How can the orthopedic surgeon ensure optimal vitamin D status in patients operated for an osteoporotic fracture?

In this narrative review, the role of vitamin D deficiency in the pathophysiology, healing of fragility fractures, and rehabilitation is discussed. Vitamin D status can be assessed by measuring serum 25(OH)-vitamin D level with standardized assays. There is a high prevalence of vitamin D insufficiency (25(OH)D < 50 nmol/l (i.e., 20 ng/mL)) or deficiency (25(OH)D < 25 nmol/l (i.e., 10 ng/mL)) in patients with fragility fractures and especially in those with a hip fracture. The evidence on the effects of vitamin D deficiency and/or vitamin D supplementation on fracture healing and material osseointegration is still limited. However, it appears that vitamin D have a rather positive influence on these processes. The fracture liaison service (FLS) model can help to inform orthopedic surgeons, all caregivers, and fractured patients about the importance of optimal vitamin D status in the management of patients with fragility fractures. Therefore, vitamin D status should be included in Capture the Fracture® program as an outcome of FLS in addition to dual-energy X-ray absorptiometry (DXA) and specific antiosteoporosis medication. Vitamin D plays a significant role in the pathophysiology and healing of fragility fractures and in rehabilitation after fracture. Correction of vitamin D deficiency should be one of the main outcomes in fracture liaison services.

Effectiveness and easiness of adherence to behavioural guidelines for diet and lifestyle changes for cholesterol-lowering: the Increasing Adherence of Consumers to Diet & Lifestyle Changes to Lower (LDL) Cholesterol (ACT) randomised controlled trial.

BACKGROUND: The present study aimed to assess perceived effectiveness and easiness of behavioural diet and lifestyle changes related to dyslipidaemia given by physicians or dieticians as a result of diet and lifestyle modifications being difficult to maintain. METHODS: One-hundred hypercholesterolaemic individuals were enrolled in a parallel, randomised 6-week study. Fifty were advised by dietitians (dietitian group: DG) in six weekly face-to-face behavioural therapy sessions and 50 received standard advice from physicians (physician group: PG). All individuals were followed-up for another 6 weeks under real-life conditions. Questionnaires regarding perceived effectiveness, easiness of adhering, forecasted and actual adherence to specific cholesterol-lowering advice were completed. RESULTS: Scores of perceived effectiveness of advice for sufficient exercise, limiting saturated fat (SFA) intake, eating fish twice a week, consuming plenty of fresh fruit and vegetables, and limiting salt intake different scientifically (all P < 0.05) in PG and DG between study phases. Scores of the individuals' perception of effectiveness at all study phases were higher in the DG compared to PG for sufficient exercise, limiting SFA intake, eating fish twice a week, eating plenty of fruits and vegetables, and limiting salt intake, whereas scores of easiness were significant only for fish consumption (P = 0.008) and using foods with added plant sterols (all P < 0.05). DG and PG significantly differed in forecasted (week 6) versus actual adherence (week 12) to various chances, with DG reporting higher adherence. CONCLUSIONS: Lifestyle and dietary changes related to dyslipidaemia can be achieved with continuous education, monitoring and follow-ups by dieticians, as well as potentially other trained healthcare professionals.

Structured advice provided by a dietitian increases adherence of consumers to diet and lifestyle changes and lowers blood low-density lipoprotein (LDL)-cholesterol: the Increasing Adherence of Consumers to Diet & Lifestyle Changes to Lower (LDL) Cholesterol (ACT) randomised controlled trial.

BACKGROUND: Evidence from healthcare professionals suggest that consumer compliance to healthy diet and lifestyle changes is often poor. The present study investigated the effect of advice provided by a physician or dietitian on consumer adherence to these measures combined with consuming foods with added plant sterols (PS) with the aim of lowering low-density lipoprotein cholesterol (LDL-C). METHODS: One hundred mildly-to-moderately hypercholesterolaemic individuals were enrolled into a parallel, randomised, placebo-controlled study. Dietitians (dietitian group; DG) advised 50 individuals in six weekly face-to-face behavioural therapy sessions, whereas the other 50 received standard advice from physicians (physician group, PG). Both groups consumed foods with added PS (three servings a day) for 6 weeks. Subsequently, all individuals were followed-up for another 6 weeks under real-life conditions. Blood lipids were measured at baseline and weeks 6 and 12 and 3-day diet diaries were taken at weeks 1, 6 and 12. RESULTS: Individuals in the DG significantly improved their dietary habits, physical activity and increased PS intake compared to the PG. After 6 weeks, LDL-C decreased in both groups compared to baseline without any significant differences between groups. At week 12, LDL-C was further significantly improved only in the DG (P = 0.006) compared to week 6. Total cholesterol, LDL-C and triglycerides were significantly lower in the DG compared to the PG at week 12 after adjusting for levels at week 6 (P < 0.001, P < 0.001 and P = 0.009, respectively). CONCLUSIONS: Although structured counselling by dietitians and common standard advice by physicians were equally effective with respect to improving blood cholesterol after 6 weeks, dietitians were more effective in the longer-term (i.e. 6 weeks after the end of the intervention period).

Long-term outcomes following closed reduction and internal fixation of femoral neck fractures with cannulated screws in patients under 65 years.

Background: The long-term studies for femoral neck fractures (FNFs) in young patients treated with closed reduction and internal fixation (CRIF) are limited. This study aimed to evaluate the long-term outcomes of a group of young patients (<65 years) with FNFs treated with CRIF at our department during the last decade. We estimated treatment failure rates and identified risk factors for poor outcomes. Methods: This retrospective cohort study included patients under 65 with a unilateral FNF treated with CRIF using partially threaded cannulated screws (CSs) between 2011 and 2021. During the latest follow-up visit, we recorded the patients' complications, re-admissions, reoperations, functional outcomes, and quality of life scores. Results: We included 52 patients with a mean age of 53.04 years and a mean follow-up of 5.3 (range: 1.3-11) years. No non-union was recorded. Nine patients (17.3 %) underwent total hip arthroplasty (THA) due to femoral head avascular necrosis (AVN) at an average of 1.68 years following the index operation (THA group). The mean age (p =0.96), trauma type (p =0.290), sex prevalence (p =0.989), Garden classification (p =0.187), CSs number (p =0.751), and comorbidities (p =0.516) were comparable between THA and non-THA groups. Time from trauma to index surgery was significantly shorter for the THA than the non-THA group (p =0.03). Conclusions: During a mid-to-long follow-up, 17.3 % of patients under 65 years who were treated with CRIF and CSs for FNFs developed AVN. Age, trauma type, comorbidities, time from trauma to treatment, and the number of screws did not affect the outcomes. HIPPOKRATIA 2024, 28 (1):29-34.

Calcitonin delays the progress of early-stage mechanically induced osteoarthritis. In vivo, prospective study.

BACKGROUND/RATIONALE: Introducing new or testing existing drugs in an attempt to modify the progress of osteoarthritis (OA) is of paramount importance. QUESTIONS/PURPOSES: This study aims to determine the effect exerted by Calcitonin on the progress of early-stage osteoarthritic lesions. METHODS: We used 18, skeletally mature, white, female, New Zealand rabbits. OA was operatively induced in the right knee of each animal by the complete dissection of the anterior cruciate ligament, complete medial meniscectomy and partial dissection of the medial collateral ligament. Postoperatively, animals were divided into two groups. Starting on the ninth postoperative day and daily thereafter, group A animals (n = 9) received 10 IU oculus dexter (o.d.) of synthetic Calcitonin IntraMuscularly (I.M.); group B animals (n = 9) received equal volume of saline o.d. Three animals from each group were sacrificed at 1, 2 and 3 months following treatment's initiation. The extent and the grade of OA were assessed macroscopically, histologically and by radiographs, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)-scans. The Osteoarthritis Research Society International (OARSI) score, incorporating histological and macroscopic information, was calculated for each knee. RESULTS: Osteoarthritic changes in group A animals were less severe and progressed less rapidly when compared with those of group B animals (sham). This difference was statistically significant in the first and second month (P = 0.05), but not in the third month (P = 0.513). CONCLUSIONS: I.M. administration of Calcitonin seems to delay the progress of early-stage osteoarthritic lesions induced by mechanical instability in a rabbit experimental model.

Conservative treatment may be still considered a viable therapeutic option for patients with spontaneous non-specific pyogenic spondylodiscitis. A retrospective audit study of 47 patients.

Background: Spontaneous non-specific pyogenic spondylodiscitis (SNPS) is a rare medical condition, whose optimal treatment remains controversial. We evaluated the multidisciplinary protocol implemented at our department for the conservative treatment of patients with SNPS. Methods: Patients with lumbar or thoracic SNPS, whose treatment was initiated conservatively and had at least six months of follow-up, were enrolled in this retrospective audit study. Patients with specific, postoperative, or iatrogenic spondylodiscitis or necessitating immediate operative treatment were excluded. The location of the infection, initial symptoms, co-morbidities, pathogens, duration of antibiotic treatment, hospitalization and follow-up, and outcome were retrieved. The visual analogue scale (VAS) score was used to register pain improvement after treatment. Results: Between January 2011 and December 2021, forty-seven patients (male: 26, mean age: 68.5 years) with SNPS (lumbar: 29, thoracic: 18) were hospitalized. The main co-morbidity was diabetes mellitus (23 patients). Pain was the predominant (46 patients), and fever was the second most common (19 patients) symptom. The most frequent causative microorganism was staphylococcus aureus (29 patients); no pathogen was identified in ten patients. The mean hospitalization duration for patients completing their conservative treatment (43/47) was 27 (range: 22-41) days. They received antibiotics for a mean period of 23 days intravenously (range: 21-29), 23.8 days per os (range: 21-35), and 46.8 days in total (range: 42-63). Conservative treatment was discontinued in two females. Two male patients died due to septic shock. The mean follow-up was 11.5 months (range: 6-15). During follow-up, no one developed any neurologic deficit and/or recurrence. There was a significant improvement in the mean VAS, from 8.3 ± 0.8 pre-treatment to 1.6 ± 0.5 at the latest follow-up (p <0.001). Conclusions: Although treatment is gradually shifting towards surgical intervention, conservative therapeutic management of SNPS patients with antibiotic administration, bed rest, and careful mobilization remains a viable and efficacious option. HIPPOKRATIA 2023, 27 (2):106-111.

The pathogenetic influence of I-parathyroid hormone on slipped capital femoral epiphysis. Towards a new etiologic approach?

The displacement of the femoral head along the upper femoral physis that occurs during adolescence or slipped capital femoral epiphysis (SCFE) is not a very common traumatic entity. Ever since Muller1 first described it in 1888, its symptoms, clinical manifestations, diagnosis, treatment and complications have been thoroughly described and studied. Nevertheless little progress has been accomplished as far as its etiology is concerned. In order to assess the potential pathologic influence of any parathyroid hormone (PTH) disturbances on the development of SCFE, we conducted a prospective clinical study with 14 patients, 7 boys and 7 girls (16 hips), suffering from SCFE (Group A). Another 5 patients who had been treated for SCFE a few years before the study, were used as a control group (Group B). We measured the level of I-PTH along with serum calcium (Ca) and phosphorus (P) levels. Furthermore, we checked all the necessary anthropometric characteristics of the patients (i.e., age, height, weight and sexual maturation). Each patient of Group A was categorized from grade I to grade V according to the progress of the slipping. The results showed an increased incidence of serum PTH level abnormalities (both decrease and increase) in Group A while Group B patients had normal results. The detected I-PTH serum level abnormalities were not in any pattern related to the Ca and P serum levels. We believe that a temporary parathyroid hormone disorder during the early years of adolescence may play a potentially significant role (along with other etiologic factors) in the development of SCFE.

Patellofemoral arthritis due to localize nodular synovitis (LNS).

We present the case of a 38-year-old female patient who had suffered from a progressively increasing anterior pain in her right knee for almost 10 years. She decided to seek medical advice when the pain became intolerable, not permitting her to perform normal everyday activities. The clinical examination showed evidence of patellofemoral arthritis, but the MRI that followed, apart from confirming the original diagnosis as an "Outerbridge" grade III osteoarthritic lesion, revealed an unidentifiable tumor located in the lateral part of the right patellofemoral joint, that appeared to be like a type of "reactive synovitis". The articular degeneration was treated with arthroscopic saving, followed by complete excision of the tumor and anteromedial tibial tubercle transfer under direct vision. The excised tumor was histologically categorized as a "localized type of nodular synovitis" otherwise known as "giant cell" tumor of synovial origin. The patient has fully recoreved from surgery and 3 years post-operatively she has fully returned to everyday normal activities noting only occasional slight discomfort.

Combined chemoradiotherapy with local microwave hyperthermia for treatment of T3N0 laryngeal carcinoma: a retrospective study with long-term follow-up.

The purpose of our study was to test the efficacy and toxicity of hyperthermia in conjunction with chemoradiotherapy for T3N0 laryngeal cancer. From 1997-2006, 25 patients diagnosed with T3N0 laryngeal carcinoma who denied laryngectomy were selected for this retrospective study. Patients received a total dose of 70 Gy (2 Gy per fraction, 5 days per week) in combination with 6 weekly sessions of hyperthermia, in addition to weekly cisplatin chemotherapy. The hyperthermia device was operated as a 433 MHz microwave heating with water loaded and water-cooled waveguides. The temperature was monitored subcutaneously in the skin under the aperture of the waveguide. The median follow-up was 60 months, while 23 of 25 patients (92%) presented complete response to treatment. The two patients that did not respond to thermoradiotherapy underwent total laryngectomy, and during follow-up were alive and free of disease. According to EORTC/RTOG criteria, toxicity was mild: three patients (12%) presented grade III, eight (32%) presented grade II and 14 (56%) presented grade I acute skin toxicity. Grade III laryngeal late toxicity (vocal cord malfunction due to severe oedema) was noted in two patients (8%) at 6-8 months post-thermo-chemoradiotherapy. Tmin was correlated (Spearman rho, p < 0.05) with response to treatment as well as with acute skin toxicity and laryngeal function. When a patient with T3N0 laryngeal carcinoma denies laryngectomy, an alternative treatment is combined thermo-chemoradiotherapy which seems to be effective and generally tolerable with radiation-induced skin toxicity and/or late side effects. A larger patient cohort is needed to confirm these results.

Reliability and concurrent validity of the adapted Greek version of the Scoliosis Research Society-22r Questionnaire. A cross-sectional study performed on conservatively treated patients.

BACKGROUND: The Scoliosis Research Society-22r Questionnaire (SRS-22r) is a questionnaire assessing the health related quality of life of patients with scoliosis. Aim of this study was to evaluate the validity and reliability of the Greek Version of the SRS-22r in patients suffering from scoliosis who were treated conservatively. METHODS: The (translated and adapted) Greek versions of the SRS-22r together with the previously validated Short Form-36 questionnaire were mailed to 117 patients suffering from idiopathic scoliosis. Two weeks later, the Greek SRS-22r was mailed to the same patients once again. The internal consistency, reproducibility and concurrent validity were assessed. RESULTS: Factor analysis revealed a five-factor structure. The study demonstrated high Cronbach α coefficients for all but the 'Satisfaction with management' domain, when compared with the original questionnaire. Intraclass correlation was excellent regarding every domain of the SRS-22r. Concerning concurrent validity, one domain had excellent (r=0.75-1), thirteen domains good (r=0.50-0.75) and 16 domains moderate correlations (r=0.25-0.50) when compared with the relevant domains of the SF-36 questionnaire. CONCLUSIONS: This Greek Version of the SRS-22r outcome instrument is a validated questionnaire which can be used to evaluate Greek-speaking patients suffering from Idiopathic Scoliosis who are being treated conservatively.

Pre- and postoperative chemoendocrine treatment with or without postoperative radiotherapy for locally advanced breast cancer.

From July, 1978 to September, 1981, 184 patients with localy advanced breast cancer (T3; T4a-b; any N; M0) regardless of their hormonal receptor status, entered a trial to evaluate the contribution of radiotherapy when added to an intensive preoperative chemoendocrine regimen. Seventy-eight patients were ultimately disqualified. All patients underwent sequentially: (1) two cycles of chemotherapy: Day 1--Oncovin 1.4 mg/m2, cyclophosphamide 350 mg/m2, Adriamycin 30 mg/m2; Day 2--methotrexate 20 mg/m2, 5-fluorouracil 350 mg/m2 (in addition, antiestrogens were given to postmenopausal patients); (2) mastectomy with complete axillary dissection combined with oophorectomy in patients before and one year after menopause; (3) radiotherapy randomly to one-half of the patients; and (4) ten additional chemotherapy cycles as above, with antiestrogens to all patients. No serious local sequellae were encountered from mastectomy or radiotherapy, but complications of chemotherapy were numerous, particularly in irradiated patients. One death due to toxicity occurred after preoperative chemotherapy. The results to date suggest that in irradiated patients metastases may become enhanced and that their local disease is not more effectively controlled than in patients not having radiotherapy. Two factors may have been largely responsible for the differences observed between the two groups: the delay of chemotherapy in irradiated patients and the sustained immunosuppression known to occur after mediastinal radiotherapy.