Fragility spinal fractures among cirrhotic liver transplant candidates in Croatia.

INTRODUCTION: Existing data on fragility spinal fractures prevalence in liver transplant candidates are scarce and inconsistent. This may be due to other comorbidities, besides hepatic osteodystrophy (HO), that contribute to bone loss and fragility fracture prevalence in chronic liver disease (CLD). OBJECTIVES: The aim of this study was to investigate the prevalence of spinal thoracic and lumbar fragility fractures among cirrhotic, non-chronic kidney disease (CKD), non-diabetic liver transplant candidates and to explore their relationship with clinical characteristics, laboratory markers and dual-energy x-ray absorptiometry (DXA) results. MATERIAL AND METHODS: This cross-sectional observational study was conducted at Merkur University Hospital, Croatia, between February 2019 and May 2023. Adult patients with liver cirrhosis referred for liver transplantation were included. Patients with acute infection, CKD, diabetes mellitus, malignancies, inflammatory bone diseases and those on corticosteroid or antiresorptive therapy were excluded. Clinical, laboratory and radiological assessment was carried out and patients were accordingly allocated into non-fractured and fractured group for the purpose of statistical analysis. RESULTS: A total of 90 patients were included in the study. There was 123 fractures, 87 (70.7 %) in the thoracic and 36 (29.3 %) in the lumbar region. Eighty-nine (72.4 %) fractures were grade 1, 31 (25.2 %) were grade 2 and 3 (2.4 %) were grade 3. Patients in the fractured group were significantly older (p < 0.001). No significant differences between fractured and non-fractured group according to laboratory and DXA parameters were noted. Subgroup with lumbar fractures had significantly lower bone mineral density values at L1-L4 region. Statistically significant negative correlation between bone specific alkaline phosphatase (BALP) and hip total BMD (rho = -0.414, p < 0.001) and spine total BMD (rho = -0.258, p = 0.014) values was found. CONCLUSION: Present study confirmed detrimental impact of CLD and HO on bone strength. DXA measurement correlated with the presence of lumbar fragility fractures. A combination of standard X-ray imaging and DXA is needed for adequate bone evaluation in pretransplant period and BALP could be useful for detecting HO in CLD. Searching for other risk factors and implementing bone turnover markers and additional imaging techniques for bone loss evaluation in liver transplant candidates is needed.

Fibroblast growth factor 23 and its role in bone diseases.

Fibroblast growth factor 23 (FGF23) has been casually linked to numerous hypophosphatemic bone diseases, however connection with bone loss or fragility fractures is still a matter of debate. The purpose of this review is to explore and summarise the known actions of FGF23 in various pathological bone conditions. Besides implication in bone mineralisation, elevated FGF23 showed a pathological effecton bone remodelling, primarily by inhibiting osteoblast function. Unlike the weak association with bone mineral density, high values of FGF23 have been connected with fragility fracture prevalence. This review shows that its effects on bone are concomitantly present on multiple levels, affecting both qualitative and quantitative part of bone strength, eventually leading to impaired bone strength and increased tendency of fractures. Recognising FGF23 as a risk factor for the development of bone diseases and correcting its levels could lead to the reduction of morbidity and mortality in specific groups of patients.

Stable Gastric Pentadecapeptide BPC 157 and Striated, Smooth, and Heart Muscle.

First, we review the definitively severed myotendinous junction and recovery by the cytoprotective stable gastric pentadecapeptide BPC 157 therapy, its healing that might combine both transected and detached tendon and transected muscle, ligament and bone injuries, applied alone, as native peptide therapy, effective in rat injury, given intraperitoneally or in drinking water or topically, at the site of injury. As a follow up, we reviewed that with the BPC 157 therapy, its cytoprotective ability to organize simultaneous healing of different tissues of and full recovery of the myotendinous junction might represent the particular muscle therapy against distinctive etiopathology muscle disabilities and weakness. In this, BPC 157 therapy might recover many of muscle disabilities (i.e., succinylcholine, vascular occlusion, spinal cord compression, stroke, traumatic brain injury, severe electrolyte disturbances, neurotoxins, neuroleptics, alcohol, serotonin syndrome and NO-system blockade and tumor-cachexia). These might provide practical realization of the multimodal muscle-axis impact able to react depending on the condition and the given agent(s) and the symptoms distinctively related to the prime injurious cause symptoms in the wide healing concept, the concept of cytoprotection, in particular. Further, the BPC 157 therapy might be the recovery for the disabled heart functioning, and disabled smooth muscle functioning (various sphincters function recovery). Finally, BPC 157, native and stable in human gastric juice, might be a prototype of anti-ulcer cytoprotective peptide for the muscle therapy with high curing potential (very safe profile (lethal dose not achieved), with suited wide effective range (µg-ng regimens) and ways of application).

Stable Gastric Pentadecapeptide BPC 157 as a Therapy for the Disable Myotendinous Junctions in Rats.

(1) Aim: The stable gastric pentadecapeptide BPC 157 is known to heal transected muscle, tendon, and ligament. Thereby, in this study, we investigated the effect of BPC 157 on the dissection of the quadriceps tendon from the quadriceps muscle in rats. (2) Materials and Methods: Myotendinous junction defect, which cannot heal spontaneously in rats, as evidenced with consistent macro/microscopic, biomechanical, functional assessments, eNOS, and COX-2 mRNA levels and oxidative stress and NO-levels in the myotendinous junctions. BPC 157 (10 µg/kg, 10 ng/kg) regimen was given (i) intraperitoneally, first application immediately after surgery, last 24 h before sacrifice; (ii) per-orally, in drinking water (0.16 µg/mL, 0.16 ng/mL, 12 mL/rat/day), till the sacrifice at 7, 14, 28 and 42 postoperative days. (3) Results: These BPC 157 regimens document prominent therapy effects (macro/microscopic, biomechanical, functional much like eNOS and COX-2 mRNA levels and counteracted oxidative stress and NO-levels in the myotendinous junctions), while controls have a poor presentation. Especially, in rats with the disabled myotendinous junction, along with full functional recovery, BPC 157 counteracts muscle atrophy that is regularly progressive and brings muscle presentation close to normal. Accordingly, unlike the perilous course in controls, those rats, when receiving BPC 157 therapy, exhibit a smaller defect, and finally defects completely disappear. Microscopically, there are no more inflammatory infiltrate, well-oriented recovered tissue of musculotendon junction appears in BPC 157 treated rats at the 28 days and 42 days. (4) Conclusions: BPC 157 restores myotendinous junction in accordance with the healing of the transected muscle, tendon, and ligament.

BPC 157 and Standard Angiogenic Growth Factors. Gastrointestinal Tract Healing, Lessons from Tendon, Ligament, Muscle and Bone Healing.

Commonly, the angiogenic growth factors signify healing. However, gastrointestinal ulceration is still poorly understood particularly with respect to a general pharmacological/pathophysiological role of various angiogenic growth factors implemented in growth factors wound healing concept. Thereby, we focused on the stable gastric pentadecapeptide BPC 157, a peptide given always alone vs. standard peptidergic angiogenic growth factors (EGF, FGF, VEGF), and numerous carriers. Further, we reviewed how the gastrointestinal tract healing could be generally perceived (i) in terms of angiogenic growth factors, and/or (ii) through the healing of extragastrointestinal tissues healing, such as tendon, ligament, muscle and bone, and vice versa. Respected were the beneficial effects obtained with free peptides or peptides with different carriers; EGF, FGF, VEGF, and BPC 157, their presentation along with injuries, and a healing commonality, providing their implementation in both gastrointestinal ulcer healing and tendon, ligament, muscle and bone healing. Only BPC 157 was consistently effective in all of the models of acute/chronic injury of esophagus, stomach, duodenum and lower gastrointestinal tract, intraperitoneally, per-orally or locally. Unlike bFGF-, EGF-, VEGF-gastrointestinal tract studies demonstrating improved healing, most of the studies on tendon, muscle and bone injuries provide evidence of their (increased) presentation along with the various procedures used to produce beneficial effects, compared to fewer studies in vitro, while in vivo healing has a limited number of studies, commonly limited to local application, diverse healing evidence with diverse carriers and delivery systems. Contrary to this, BPC 157 - using same regimens like in gastrointestinal healing studies - improves tendon, ligament and bone healing, accurately implementing its own angiogenic effect in the healing. Thus, we claim that just BPC 157 represents in practice a pharmacological and pathophysiological role of various peptidergic growth factors.

Esophagogastric anastomosis in rats: Improved healing by BPC 157 and L-arginine, aggravated by L-NAME.

AIM: To cure typically life-threatening esophagogastric anastomosis in rats, lacking anastomosis healing and sphincter function rescue, in particular. METHODS: Because we assume esophagogastric fistulas represent a particular NO-system disability, we attempt to identify the benefits of anti-ulcer stable gastric pentadecapeptide BPC 157, which was in trials for ulcerative colitis and currently for multiple sclerosis, in rats with esophagocutaneous fistulas. Previously, BPC 157 therapies have promoted the healing of intestinal anastomosis and fistulas, and esophagitis and gastric lesions, along with rescued sphincter function. Additionally, BPC 157 particularly interacts with the NO-system. In the 4 d after esophagogastric anastomosis creation, rats received medication (/kg intraperitoneally once daily: BPC 157 (10 µg, 10 ng), L-NAME (5 mg), or L-arginine (100 mg) alone and/or combined or BPC 157 (10 µg, 10 ng) in drinking water). For rats underwent esophagogastric anastomosis, daily assessment included progressive stomach damage (sum of the longest diameters, mm), esophagitis (scored 0-5), weak anastomosis (mL H2O before leak), low pressure in esophagus at anastomosis and in the pyloric sphincter (cm H2O), progressive weight loss (g) and mortality. Immediate effect assessed blood vessels disappearance (scored 0-5) at the stomach surface immediately after anastomosis creation. RESULTS: BPC 157 (all regimens) fully counteracted the perilous disease course from the very beginning (i.e., with the BPC 157 bath, blood vessels remained present at the gastric surface after anastomosis creation) and eliminated mortality. Additionally, BPC 157 treatment in combination with L-NAME nullified any effect of L-NAME that otherwise intensified the regular course. Consistently, with worsening (with L-NAME administration) and amelioration (with L-arginine), either L-arginine amelioration prevails (attenuated esophageal and gastric lesions) or they counteract each other (L-NAME + L-arginine); with the addition of BPC 157 (L-NAME + L-arginine + BPC 157), there was a marked beneficial effect. BPC 157 treatment for esophagogastric anastomosis, along with NOS-blocker L-NAME and/or NOS substrate L-arginine, demonstrated an innate NO-system disability (as observed with L-arginine effectiveness). BPC 157 distinctively affected corresponding events: worsening (obtained with L-NAME administration that was counteracted); or amelioration (L-arginine + BPC 157-rats correspond to BPC 157-rats). CONCLUSION: Innate NO-system disability for esophagogastric anastomoses, including L-NAME-worsening, suggests that these effects could be corrected by L-arginine and almost completely eliminated by BPC 157 therapy.

Periprosthetic infections after total hip and knee arthroplasty--a review.

Periprosthetic joint infections (PJI) in orthopedic surgery are considered to be very serious and dangerous complications of total joint arthroplasty. PJI becomes a long-lasting medical problem and a heavy burden on patient and his family. Patients with such a complication are a significant financial burden for the health care system. Recognizing this issue, investing in scientific research and simultaneously developing technologies in medicine are efforts taken to increase successfulness in preventing and treating PJI. Each year the number of total joint arthroplasties increases which entails a rise in the number of complications among which infections are the leading ones. Sometimes, in the worst case scenarios, infections can endanger patients' lives. New procedural algorithms and new diagnostic possibilities help us make accurate and early diagnoses of postoperative PJI with a great degree of certainty. These diagnostic methods include laboratory tests, imaging, histopathology and microbiological analyses. Treatment options depend on many factors which include the onset of symptoms, patients'general physical condition and type of pathogen. The approach to treating PJI is complex and it requires a multidisciplinary approach in order to ensure the most successful treatment possible. For adequate and successful treatment we need to take into account antibiotic therapy, one-stage or two-stage revision, Girdlestone operation, athrodesis and amputation. In this review we will try to sum up all relevant findings and suggest further steps in management of PJI.

Is chronic groin pain a Bermuda triangle of sports medicine?

Chronic groin pain is one the most complex conditions encountered in the field of sports medicine. Conservative treatment is long lasting and the result of treatment is often uncer- tain and symptom recurrences are common, which can be very frustrating for both the patient and the physician. The complex etiology and uncertainties during treatment of chronic groin pain is the reason why some authors call it the Bermuda Triangle of sports medicine. In our prospective, 7-year study, 114 athletes with chronic groin pain resistant to conservative therapy were treated surgically. In 109 athletes with sports hernia, we performed nerve neurolysis along with resection of the genital branch of the genitofemoral nerve and we also reinforced the posterior wall of inguinal canal using a modified Shouldice technique. In 26 athletes that had concomitant adductor tendinosis and in 5 athletes with isolated tendinosis we performed tenotomy. Eighty-one of 83 patients with isolated sports hernia returned to sports within a mean of 4.4 (range, 3-16) weeks. Thirty-one athletes with adductor tenotomy returned to sports activity within a mean of 11.8 (range, 10-15) weeks. If carefully diagnosed using detailed history taking, physical examination and correct imaging techniques, chronic groin pain can be treated very successfully and quickly, so it need not be a Bermuda Triangle of sports medicine.

Isolated inferior peroneal retinculum tear in professional soccer players.

INTRODUCTION: Peroneal tendon dislocations are rare injuries that can easily be misdiagnosed. Up to date literature mostly describes proximal peroneal tendon dislocations due to superior peroneal retinaculum (SPR) tear. In this article, we present the assessment, diagnostic algorithm and a new therapeutic option for the distal dislocation of the long peroneal tendon due to isolated inferior peroneal retinaculum (IPR) tear. PATIENTS AND METHODS: Between 2001 and 2011 three patients with distal peroneal tendon dislocation were operated. All of them were competitive athletes in the national soccer league. They presented with an ankle sprain and prolonged problems on the lateral side of the foot with no improvement after conservative therapy measures. Coleman block test was performed; ultrasound and MRI showed a tendon dislocation under the IPR. The patients underwent surgical repair that consisted of peroneal tubercle excision, a new lateral calcanear groove formation for both peroneal tendons and IPR plasty. RESULTS: At the two year follow up the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score showed a significant increase. The decrease of painful stimuli assessed by a Visual Analogue Scale (VAS) was significant as well. At an average of 12 weeks after the surgery, the patients returned to their level of sport activity before injury and didn't report similar problems later. CONCLUSION: Description of distal peroneal tendon dislocations is limited in the literature. This topic should be considered in differential diagnostics of an acute and chronic ankle sprain which leads to chronic ankle pain and instability. The authors recommend surgical treatment as a method of choice especially in professional athletes.

The role of external fixation in displaced pilon fractures of distal tibia.

Results of treatment in patients with high-energy displaced pilon fractures are presented. During five years, 15 patients with displaced pilon fractures (AO type C2 and C3) were treated. All other types of fracture were excluded from the study. Fractures were identified using standard radiographs and computed topography scanning. The method and timing of the operation were dictated by the status of soft tissues. In all fractures, external fixation was placed immediately and was left until the initial callus bridged the fracture fragments. In case of moderate contusion of soft tissues, limited incision and minimal internal osteosynthesis was done in the same act. In patients with more severe soft tissue damage, limited open reduction and restoration of articular surface was undertaken in second procedure after 7 days on average. All fractures united and the average time of healing was 4 months. Two patients had superficial infections that resulted in prolonged wound healing, and another four patients had pin site infection. There were no cases of deep infection, nonunion or malunion, but we had five cases of secondary osteoarthritis. Results were evaluated by Teeny and Wiss rating system. The results were as follows: 5 excellent results, 10 good and fair results, and no poor results. This study showed that external fixation with open reduction and limited internal osteosynthesis, with or without bone grafting, could be an option in the management of displaced multifragmentary pilon fractures with soft tissue injury. It was followed by significantly less complications with better functional results compared to open reduction and internal plate fixation.

Aggressive granulomatosis after cementless total hip arthroplasty as a result of inflammatory reaction to metal debris: case report.

Massive osteolysis and granulomatous pseudotumor tissue reactions are long-term complications of total hip replacement. It is a condition of localized bone resorption in contact with prosthetic material. It is speculated to be a consequence of metal hypersensitivity or inflammatory reaction to excessive wear. Ten years after total cementless hip replacement (metal on polyethylene surface), a 70-year-old patient presented with hip pain and pseudotumor with massive osteolysis of proximal femur on x-ray. Intraoperatively, extensive metallosis with significantly worn metal head (316L stainless steel) and only slightly worn polyethylene insert was found. Upon extraction, parts of the affected tissue and bone that were in direct contact with the prosthesis were sent for histopathologic analysis. Microscopic examination showed necrotic soft and bone tissue, mainly bone marrow with numerous histiocytes and multinucleated giant cells containing lots of pigmented particles (presumed to be metal particles as a result of implant surface wear). In this case, the primary cause of osteolysis and granulomatosis was inflammatory reaction to metal debris. Aggressive granulomatosis has been first described in cemented prostheses and afterwards also in cementless ones. Conditions such as primary or metastatic neoplastic processes and infection should be excluded. The presence of foreign molecular particles due to wear of the prosthesis by different mediators has been presumed to cause an inflammatory reaction that leads to bone resorption and loosening of the prosthesis.

Surgical treatment of chronic groin pain in athletes.

PURPOSE: Conservative treatment of chronic groin pain is prolonged and recurrence is quite common. Coexistence of sports hernia and adductor tendinitis/tendinosis in a single patient is noted in the literature. In our study we evaluated our operative treatment that should enable pain elimination and fast return to sports activities. METHODS: We performed a prospective study over a six-year period. Ninety-nine (99) patients, all male, with chronic groin pain, resistant to conservative treatment, underwent a surgical procedure. RESULTS: Seventy athletes with sports hernia returned to sports in an average 4.23 weeks (range three-16). Adductor tendinosis symptoms were present in 24 patients (2 %) with sports hernia. Twenty-four patients that had an additional adductor tenotomy performed returned to sports in an average 11.6 weeks (range ten-15). Five patients with isolated adductor tendinosis (7 %) returned to sports in an average 13.4 weeks (range 12-16). All athletes except two (2.8 %) treated for sports hernia were satisfied with the results of treatment and could continue their previous level of activity. CONCLUSION: Any surgical procedure used for treating chronic groin pain should address the common causes of pain in this region. Adductor tendinosis can be present in up to 24.2 % of cases with sports hernia or may be isolated in 7 % of cases with chronic groin pain and must be treated by tenotomy. Resection of the genital branch of genitofemoral nerve and ilioinguinal nerve neurolysis should also be performed in patients with sports hernia.

Minimally invasive hip arthroplasty: advantages and disadvantages.

BACKGROUND: To present the method and advantages of anterior minimally invasive surgery (AMIS) in coxarthrosis and hip fractures treatment. METHODS: During 2008 and 2009, 35 patients were treated with AMIS method. They were compared with 35 patients treated with lateral, transgluteal approach (control group) in the same period. All operations were performed by the same surgical team. The main reason for surgery was hip arthrosis, only two patients in AMIS group underwent surgery because of femoral neck fracture. Early postoperative complications and functional status are followed by Haris Hip Score (HHS). RESULTS: Operation time was shorter and postoperative blood loss was lesser in AMIS group (78 min, 490 ml) than in the control group (85 min, 570 ml). In the AMIS group one patient had each post-operative knee pain, fractured tip of a large trochanter, acetabular overreaming, perforation of shaft with rasp, and two patients had parestesis n.cutaneus femoris lat. They had no infections or hip luxation. In the control group early hip luxation and superficial wound infections have occurred in one and two cases, respectively. Patients in the AMIS group were more satisfied, demanded less analgesics and their rehabilitation was faster. Haris Hip Score in the AMIS group after 2 months was 80 compared with 69 in the controls, and after 4 months 92 compared to 88 in controls. CONCLUSIONS: AMIS is a safe, reproducible and rewarding technique which provides low morbidity and fast postoperative recovery for the patient.