[Stupor due to sleep apnea syndrome after total knee replacement].

Obstructive sleep apnea syndrome is defined as a condition of repeated episodes of apnea and hypopnea during sleep, accompanied by excessive daytime sleepiness. This syndrome is common among the adult population, and is related to an increased risk for significant complications, during and immediately after surgery. Often, this condition is undiagnosed, and is not considered in the pre-operative evaluation. Therefore, it is highly important to recognize this syndrome in patients who are scheduled for elective surgery, and provide appropriate management, in order to avoid life-threatening exacerbation in the perioperative period. Although this syndrome is common, there is low awareness of its expression in elective surgery in-patients. We present a case report of a patient who suffered from obstructive sleep apnea related respiratory distress following total knee replacement surgery.

Isolation and hormonal responsiveness of primary cultures of human bone-derived cells: gender and age differences.

We present a model for isolating human cell culture derived from biopsies obtained during orthopedic surgery. Four donor groups were defined by gender and age: pre- and postmenopausal women (<50 and >55 years, respectively), and younger (30-55 years) and older (>60 years) men. Bone-derived cells were identified as osteoblasts by major osteoblastic characteristics; that is, high alkaline phosphatase (ALP) activity, dose-dependent increase of ALP by 1,25(OH)2D3, high levels of parathyroid hormone (PTH)-induced cyclic AMP, and 1,25-(OH)2D3-induced osteocalcin. In all cells, levels of osteocalcin were significantly elevated (p < 0.05 and 0.01). In cells derived from men, no significant age differences were found in ALP and osteocalcin values of basal activity and in fold stimulation 1,25(OH)2D3. Cells from postmenopausal women showed a nonsignificant lower basal ALP activity than premenopausal cells. In postmenopausal cells, ALP responded less to 1,25(OH)2D3 (33% increase, p < 0.05) than the premenopausal cells (100% increase, p < 0.05). In cells from either age group, ALP did not respond to the gonadal steroids 17beta-estradiol (E2) and dihydrotestosterone (DHT) or progesterone. Basal levels of osteocalcin were higher in cells of premenopausal origin as compared with postmenopausal cells (p = 0.05), but response to 1,25(OH)2D3 was the same. PTH significantly stimulated cAMP (p = 0.001) in all age and gender groups analyzed. In all groups, no differences were found in either basal activity or in PTH response. Unlike men, cells derived from the bone of women were more susceptible to age changes. We postulate that the postmenopausal cell population had a decreased number of osteoblasts, or cells in a lower differentiation stage. These results extend our knowledge of bone biology found in animal models and reveal that human osteoblasts from men do not show the same age-dependent differences observed in women.

Arthrographic findings in Legg-Calvé-Perthes disease and transient synovitis of the hip.

Bilateral arthrography of the hip was performed in thirty-seven patients with unilateral Legg-Calvé-Perthes disease. Measurements made on the plain roentgenograms and on the arthrograms of the diameter of the femoral head, the width of the medial joint space, and the thickness of the acetabular cartilage were compared. The acetabulum-head quotients also were calculated. When present, evidence of flattening of the femoral head cartilage and of pooling of the contrast material also was noted. These data showed that in the early stages of Legg-Calvé-Perthes disease the articular cartilage is thickened, and that the cartilaginous femoral head is deformed and protrudes from the acetabulum. Arthrograms made with the hip in different positions also indicated the extent and location of collapse of the (osteochondroal) femoral head and therefore proved useful as a means to determine the best therapeutic position of the hip to provide coverage of the head. In three patients with severe transient synovitis, thickening of the articular cartilage resembling that seen in Legg-Calvé-Perthes disease was demonstrated.

Residual shortening after osteotomy for Perthes' disease. A comparative study.

The residual shortening of the affected limbs in 55 patients treated by subtrochanteric varus derotation osteotomy was compared with that in 71 patients treated with weight-relieving calipers. When last examined, 43 of the former group and 47 of the latter had reached complete or near-complete skeletal maturity. The average follow-up was 9.1 years in the osteotomised patients and 5.25 years in the conservatively treated group. The average residual shortening (0.9 cm) was identical in both groups. In most patients the initial shortening caused by the osteotomy gradually corrected as, over a period of several years, the postosteotomy angle gradually became less varus. Any residual shortening depended principally on the severity of inhibition of endochondral ossification at the proximal femoral growth plate. Less residual shortening was seen in children who were under seven years of age at the onset of symptoms (under eight at operation) in whom the open-wedge technique of osteotomy was employed and who had good anatomical results.

Abduction-traction injury of the knee.

Disruption of the major ligaments of the knee was seen in six young men, five parachutists and a house painter, after what we have termed abduction-traction injury. This unusual complaint results from the application of a sudden block to the ankle while falling head first, leading to traction and abduction of the knee. All the patients underwent operations, generally with unsatisfactory results. At operation tears of the anterior cruciate ligament, medial collateral ligament and posterior oblique ligament were seen in each case; in four patients the posterior capsule and in three the posterior cruciate ligament also were torn. In one patient the lateral collateral ligament was torn and the lateral meniscotibial ligament was avulsed. The compression component is absent in this type of injury and consequently the menisci and the osteochondral surfaces of the tibia and femur remained intact in each case.

Medial unicompartmental replacement for tricompartmental disease in the elderly.

Between 1993 and 1998, we performed 18 unicompartmental arthroplasties of the knee, all on the medial side, in a selected group consisting of 18 elderly patients aged 74-81 (mean 77.2), with severe arthrosis mainly in the medial compartment and mild arthrosis in the lateral compartment and the patellar articular surface mostly covered with articular cartilage. The patients were mainly housebound due to relatively advanced age and severe pain. Unicompartmental arthroplasty was chosen for this group because of a quicker and easier rehabilitation. Two patients had had a high tibial osteotomy 7 and 10 years ago. The average follow up was 5.5 years ranging in age from 5 to 8 years. The average initial American Knee Society Knee Score was 52, ranging from 28 to 70 which improved at follow up to 83 (range 60-92). All prostheses used were Allegretto (Sulzer). The operation was done through short medial arthrotomy. The purpose of this study is to report our results in these low demand patients and although the follow-up was only 5-8 years, the results are promising.

Musculoskeletal problems in Down Syndrome European Paediatric Orthopaedic Society Survey: the Israeli sample.

An Israeli sample of 475 individuals representing the full spectrum of those with Down syndrome in the Jewish population is presented. The sample is part of a European multicenter study evaluating musculoskeletal disorders. Generalized joint laxity was found to have significant relationships with a number of medical conditions (knee problems, patello-femoral instability, genu valgus, pes planus, heart defects, and gastrointestinal problems). Body mass index was also related to feet problems, vertical talus, spinal problems, genu valgum, pes planus, and heart problems. Yearly multidisciplinary clinical follow-up is recommended in persons with Down syndrome.

[Recurrent late hemarthrosis after total knee replacement].

A patient who had a successful total knee replacement for severe degenerative osteoarthritis of the right knee had an excellent functional result. 2 years after the operation there was spontaneous intra-articular bleeding that was treated successfully conservatively. Recurrent hemarthrosis 2 months later was treated similarly and also resolved without residual functional impairment after a follow-up of over 1 year. Recurrent late hemarthrosis in the knee is a fairly rare complication following total knee arthroplasty, but is amenable to conservative measures. Frequently, persistent recurrent hemarthrosis requires debridement of the bleeding synovium of the knee.

[Local necrosis of finger following stab with needle used to pump terbutaline sulfate (Bricalin)].

Terbutaline sulfate (Bricalin) is a widely used medication for asthma. It works mostly, but not only, on beta-adrenergic receptors. In this case study we describe a 50-year-old nurse referred to the emergency department after she was stabbed by needle that was used to draw bricalin for inhalation. She arrived at the emergency room with an inflamed necrotic area at the point of the stab. Later, she developed acute infection that was treated with antibiotics. Following the acute phase there was still a necrotic area, that required surgical debridement. It seems that this is the result of the vasoconstrictive influence of terbutaline sulfate via alpha adrenergic receptors. In the medical literature there is scarce data regarding this side effect.

[Rupture of pectoralis major muscle: operative treatment of an uncommon sport injury].

Rupture of the pectoralis major muscle in an athlete is rare, but is said to be common in weight lifters. The muscle usually ruptures at the musculotendinous junction during forceful contraction of the muscle in adduction, forward flexion and internal rotation of the arm. We describe an athlete who suffered such a major tear during a rugby game. It was treated surgically and after adequate rehabilitation, athletic activities were resumed.

[Ilizarov reconstructive surgery--a solution for complex problems of the musculoskeletal system].

The Ilizarov technique is an important modality of reconstructive surgery for limb deformities, such as malunion and nonunion of fractures, persistent osteomyelitis, and bone loss following complex limb injuries, as well as in limb-lengthening procedures. It has received wide recognition in the Western world over the past decade. In MEDLINE we found 537 articles published between 1971-1995 that describe the use of this technique. Of these, only 18 were published between 1971-1975, while 261 were published between 1991-1995. The present paper describes the developments and updates in this method, as a result of the large experience gained by the authors in a number of centers in Israel using this technique. The Ilizarov apparatus is a circular frame that allows accurate control, much more than any other external fixator, during correction of limb deformities and limb-lengthening. It is minimally invasive, and open techniques and use of internal hardware and bone grafts are not needed. Based on our experience, we suggest that this method requires careful preoperative planning and meticulous surgical technique. More important, cooperation between surgeon and patient throughout the lengthy treatment is a prerequisite to ensure complete success, even in the most complicated cases.

Degenerative disease in lumbar spine of military parachuting instructors.

Parachuting, be it static line or skydiving, places enormous stresses on the human spine. It is, therefore, important to determine the prevalence and severity of degenerative changes in the lumbar spine of subjects who practice this sport activity. Seventy four parachuting instructors, mean age 33 years and with an average of 410 static line and skydiving jumps, were included in the study. Past radiographs were examined and compared to current anterolateral and lateral views of the lumbar spine, in order to determine the prevalence of degenerative changes and document possible progression. Doubtful radiographic changes in the lumbar spine were identified in 47.4 percent of the parachuting instructors, mild degeneration in 9.6 percent, moderate degenerative disease in 10.9 percent and severe radiographic changes in 5.5 percent. Schmorll nodes were found in 8.1 percent of the subjects. Traction spurs--osteophytes were identified in 6.8 percent. The degenerative changes correlated with age and the number of jumps. Spondylolysis of L5-S1 and L3-L4 segments were observed in 12.2 and 1.4 percent respectively. Progressive spondylolisthesis was found in 2 subjects. No correlation was found between the severity of radiographic changes and either the prevalence and the severity of low back pain. The present findings provide a rational for considering repeated sheer stress as an etiology of degenerative changes in the spinal cord, and as a possible contributing factor to the pathogenesis of spondylolysis. Further study has to be done comparing parachuting instructors to a non-parachuting group, or equivalent physically active individuals, in order to assess the effect of sport-background on the development of degenerative changes.

Arthroscopic adhesiolysis of the knee joint in arthrofibrosis.

Arthroscopically assisted adhesiolysis is a relatively new method for the treatment of arthrofibrosis of the knee. It is as effective as other known techniques and has the advantage of being minimally traumatic to the joint and the surrounding soft tissues. The operative method is presented here, together with three case reports of patients representing part of a series of 10 patients treated in our ward by arthroscopic adhesiolysis. Results, which were very favorable--average flexion improved 72 degrees and average extension improved 12 degrees--were stable over time, and all patients were pain-free at follow-up. Our experience supports previous positive reports concerning this additional mode of treatment for arthrofibrosis.

Changes in the pattern of fractures of the hip in patients 60 years of age and older between 2001 and 2010: A radiological review.

The purpose of this study was to identify changing trends in the pattern of distribution of the type and demographics of fractures of the hip in the elderly between 2001 and 2010. A retrospective cross-sectional comparison was conducted between 179 fractures of the hip treated in 2001, 357 treated in 2006 and 454 treated in 2010. Patients aged < 60 years and those with pathological and peri-prosthetic fractures were excluded. Fractures were classified as stable extracapsular, unstable extracapsular or intracapsular fractures. The mean age of the 179 patients (132 women (73.7%)) treated in 2001 was 80.8 years (60 to 96), 81.8 years (61 to 101) in the 357 patients (251 women (70.3%)) treated in 2006 and 82.0 years (61 to 102) in the 454 patients (321 women (70.1%)) treated in 2010 (p = 0.17). There was no difference in the gender distribution between the three study years (p = 0.68). The main finding was a steep rise in the proportion of unstable peritrochanteric fractures. The proportion of unstable extracapsular fractures was 32% (n = 57) in 2001, 35% (n = 125) in 2006 and 45% (n = 204) in 2010 (p < 0.001). This increase was not significant in patients aged between 60 and 69 years (p = 0.84), marginally significant in those aged between 70 and 79 years (p = 0.04) and very significant in those aged > 80 years (p < 0.001). The proportion of intracapsular fractures did not change (p = 0.94). At present, we face not only an increasing number of fractures of the hip, but more demanding and complex fractures in older patients than a decade ago. This study does not provide an explanation for this change.

DT56a (Femarelle), contrary to estradiol-17ß, is effective in human derived female osteoblasts in hyperglycemic condition.

We have reported previously, that female-derived cultured osteoblasts (hObs) responded to DT56a (Femarelle) measured by the stimulation of creatine kinase specific activity (CK), which is a marker for hormone responsiveness and (3)[H] thymidine incorporation into DNA (DNA synthesis). Since the skeletal protective effects of estrogens are not discernable in hyperglycemic diabetic women, we sought to analyze the effect of estrogenic compounds on CK and DNA synthesis in hObs when grown in high glucose concentration (HG). Cells were grown either in normal glucose (NG) (4.5g/L; 22mM) or HG (9.0g/L; 44mM) for 7 days. HG increased constitutive CK but, the response of CK activity and DNA synthesis to estradiol-17ß (E(2)) treatment was reduced. In contrary, DT56a was found to be active (as measured by CK activity and DNA synthesis) in both NG and HG. HG decreases the hormonal responsiveness and might block important effects of estrogenic compounds, most likely contributing to their decreased skeletal preserving properties in hyperglycemic women. In hObs from post-menopausal women grown in HG, ERs mRNA expressions were unchanged. On the other hand, in hObs from pre-menopausal women HG increased ERs mRNA expressions. Since DT56a unlike E(2) is active in HG environment as well as in normal glucose, it may be an effective bone restoring agent in diabetic post-menopausal women.

Mutual interaction of special phytoestrogenic compounds, their synthetic carboxy-derivatives and the less-calcemic vitamin D analog activities in human derived female cultured osteoblasts.

Cultured female-derived human bone cells (hObs) responded by different parameters to different phytoestrogenic and vitamin D compounds. Pre- and post-menopausal hObs express ERα and ERß mRNA with higher abundance of ERα. Pre-treatment with the less-calcemic vitamin D analog JKF 1624F(2)-2 (JKF) upregulated responsiveness to estrogens via modulation of ERs expression. These estrogenic compounds induce the expression and activity of 25 hydroxy-vitamin D(3)-1α hydroxylase (1OHase). We now analyzed the effects of carboxy-genistein (cG), carboxy-biocainin A (cBA) and carboxy-daidzein (cD), of BA, D or G and of licorice derived compounds glabridin (Glb) and glabrene (Gla) and estradiol-17ß (E(2)) on DNA synthesis, creatine kinase specific activity (CK), intracellular and membranal E(2) binding and their modulations by JKF in hObs. We also analyzed modulation by phytoestrogenic compounds of 1OHase mRNA expression and activity. We showed that: (1) all compounds stimulated DNA synthesis and CK. (2) JKF and all estrogenic compounds modulated ERα and ERß mRNA expression. (3) Pre-treatment with JKF increased DNA synthesis and CK responses only to E(2), D, G and Gla. (4) JKF increased the intracellular competitive binding only of E(2), D and G. (5) JKF abolished the membranal binding of all protein-bound estrogens. (6) JKF and all estrogenic compounds except the protein-bound ones up-regulated 1OHase expression and activity. In conclusion phytoestrogens and their analogs increase DNA synthesis and CK, and lead to increased production of 1,25(OH)(2)D(3) in hObs, while pre-treatment with JKF modulates the effect of estrogenic compounds via regulation of ERs mRNA expression in a yet unclear mechanism.