Heterotopic ossification with concurrent chronic osteomyelitis of the leg following licking of a wound by a domesticated dog.

INTRODUCTION: HO with concurrent chronic osteomyelitis is extremely rare. To the authors' knowledge, this is the first case in the English-language literature with wound infection and mature HO with chronic osteomyelitis caused by mixed infection of Pasteurella canis, Peptoniphilus coxii, Peptostreptococcus canis, and Fusobacterium nucleatum following licking of a wound by a domesticated dog. CASE REPORT: A 49-year-old female with a painful, swollen, and purulent wound with bone exposure, measuring 2.5 cm × 1.5 cm, on the right leg was referred after an unsuccessful 3-month treatment regimen for an open wound resulting from a motorcycle accident. The patient's dog licked the wound several times 1 week after the accident. Sequestrectomy and debridement were performed after a 3-week OPD treatment. Postoperative treatment included NPWT applied for 6 days, 1 week of open wound care, STSG 2 weeks after the first operation, and IV antibiotics for 3 weeks. Pathologic examination was positive for HO with chronic osteomyelitis. The patient was discharged 3 weeks after admission under stable condition followed by OPD treatment. Wound healing was achieved 2 months after discharge. CONCLUSIONS: Repeated licking of the patient's wound by her dog caused the colonization of pathogens from the dog's saliva, and inappropriate wound care by the patient herself resulted in HO with chronic osteomyelitis, which was successfully treated with a regimen of NPWT, open wound care, STSG, and IV antibiotics.

Liquid combination of hyaluronan, glucosamine, and chondroitin as a dietary supplement for knee osteoarthritis patients with moderate knee pain: A randomized controlled study.

BACKGROUND: Hyaluronan (HA), glucosamine, and chondroitin sulfate are widely consumed as dietary supplements for the treatment of knee osteoarthritis (OA). This study aimed to explore the efficacy and safety of a dietary liquid supplement mixture containing HA, glucosamine, and chondroitin in patients with knee OA who had moderate knee pain (visual analogue scale of 4-6 points). METHODS: This was a short-term, randomized, double-blind, placebo-controlled study. Subjects were allocated to administer either a bottle of 20 mL supplement mixture (50 mg HA plus 750 mg glucosamine plus 250 mg chondroitin, namely A + HA) or placebo once daily for 8 weeks. Outcome measures included the Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, 36-item Short Form Survey (SF-36), Chinese version of Pittsburgh Sleep Quality Index, and incidence of adverse event were evaluated at the end of week 8. Efficacy analyses were conducted in the modified intent-to-treat population. RESULTS: Of the 80 subjects in the modified intent-to-treat population, 39 received A + HA while 41 received placebo. After 8 weeks of treatment, the A + HA group failed to demonstrate a significant symptomatic efficacy and quality of life improvement in terms of Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, SF-36, and Chinese version of Pittsburgh Sleep Quality Index as compared to the placebo group. However, the mean changes in most of the SF-36 scale scores were numerically higher in the A + HA group than in the placebo group. No treatment-related adverse event was reported in both groups. CONCLUSIONS: This present study found that the combination of liquid low molecular weight HA, glucosamine, and chondroitin oral supplement did not effectively improve knee OA pain and symptoms after short-term use in knee OA patients with moderate knee pain. However, these results should be interpreted with caution due to the intrinsic limitation of the study design.

The effect of oral low molecular weight liquid hyaluronic acid combination with glucosamine and chondroitin on knee osteoarthritis patients with mild knee pain: An 8-week randomized double-blind placebo-controlled trial.

BACKGROUND: The popularity of dietary supplements for knee osteoarthritis (OA) management is on the rise; however, their effects are still debated. METHODS: This study aimed to investigate the effect of an oral low molecular weight liquid hyaluronic acid supplement in the treatment of knee OA patients with mild knee pain (visual analogue scale [VAS] ≤ 3) in Taiwan population. This was a randomized, double-blind, placebo-controlled study. Forty-seven subjects were enrolled and randomly allocated to either the A+HA or the placebo groups. The subjects were required to drink a bottle contained 20 mL of A+HA or placebo daily throughout an 8-week study period. The efficacy was assessed by using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the 36-item Short Form Survey (SF-36). RESULTS: At Week 8, significant reductions from baseline in the WOMAC pain (-2.6 ±â€Š1.68, P < .0001), stiffness (-1.2 ±â€Š1.50, P = .007), physical function (-5.8 ±â€Š4.39, P < .0001), and total (-9.4 ±â€Š5.82, P < .0001) scores were observed in the A+HA group but not in the placebo group. Significant differences in the mean change of WOMAC scores from baseline at Week 8 between groups were detected (P < .01). At Week 8, the A+HA group also showed significant improvements in SF-36 physical functioning (2.7 ±â€Š3.10, P = .001) and bodily pain (0.7 ±â€Š1.50, P < .05) domains. Although the A+HA group had a higher increase in the SF-36 total score than the placebo group but the difference was not statistically significant (2.1 ±â€Š12.75 vs 0.3 ±â€Š19.66, P = .12). CONCLUSIONS: Oral administration of low molecular weight liquid HA appeared to be effective for knee OA patients with mild knee pain (VAS ≤ 3) in the relief of knee OA symptoms, particularly in pain and physical function.Clinical Trial Registration: NCT04352322.

Stress fractures of forearm bones in military recruits of rifle drill training.

BACKGROUND: Stress fractures rarely occur in the forearms. These injuries usually occur in healthy young patients, which are usually neglected by patients or physicians. Early diagnosis and treatment are important to avoid late complications of these fractures. The purpose of this study was to analyze a case series of military recruits who participated in rifle drill training and presented with forearm stress fractures at our institution. METHODS: We evaluated 216 military recruits of rifle drill training. Twelve patients were diagnosed with forearm stress fractures by typical history, physical examination, laboratory studies, serial radiographs, and bone scan examinations. RESULTS: Eighteen fractures were found in 12 patients. On initial radiographs, 11 had periosteal reactions, 4 had callus formation with complete fracture lines, and 3 were normal. All 18 fractures had increase radioactivity in the involved middle (15 of 18) or distal (2 of 18) ulnae and one middle radius (1 of 18). CONCLUSIONS: Stress fractures of the forearms in military rifle drill training usually occur in middle ulnae. Fifty percent of them were bilateral fractures. A high index of suspicion is the key to diagnosis. Early diagnosis with conservative treatment can achieve satisfactory results and avoid late complications of stress fractures.

Retinoid acid inhibits IL-1-induced iNOS, COX-2 and chemokine production in human chondrocytes.

This study aims to investigate the effects and mechanisms of all-trans retinoic acid (t-RA) on interleukin(IL)-1-induced production of several inflammatory mediators in human chondrocytes. The cartilage from OA patients receiving total knee or total hip replacement was obtained and chondrocytes were prepared. Chemokine concentrations were measured by ELISA. The expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) was determined by Western blotting and/or RT/PCR. Nitrite levels were measured by Griess assays. The DNA-binding activity and transcriptional activity of activator protein-1 (AP-1) were measured by electrophoresis mobility shift assay and luciferase assay. We showed that t-RA suppressed IL-1-induced release of chemokines, including regulated upon activation, normal T cell expressed and secreted (RANTES), monocyte chemoattractant protein 2 (MCP-2), macrophage inflammatory protein-1alpha (MIP-1alpha) and MIP-1beta. Four different retinoid derivatives all preserved inhibitory effects albeit the potency was different. t-RA potently suppressed IL-1-induced expression of iNOS and COX-2 and production of nitric oxide and prostaglandin E(2). In consistent with the results in primary chondrocytes, t-RA down-regulated IL-1-induced AP-1 DNA binding activity and transcriptional activity in a human fibroblast-like (commercially labeled as chondrocyte) cell line. By examining the effect of a c-jun N-terminal kinase (JNK) specific inhibitor, we showed that the suppression of JNK-AP-1 signaling was enough to inhibit IL-1-induced production of chemokines and activation of iNOS and COX-2 pathways. Collectively, our results raise a therapeutic option that intra-articular administration of retinoid derivatives at 10-1000 nanomolar concentrations may be effective to suppress the progression of inflammatory OA.

Extra-articular knowles pin fixation for unstable distal clavicle fractures.

BACKGROUND: Unstable distal clavicle fractures may benefit from surgical treatment. This report described a new method with transacromial extra-articular Knowles pin fixation to treat these unstable fractures. The hypothesis is that the results would be improved. METHODS: Twenty-five patients with unstable distal clavicle fractures were treated by transacromial extra-articular Knowles pin fixation, coracoclavicular ligament repair and augmentation. The mean clinical and radiographic follow-up was 51 months. Functional outcomes were evaluated by a modified Constant-Murley score. RESULTS: Ninety-two percent of patients had uneventful fracture union. Eight percent had delayed or nonunion with pin loosening. Both had successful union after revision surgery. The injured shoulders functioned similar to the uninjured shoulders. CONCLUSION: The transacromial extra- articular Knowles pin fixation method is a reliable method to treat the unstable distal clavicle fractures with an acceptable complication rate.

Transacromial extra-articular Knowles pin fixation treatment of acute type V acromioclavicular joint injuries.

BACKGROUND: Type V acromioclavicular (AC) joint dislocations need surgical treatment. This report described a new transacromial extra-articular Knowles pin fixation method to treat this very unstable dislocations to analyze this treatment. The hypothesis is that the results would be improved. METHOD: Thirteen consecutive patients with type V AC joint dislocations within 9 days of injuries were treated by open reduction transacromial extra-articular Knowles fixation, AC ligament repair, coracoclavicular (CC) ligament repair, CC augmentation sutures. All of them received postoperative arm sling supports for 3 weeks. The radiographic and clinical follow-up was at least 23 months. A modified Constant-Murley score was used for evaluation of bilateral shoulder functions. RESULTS: All AC ligaments were torn at the clavicle sides. All CC ligament were torn at the mid-substances. The anterior deltoid insertions and the superior-posterior trapezius insertions to the clavicles were torn. Radio-lucent zones around the pins 1 mm to 3 mm were noted in all patients before pin removal. Lateral pin migration 1 mm to 2 mm were noted in nine patients before pin removal. Nine patients had increase of CC distances 1 mm to 4 mm at follow-up. Six patients had CC space calcifications. The mean modified Constant-Murley score of the injured shoulders was 94.5 +/- 2.7, the mean score of the uninjured shoulders was 93.9 +/- 1.3, which was not statistically different. CONCLUSIONS: The transacromial extra-artocular Knowles pin fixation method is a reliable method to treat acute type V AC joint dislocations.

Stress fracture of the ulna in a break-dancer.

Break dancing is a popular activity in teenagers and is associated with severe trauma to bones and tissues. We report the first known case of a break dancer with an ulnar stress fracture. Such injuries occur in a variety of sports due to substantial stress on the ulna and repetitive excessive rotation of the forearm. In this study we describe a patient who experienced an ulnar stress fracture during break dancing training. The diagnosis was established by history and physical examination. Initial radiographic findings were negative. However, radiographs taken 3 months after initial presented revealed callus formation over the ulnar shaft. This suggested that readjustment is required in break dancing training protocols. It is important to increase awareness of this injury among physicians to expedite the diagnosis and to prevent the possibility of conversion to an overt fracture in the future. Key pointsStress fractures should not be ignored when the patient changes exercise loading.A thoroughly detailed clinical history, physical examination, and plain radiographs were used diagnostically in this clinical case.The best methods for the treatment of stress fractures include readjustment training protocols to prevent conversion to overt fractures.

Intraosseous ganglion cyst of the capitate treated by intralesional curettage, autogenous bone marrow graft and autogenous fibrin clot graft.

We report a very rare case of intraosseous ganglion cyst of the capitate in a 54-year-old female who complained of a painful right wrist mass for 1 year. Computed tomography study showed an expansile osteolytic lesion with sclerotic margin and thinning of the cortex. Combined soft tissue ganglion cyst was also noted at operation and confirmed by pathologic study. The case was treated by a new method of autogenous bone marrow and fibrin clot graft after intralesional curettage. After a 2-year follow-up, the capitate revealed complete bony union and the symptoms were relieved with good functional results.

Spontaneous rupture of the patellar and contralateral quadriceps tendons associated with secondary hyperparathyroidism in a patient receiving long-term dialysis.

Although spontaneous rupture of the extensor tendon of the knee is more likely to occur in uremic patients with secondary hyperparathyroidism, simultaneous ruptures of bilateral knee extensor tendons is a rarely reported condition. We describe a 30-year-old man with uremia who underwent subtotal parathyroidectomy because of secondary hyperparathyroidism with very high serum parathyroid hormone (PTH) level (1940.4 pg/mL). Two weeks later, he complained of a sharp pain in both knees without trauma when he walked downstairs with his left knee forward and right knee behind. Spontaneous simultaneous ruptures of the right patellar tendon and the left quadriceps tendon were diagnosed and surgically repaired. The mechanism of spontaneous tendon rupture in uremic patients with secondary hyperparathyroidism seems to be related to high PTH level which results in osteolytic bone resorption at the tendon insertion site. Early surgical repair, control of secondary hyperparathyroidism, early use of vitamin D analogs, and total parathyroidectomy with or without autotransplantation of part of the parathyroid gland, can treat and prevent tendon rupture or re-rupture with satisfactory results.

Retinoic acid blocks pro-inflammatory cytokine-induced matrix metalloproteinase production by down-regulating JNK-AP-1 signaling in human chondrocytes.

The development of osteoarthritis (OA) has recently been implicated as a result of immune-mediated damage of chondrocytes and their supporting matrixes. Pro-inflammatory cytokines like interleukin (IL)-1 and tumor necrosis factor alpha (TNF-alpha) play pivotal roles in immunopathogenesis of OA. Because vitamins preserving anti-oxidative effects are suggested to provide protection in OA patients from joint damage, in the present study, we examined the effects and mechanisms of all-trans retinoic acid (t-RA) in suppressing pro-inflammatory cytokine-induced matrix metalloproteinases (MMPs) production in human chondrocytes. Chondrocytes were prepared from cartilage specimens of OA patients receiving total hip or total knee replacement. The protein concentration was measured by ELISA, the mRNA expression by reverse transcriptase-polymerase chain reaction, the protein expression by Western blotting, the transcription factor DNA-binding activity by electrophoretic mobility shift assay and the protein kinase activity by kinase assay. We showed that both MMP-1 and MMP-13 mRNA expression, protein production and enzyme activity induced by either IL-1 or TNF-alpha were suppressed by t-RA or different retinoid derivatives. The molecular investigation revealed that the t-RA-mediated suppression was likely through blocking p38 kinase and c-Jun N-terminal kinase-activator protein-1 signaling pathways. In contrast, t-RA had no effect on extracellular signal-regulated kinase activity, nuclear factor (kappa)B (NF-(kappa)B) DNA-binding activity and I(kappa)B(alpha) degradation. Furthermore, we showed that t-RA could reduce IL-1-induced TNF-alpha production in chondrocytes. Our results suggest that vitamin A may protect OA patients from pro-inflammatory cytokine-mediated damage of chondrocytes and their supporting matrixes.

The nutcracker fracture of the cuboid in children: a case report.

The fracture of the cuboid in children is rarely diagnosed and has probably been underreported for nondisplaced fractures. The diagnosis is often missed, and overlooked cuboid fracture can lead to severe alterations in foot mechanics and function. This case report involves a displaced compression fracture of the left cuboid in a 9-year-old girl after a fall from a height, which was treated by open reduction, bone graft, internal fixation with pins, and plaster splint immobilization. Follow-up examination 2 years after the injury revealed good bone union and a very good functional result.

Discontinuation of alendronate and administration of bone-forming agents after surgical nailing may promote union of atypical femoral fractures in patients on long-term alendronate therapy.

BACKGROUND: Long-term alendronate therapy may lead to atypical femoral fractures in a very few patients. However, the management protocol to optimize fracture healing remains undetermined. The purpose of this study was to describe the time to union of atypical femoral fractures after surgical nailing in patients on long-term alendronate therapy, with continuation of alendronate or discontinuation of alendronate, and administration of bone-forming agents. FINDINGS: From January 2004 to December 2011, the records of patients at our institution on long-term alendronate therapy for more than 36 months and sustaining atypical femoral fractures that had undergone surgical nailing, with continuation of alendronate or discontinuation of alendronate and administration of bone-forming agents were reviewed.During the 8-year study period, we treated 10 atypical femoral fractures with surgical nailing in 7 consecutive osteopenic or osteoporotic patients on long-term alendronate therapy for more than 36 months. There were no post-operative complications or needs for revision surgery. All fractures achieved union during follow-up. Mean union time was 23.5 months (range, 18-31 months) for 6 fractures with continuation of alendronate after surgery, and 4.5 months (range, 4-5 months) for 4 fractures with discontinuation of alendronate and administration of bone-forming agents after surgery. CONCLUSIONS: Discontinuation of alendronate and administration of bone-forming agents after surgical nailing may promote union of atypical femoral fractures in patients on long-term alendronate therapy.

Infected primary non-Hodgkin lymphoma of spine.

Primary bone lymphoma (PBL) comprises less than 5% of all malignant bone tumors and almost 7% of all extranodal lymphomas. Only 1.7% of all PBLs have been reported to involve the vertebrae. In our case, osteomyelitis was accidentally found during surgery, which might have resulted in the rapid collapse of vertebral body. This is the first report on primary lymphoma of the vertebrae with superimposed osteomyelitis in the English literature to the best of our knowledge. The patient reported here received anterior vertebrectomy and posterior interbody fusion with instrumentation for spinal instability. Tumor mass and the necrotic debris were removed. After the procedure, the patient received treatment with antibiotics and six cycles of chemotherapy. This case reminds us the possibility of hematologic seeding of bacteria in the tissue, especially with tumor necrosis. We suggest percutaneous needle aspiration for pathology and culture before making a decision whether or not to proceed with surgical decompression for fear of missing the occult bacterial infection.

A new peroneal tendon rerouting method to treat recurrent dislocation of peroneal tendons.

BACKGROUND: The surgical treatment methods for recurrent dislocation of peroneal tendons are controversial. A simpler and more effective treatment method is valuable for these patients. HYPOTHESIS: A new rerouting operation designed by the authors will have satisfactory results and avoid disadvantages of the old rerouting methods. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Seventeen consecutive male patients with unilateral recurrent peroneal tendon dislocations were treated by transposition of the calcaneofibular ligament from the tubercle of calcaneofibular ligament with a 1 x 1 x 1 cm3 bone block and elevation of this tubercle with another 1 x 1 x 1 cm3 calcaneal bone block, which were fixed by a 3.5-mm cancellous screw with a washer. All patients received clinical and radiographic follow-up for at least 2 years. The preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scales were used for functional results assessment. RESULTS: All bone transposition sites healed radiographically at 6 weeks after surgery. Four patients had transient numbness over the lateral aspect of the injured foot, and 3 patients had swelling and pain involving the operative sites. All complications resolved by 3 to 5 months after the operation. No recurrent dislocation of the peroneal tendons was noted. The mean AOFAS ankle-hindfoot scale improved significantly, from 73.4 +/- 5.5 preoperatively to 100 at 2- to 5-year follow-up (P < .001). Normal ankle stability and no tightening of the lateral side of the injured ankles in the inversion position were noted. CONCLUSION: This method is a simple, reliable, and reproducible operation to treat recurrent dislocation of the peroneal tendons. It allows early return to daily, working, and sports activities with satisfactory results.

The analysis of axisymmetric viscoelasticity, time-dependent recovery, and hydration in rat tail intervertebral discs by radial compression test.

The goal of this study was to develop a nondestructive radial compression technique and to investigate the viscoelastic behavior of the rat tail disc under repeated radial compression. Rat tail intervertebral disc underwent radial compression relaxation testing and creep testing using a custom-made gravitational creep machine. The axisymmetric viscoelasticity and time-dependent recovery were determined. Different levels of hydration (with or without normal saline spray) were supplied to evaluate the effect of changes in viscoelastic properties. Viscoelasticity was found to be axisymmetric in rat-tail intervertebral discs at four equidistant locations. Complete relaxation recovery was found to take 20 min, whereas creep recovery required 25 min. Hydration was required for obtaining viscoelastic axisymmetry and complete viscoelastic recovery.

Direct repair of multiple levels lumbar spondylolysis by pedicle screw laminar hook and bone grafting: clinical, CT, and MRI-assessed study.

INTRODUCTION: A prospective analysis of 6 cases with multiple-level spondylolysis treated by direct repair with pedicle screw laminar hook is presented. The objective of the study was to evaluate the clinical outcome, plain radiographs, computed tomography (CT) scan, and magnetic resonance imaging to demonstrate the result of direct repair in the treatment of multiple-level spondylolysis. MATERIALS AND METHODS: Ten patients with multiple-level spondylolysis of lumbar spine were treated with segmental pedicle screw hook fixation and autogenous bone graft. Four patients had lost follow-up. Six patients were followed up for a minimum of 2 years (mean 34.3 mo, range 24 to 55 mo). Patient's average age was 22 years old (range from 20 to 25 y old). All lytic defects were bilateral and located at 2 different lumbar vertebras (levels). CT scans and MR images were obtained at the latest follow-up postoperatively to assess the healing of the bony defects and the adjacent disc conditions. Fusion was considered to be presented when trabecula across the lytic defect was detected. RESULTS: The union rate was 87% (21 pars/24 pars) on plain radiographs and 75% (18 pars/24 pars) on CT scans. Follow-up magnetic resonance imaging of lumbar spine showed no disc degeneration. All patients were satisfied (either excellent or good) with the postoperative outcomes. CONCLUSIONS: Direct repair of multiple-level spondylolysis by pedicle screw laminar hook and autogenous bone graft would be the alternative of treating patients with persistent back pain after 6 months of conservative treatment The favorable clinical outcome was correlated with bony healing rate in this series.

Reconstruction of the coronoid process with iliac crest bone graft in complex fracture-dislocation of elbow.

A 36-year-old man sustained posterior dislocation of left elbow joint with olecranon fracture, comminuted coronoid fracture and subluxation of proximal radioulnar joint. We reconstructed the coronoid process with autogenous iliac crest bone graft and reduced the olecranon fracture with internal fixation. In addition, we also repaired the medial collateral ligament, annular ligament and anterior capsule during the operation. He received immobilization of the left elbow for 3 weeks after surgery and started range of motion exercises. The radiographic bone union was found 2 months after operation. The range of motion of the elbow was full at 12 months after operation. The latest 2-year follow-up, the functional result of the elbow was excellent.