miR-33a. Moreover, treatment of normal chondrocytes with miR-33a resulted in significantly reduced ABCA1 and ApoA1 mRNA expression levels and significantly elevated MMP-13 expression levels, promoting the OA phenotype, whereas miR-33a’s suppressive effect was reversed using its inhibitor.

Conclusions

Our findings suggest, for the first time to our knowledge, that miR-33a regulates cholesterol synthesis through the TGF-β1/Akt/SREBP-2 pathway, as well as cholesterol efflux-related genes ABCA1 and ApoA1, in OA chondrocytes, pointing to its identification as a novel target for ameliorating the OA phenotype.

Fast sequences MR imaging at the investigation of painful skeletal sites in patients with hip osteonecrosis

BACKGROUND

Multiple osteonecrotic foci can be clinically silent when located in metaphyses and becomes painful when it affects juxta-articular areas. The purpose of this study was to assess the value of fast MR imaging to depict the underlying pathology in cases with skeletal pain other than the already diagnosed hip osteonecrosis.

METHODS/DESIGN

Between 2008 and 2013, 49 patients with already diagnosed hip osteonecrosis reported symptoms of deep skeletal pain in an anatomical site different from the affected hip joint. All patients after thorough history & clinical examination underwent evaluation with x-rays and a single fat suppressed sequence with MR Imaging applying either T2-w TSE or STIR-TSE at the painful site. False positive and false negative findings were recorded for the conventional x-rays and compared to MRI.

DISCUSSION

Forty four (89.8%) patients were positive for osteonecrotic lesions in this study and 76 symptomatic osteonecrosis lesions were revealed at 14 distinct anatomic sites. The agreement between the x-ray findings and the MR imaging regarding osteonecrosis was 46.9%. Plain x-rays showed 43.4% sensitivity, 100% specificity, 100% positive predictive value and 10.4% negative predictive value. Fast MR imaging with fat suppressed sequences is necessary and adequate as a single method for the investigation of painful skeletal sites in patients with already diagnosed hip osteonecrosis. It allows early diagnosis of the potentially debilitating multiple juxta-articular lesions and consequently their prompt management.

Repair and tissue engineering techniques for articular cartilage

Chondral and osteochondral lesions due to injury or other pathology commonly result in the development of osteoarthritis, eventually leading to progressive total joint destruction. Although current progress suggests that biologic agents can delay the advancement of deterioration, such drugs are incapable of promoting tissue restoration. The limited ability of articular cartilage to regenerate renders joint arthroplasty an unavoidable surgical intervention. This Review describes current, widely used clinical repair techniques for resurfacing articular cartilage defects; short-term and long-term clinical outcomes of these techniques are discussed. Also reviewed is a developmental pipeline of acellular and cellular regenerative products and techniques that could revolutionize joint care over the next decade by promoting the development of functional articular cartilage. Acellular products typically consist of collagen or hyaluronic-acid-based materials, whereas cellular techniques use either primary cells or stem cells, with or without scaffolds. Central to these efforts is the prominent role that tissue engineering has in translating biological technology into clinical products; therefore, concomitant regulatory processes are also discussed.

Meniscal and articular cartilage lesions in the anterior cruciate ligament-deficient knee: correlation between time from injury and knee scores

PURPOSE

Anterior cruciate ligament (ACL) rupture is associated with meniscal tears and/or articular cartilage damage. The aim of this study was twofold: (a) to report and correlate the incidence of meniscal and cartilage lesions in ACL-deficient knees with time from injury and (b) to correlate lesions of menisci and cartilage with widely used knee scores.

METHODS

Data were analysed from 109 consecutive patients with ACL rupture. Meniscal and articular cartilage lesions were documented during the arthroscopic reconstruction of the ACL. Patients were distributed into 3 groups according to time from injury; group A: 0-3 months (35 patients), group B: 3-12 months (39 patients) and group C: more than 12 months (35 patients). Lysholm, KOOS and IKDC rating scales were recorded preoperatively. Logistic regression analyses were applied to correlate the concomitant intra-articular pathologies with the time from injury and knee-rating scales.

RESULTS

Of 109 patients, 32 (29%) had a medial meniscus tear, 20 (19%) had a lateral meniscus tear, 17 (15%) had both menisci torn and 40 (37%) had no meniscal tear. Analysis revealed that time from injury was not a significant factor for the presence of a meniscal lesion. The odds of development of a high-grade cartilage lesion in an ACL-deficient knee reconstructed more than 12 months from time from injury are 5.5 and 12.5 times higher when compared with knees that underwent ACL reconstruction less than 3 months and between 3 and 12 months after knee injury, respectively. No association was found between intra-articular pathology and the KOOS and Lysholm scores. A positive correlation between the IKDC score and patients without any intra-articular pathology was found.

CONCLUSIONS

The presence of high-grade cartilage lesions is significantly increased in an ACL-deficient knee when reconstruction is performed more than 12 months after injury. However, the incidence of meniscal tears is not increased significantly. Correlation of intra-articular pathology in ACL-deficient knees with knee-rating scales is weak.

LEVEL OF EVIDENCE

Diagnostic study, Level II.

Psychological distress, personality traits and functional disability in patients with osteonecrosis of the femoral head

BACKGROUND

The aim of the present study was to investigate personality traits, psychological distress and functional disability in patients with non-traumatic osteonecrosis of the femoral head (ONFH).

METHODS

Sixty-seven patients participated in the study, 48 males and 19 females. The mean age was 37.6 years (SD: 10.92, range: 15 - 61). Seventy-five healthy individuals, age and sex matched, served as controls. Socio-demographic information and clinical data were collected. The following instruments were used: the General Health Questionnaire (GHQ-28), the Defence Style Questionnaire (DSQ) and the World Health Organization Disability Assessment Schedule II (WHO-DAS II).

RESULTS

Patients suffering from ONFH presented higher scores at the GHQ-28 compared to healthy controls (P < 0.001). Duration of disease (P < 0.047) and age (P < 0.023) were the main factors associated with psychological distress (P < 0.003). Personality traits such as image distorting (P < 0.025) and self-sacrificing (P < 0.029) were identified in patients with ONFH compared to healthy controls. Functional disability was associated with high scores at GHQ-28 scale (P < 0.001). The "adaptive personality structure", as measured by DSQ was negatively associated with functional impairment (P < 0.022).

CONCLUSIONS

Patients with ONFH more commonly present symptoms of psychological distress associated with distinct functional clinical parameters. The present study also reveals the role of personality traits. Further investigation could specify the possible influence of psychopathology and personality traits or coping strategies on the course of disease.

Eosinophilic granuloma of the sternum in a child treated with closed biopsy

Langerhans cell histiocytosis is a rare neoplastic proliferative disorder of the Langerhans cells. The clinical course is variable, ranging from a low symptomatic single bone lesion to fatal multiple organ involvement. Rarely, the sternum can be the first and single location of the disease. We report on a 12-year-old boy who presented with an aggressive lytic lesion of the proximal sternum associated with local pain and afternoon fever. Histopathological analysis of the closed biopsy specimen indicated eosinophilic granuloma of bone/Langerhans cell histiocytosis. Soon after the biopsy procedure the pain and fever subsided. Computed tomography at 2 months showed healing of the lytic lesion. The patient received no other type of treatment. At 2 year follow up he was symptom and disease free.

Vascularized bone grafting and distal radius osteotomy for scaphoid nonunion advanced collapse

PURPOSE

To determine the outcome of an alternative treatment for wrists with stages I to III scaphoid nonunion advanced collapse using a closing-wedge osteotomy of the distal radius and a vascularized bone graft for scaphoid reconstruction.

METHODS

Twelve patients with scaphoid nonunion advanced collapse (stage I, 3; stage II, 7; stage III, 2) treated with a vascularized bone graft interposition for the scaphoid and a closing-wedge osteotomy for the distal radius were retrospectively reviewed. Data were obtained and analyzed from the radiographs, and we assessed the pre- and postoperative range of motion, grip strength, visual analog scale pain score, as well as the Mayo and Disabilities of the Arm, Shoulder, and Hand (DASH) functional scores.

RESULTS

Follow-up ranged from 2 to 11 years. All scaphoid nonunions united after an average of 9 weeks, and all osteotomies united after an average of 8 weeks. Although there was radiographic progression of the scaphoid nonunion advanced collapse stage in 5 of 12 cases, there was major improvement in visual analog scale pain score (from 6.1 to 0.8) and in both Mayo (from 64 to 85) and DASH (from 40 to 9) functional scores. The range of motion remained unchanged, and grip strength trended toward minor improvement. The carpal height was preserved, and the dorsal intercalated segmental instability was corrected.

CONCLUSIONS

Scaphoid reconstruction with vascularized bone graft combined with closing-wedge distal radius osteotomy preserved wrist function for scaphoid nonunion advanced collapse. The method offers pain relief and does not compromise wrist motion or grip strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Tuberculous pyomyositis: a re-emerging entity of many faces

Tuberculosis (TB) has become a global concern due to its increasing incidence, particularly in immunocompromised patients, closely following the migratory patterns of populations. TB pyomyositis is a rare extrapulmonary manifestation of TB. Its clinical presentation varies and requires a high degree of suspicion for early diagnosis. We present three patients diagnosed with TB pyomyositis: a 46-year-old man with dermatomyositis (DM) and hepatitis B who presented with fever, muscle weakness, and an abscess at the right proximal arm; a 71-year-old immunocompetent male, with a past medical history of tuberculous lymphadenopathy in childhood, who presented with a 2-month history of fever and pain at the right thigh, and a 44-year-old woman with systemic lupus erythematosus (SLE) on prednisone and methotrexate who presented with skin eruption at her thighs mimicking lupus panniculitis. In all three patients, Mycobacterium tuberculosis was identified as the causative agent. The lack of specific signs, the false negative tuberculin skin test in some cases, and the unfamiliarity of many clinicians with this entity can cause diagnostic delays. Prompt diagnosis requires a high index of suspicion especially in immunocompromised patients with fever.

Autologous (non-vascularised) fibular grafting with recombinant bone morphogenetic protein-7 for the treatment of femoral head osteonecrosis: preliminary report

This preliminary study evaluates a combination of bone morphogenetic protein (BMP)-7 and non-vascularised autologous fibular grafting (AFG) for the treatment of osteonecrosis of the femoral head. BMP-7/AFG combination was applied in seven pre-collapse femoral heads (five Steinberg stage II, two stage III) in six patients. Pre- and post-operative evaluation included clinical (Harris hip score (HHS), visual analogue scale (VAS) for pain) and radiological assessment (radiographs, quantitative CT) at a mean follow-up of 4 years (2 to 5.5). A marked improvement of function (mean HHS increase of 49.2) and decrease of pain level (mean VAS decrease of 5) as well as retention of the sphericity of the femoral head was noted in five hips at the latest follow-up, while signs of consolidation were apparent from the third post-operative month. One patient (two hips) required bilateral total hip replacement at one year post-operatively. In the series as a whole, quantitative-CT evaluation revealed similar densities between affected and normal bone. Heterotopic ossification was observed in four hips, without compromise of the clinical outcome. In this limited series AFG/BMP-7 combination proved a safe and effective method for the treatment of femoral head osteonecrosis, leading to early consolidation of the AFG and preventing collapse in five of seven hips, while the operative time and post-operative rehabilitation period were much shorter compared with free vascularised fibular grafts.