Polymorphisms of the vitamin D receptor gene and stress fractures.

Our aim was to evaluate the association between VDR polymorphisms and calcaneal Stiffness Index (SI) with stress fractures in a case control study including male military personnel. Thirty- two patients with stress fractures were matched with 32 uninjured healthy volunteers (controls), by gender, age, height, body weight, and level of physical activity. The two groups were genotyped for the FokI, BsmI, ApaI, and TaqI polymorphisms of the VDR gene with PCR-RFLP method. In addition, calcaneal SI was measured by heel quantitative ultrasound in both groups. Data were analyzed by chi-squared test and logistic regression analysis. The f allele was significantly more frequent in patients than in controls (p=0.013), while the B allele showed such a tendency without reaching statistical significance (p=0.052). Among the entire cohort, a 2.7-fold and a 2.0-fold increase in risk of stress fractures was associated with the f and B alleles (OR, 2.7, 95% CI, 1.2-5.9; p=0.014 and OR, 2.0, 95% CI, 1.0-4.1; p=0.053, respectively). No statistically significant association was found between the incidence of stress fractures and t or a alleles. Decreased T-scores were also associated with the presence of f and B alleles. Mean values of T-scores of SI were statistically significantly lower in patients than in controls (p=0.018). These results suggest that the FokI and BsmI polymorphisms of the VDR gene could be associated with increased risk of stress fractures among military personnel. Moreover, a low calcaneal SI could represent a measurable index of this increased risk.

Bilateral transient bone marrow edema or transient osteoporosis of the knee in pregnancy.

Transient osteoporosis or transient bone marrow edema is an uncommon self-limiting condition of unknown etiology. The most commonly affected joint is the hip, followed by the knee, ankle, and the foot. Simultaneous involvement of both hips has been reported exclusively in pregnant women. Bilateral knee involvement during pregnancy seems to be extremely rare. We present a case of bilateral transient bone marrow knee edema during pregnancy with complete resolution of symptoms and radiological findings after 10 months.

Anterior cruciate ligament reconstruction: outcome using a patellar tendon bone (PTB) autograft (one bone block technique).

OBJECTIVE: The aim of this study was to determine the outcome of anterior cruciate ligament (ACL) reconstruction using a patellar tendon bone autograft (one bone block technique). METHOD: We retrospectively evaluated a case series of patients who had received arthroscopic ACL reconstructions using patellar tendon bone autograft. Fifty-four (54) ACL reconstructions were evaluated at a mean of 38 months (range 25-62 months). Clinical assessment was made using a modified Lysholm score, documentation of International Kappanee Documentation Committee (lKappaDC), the anterior knee pain questionnaire of Shelbourne and Trumper, and by KappaTau-Rolimeter arthrometric analysis. Radiographic assessments were also performed. RESULTS: Arthrometric analysis showed that 51 knees (94%) were graded Alpha or Beta with a median laxity of 2 mm, postoperatively. The Lysholm score improved postoperatively from 70 to 89. The patellar position in terms of congruence angle did not show any significant change, and the final shortening of the patellar tendon using the Insall-Salvati ratio was 6.07%. Only three patients complained of moderate pain on kneeling, one patient was unable to participate in strenuous works and one patient complained of harvest-site tenderness. CONCLUSION: It is concluded that the use of patellar tendon autograft with a single tibial-tubercule bone block and a strip of patellar periosteum have the advantages of being available and comparable in terms of graft size and strength and shows satisfactory results with reduced anterior knee pain.

Vacuum-assisted closure downgrades reconstructive demands in high-risk patients with severe lower extremity injuries.

BACKGROUND: Primary soft tissue reconstruction in complex leg injuries is mandatory in order to protect exposed tissues; however, it may be precluded by the patient's clinical status or by local wound conditions. This retrospective study aims to evaluate the use of negative pressure as an adjunct to delayed soft tissue reconstruction in patients with complex lower limb trauma. MATERIAL AND METHODS: Forty-two patients with 49 complex lower limb injuries were treated with Vacuum assisted closure (VAC) 48 hours after bone fixation, vascular repair and surgical debridement. Wound swab cultures were obtained before and after every VAC application. Duration of therapy, wound flora, final reconstructive technique required, outcome and follow-up period were retrieved from medical records. RESULTS: Twenty-four male and eighteen female patients were recruited, with a mean age of 47 years. All were treated with VAC therapy for 15-42 days. Reconstruction was delayed due to the patients' critical condition, advanced age, medical co-morbidities, heavily exuding wounds and questionable viability of soft tissues. Patients were followed up for 90-895 days. Two wounds healed spontaneously, 6 were managed with delayed direct suture, 31 with split thickness skin grafts and 9 required local cutaneous, fasciocutaneous or muscular flaps. One patient died due to fat embolism. Wound bacterial flora progressively decreased in all but one patient. Scar formation was aesthetically acceptable by the patients while function depended on the initial injury. CONCLUSIONS: Negative pressure is a safe and effective adjunct to delayed soft tissue reconstruction in high-risk patients with severe lower extremity injuries, minimizing reconstructive requirements and therefore postoperative morbidity.

Maggot infestation (myiasis) of external fixation pin sites in diabetic patients.

Diabetic patients, and especially elderly patients in a low-nutritional or immunocompromised state, are prone to a variety of opportunistic infections. 'Myiasis' is a term that refers to non-iatrogenic infestation of tissues by larvae, commonly known as maggots, of dipterous flies. Myiasis as a complication of fracture treatment by means of external fixation of long bones has not been reported. We present three diabetic patients, who suffered maggot infestation of their external fixation pin holes, and their outcome. Diabetes, immobilization, poor hygiene and low immune status are predisposing factors for developing myiasis, an extremely rare complication for external fixation of fractures.

Simultaneous dislocation of the radial head and distal radio-ulnar joint. A case report.

Isolated dislocation of the distal radio-ulnar joint and isolated dislocation of the radial head in adults are not common injuries. A simultaneous dislocation of the radial head and distal radio-ulnar joint with no other injury seems to be extremely rare since only one report was found in the English literature. A similar case, but with some differences in presentation and treatment is reported.

Intramuscular haemangioma of the extensor pollicis brevis muscle with periosteal reaction of the radius: a case report and review of the literature.

We report the rare case of a histologically proven mixed-type intramuscular haemangioma, adjacent to the periosteum of the radius, that caused a periosteal reaction. We also carried out a review of the literature relevant to this case. A 28-year-old male professional drummer presented with an 8-month history of pain and swelling of the dorsal aspect of the right radius. Diagnosis was established on the basis of plain radiographs and magnetic resonance imaging, and was confirmed by histology. The lesion was treated solely by resection of the soft-tissue mass. The patient remained asymptomatic 4 years post-operatively, with no radiographic signs of recurrence. From a review of the literature, it is evident that the terminology for haemangiomas causing regional bone changes is unclear. A new classification of the intramuscular haemangiomas is proposed in order to distinguish between lesions that, according to current knowledge, exhibit radiological and clinical areas of overlap.

Tuberculous spondylitis in patients with end-stage renal disease undergoing chronic hemodialysis therapy.

Tuberculosis of the spine is not rare in immunocompromised patients and particularly in those with end-stage renal disease (ESRD). Furthermore, the possible vascular compromise of the spinal cord in patients with diabetic nephropathy may result in symptoms of neurological involvement that could lead to deterioration and paralysis. We report a series of 4 patients with ESRD undergoing dialysis that developed tuberculous spondylitis of the thoracic spine. Diabetic nephropathy was the primary cause for chronic kidney disease in 2 patients; 3 of these patients were treated conservatively with anti-tuberculous medication and orthotic splints and were cured. The fourth patient with diabetes mellitus and clinically evident signs and symptoms of severe vascular insufficiency has additionally developed incomplete paraplegia. A complete sensory recovery and partial recovery of the hip flexors and abductors within 3 months occurred, following decompression of the spine and drainage of the abscess, in combination with long-term anti-tuberculous treatment and spinal orthosis.

Human embryonal tissues of all three germ layers can express the CD30 antigen. An immunohistochemical study of 30 fetuses coming after therapeutic abortions from week 8th to week 16th of gestation.

Originally, expression of the CD30 antigen was shown to be typical of the tumor cells of Hodgkin disease and of anaplastic large cell lymphomas. In reactive lymphoid tissue, CD30 is expressed only in a small population of activated lymphoid blasts. Since then, several reports have been published describing CD30 expression in non lymphoid tissues and neoplasms, such as embryonal carcinomas, seminomas, cultivated macrophages, histiocytic neoplastic cells, deciduals cells, and mesothelioma cells. In order to gain insight into the functions of CD30, given that it can mediate signals for cell proliferation and apoptosis, we studied the distribution of the antigen in different fetal archival paraffin-embedded tissues from week 8th to 16th of gestation. We investigated the immunohistochemical expression of CD30 in 30 paraffin-embedded tissue samples representing all three germ layers, using the monoclonal antibody Ber-H2 CD30 is expressed early in human fetal development (8th-10th week) in a wide variety of tissues, with the exception of the skin and thymus in which it is expressed later on. This is consistent with the observation that these organs are not fully differentiated before 10th and 13th week, respectively. No expression was observed in the cardiovascular and respiratory systems. The finding of CD30 expression in the terminal period of organogenesis, period, which is highly hormone related, implies that the antigen has an important role in cell development, maturation, and pathway to terminal differentiation in almost all fetal tissues and structures.

Primary hydatid disease in femoral muscles.

Usually, intramuscular hydatid cysts are secondary, resulting from the spread cysts from other areas either spontaneously or after operations for hydatidosis in other regions. We present an unusual case of a primary hydatid cyst found in the left thigh of a 35-year-old woman, presenting as an enlarging soft-tissue tumour. Ultrasound, computed tomography and magnetic resonance imaging examinations revealed a multilocular intramuscular cyst in the anterior aspect of her left thigh, and no disease at any other location. We removed the entire cyst surgically, and macroscopic and microscopic histopathological examinations confirmed the diagnosis of muscular hydatidosis. Three years after the operation there had been no recurrence. In regions where hydatidosis is endemic, a tumour in any part of the body should be considered a hydatid cyst until proven otherwise.

Malignant haemangiopericytoma of the knee joint: MR findings.

The imaging findings of intra-articular haemangiopericytomas have not been described previously. We report on a 35-year-old man with a primary malignant haemangiopericytoma of the left knee joint. MRI demonstrated joint effusion and a heterogeneous mass with haemorrhagic components and multiple peripheral serpentine signal voids, suggesting the presence of vascular channels. Multiple pulmonary metastases were seen on chest CT. These imaging findings, although not pathognomonic, might be useful in suggesting the diagnosis of intra-articular haemangiopericytoma.

Antibiotic-loaded acrylic cement.

Laboratory experiments and clinical investigations have confirmed the various claims made originally by Buchholz and Engelbrecht (1970) that antibiotic-loaded acrylic cement releases the antibiotic into the surroundings in useful concentrations. Palacos R cement released higher concentrations than CMW, Simplex and Sulfix brands of cement and over longer periods. Concentrations of gentamycin and fucidin were sufficient to penetrate dead cortical bone. These conclusions need to be assessed with animal studies, mechanical testing and clinical results before the ideal place of antibiotic-loaded acrylic cement is established.

Bacterial infection and acrylic cement in the rat.

In thirty-one rat tibiae, plugs of plain acrylic cement were inoculated with Staphylococcus aureus; these all remained contaminated at the end of two weeks when the animals were killed. Inoculation with known strains of Pseudomonas, Proteus and Gp. G Streptococcus resulted in 70 to 93 per cent persisting contamination. Gentamicin, to which the organisms were fully sensitive, was efficacious in controlling the infection (90 per cent plugs proving sterile after two weeks). Fucidin was less successful against Staphylococcus aureus although effective in vitro. Intravenous inoculation with a suspension of Staphylococcus aureus succeeded in contaminanting 70 per cent of sixty plain cement plugs when injected into the tail vein half an hour after closure of the leg wounds. Only 11 per cent of sixty-four plugs were so contaminanted when the injection was delayed for two weeks. This animal model is submitted as a possible future means of testing different antibiotic-cement combinations against infection.

Immunophenotypic profile and FISH analysis in a case of Ewing's sarcoma.

Ewing's sarcoma arising in the right fibula was diagnosed in a 12 years old female, considering clinical presentation, radiological findings and histological features. Our work points towards a possible neuroectodermal origin of Ewing's sarcoma, since MIC2/12E7 marker was found to be positive. Translocation t (11;22) (q24;q12) was found as the main cytogenetic change in this tumor, by means of FISH analysis.

Nonunion of tibial fractures treated with external fixation. Contributing factors studied in 71 fractures.

We analyzed factors of importance for nonunion in a series of 39 closed and 32 open fractures of the tibia which were treated with external fixation. Factors analyzed included, age and sex of the patients, the mechanism of injury, the amount of soft tissue damage, the grade of comminution, the level at which the tibia was fractured, the presence of an intact fibula, the presence of multiple injuries, the type of external fixation used (Orthofix, STAR-90 or Hoffmann) and the need to supplement the stability of the reduction. We found that the type of open fracture, comminution of the fracture, extension the original wound for satisfactory reduction and fracture of the ipsilateral fibula, played a role in the development of nonunion.

Wound closure of leg fasciotomy: comparison of vacuum-assisted closure versus shoelace technique. A randomised study.

BACKGROUND: Fasciotomies, though essential for the prevention and management of compartment syndromes, may increase morbidity and prolong hospitalisation. Two widely applied methods of delayed primary closure are compared in leg fasciotomy wounds. PATIENTS AND METHODS: Two groups, each of 25 patients with leg fasciotomies due to fractures and soft tissue injuries, who were randomly assigned to be treated either by vacuum assisted closure (VAC®, n=42 wounds, group V) or by the shoelace technique (n=40 wounds, group S), were evaluated in this study. Wound length, time to definite closure, complications, need for additional interventions and daily treatment costs were data collected and statistically assessed. RESULTS: Wound closure time was significantly higher in group V compared to group S (p=0.001; 95% CI of the difference, 1.8-6.3 days). Five group V patients required split thickness skin grafts. In six group S patients, the vessel loops had to be replaced. The mean daily cost of negative pressure therapy alone was 135 euro (range 117-144 euro), whilst the mean daily cost of treatment for the shoelace technique was 14 euro ranging from 8 to 18 euro (p=<0.001). CONCLUSIONS: Both VAC® and the shoelace technique are safe, reliable and effective methods for closure of leg fasciotomy wounds. VAC® requires longer time to definite wound closure and is far more expensive than the shoelace technique, especially when additional skin grafting is required.

Mechanical characterization of bone graft substitute ceramic cements.

The aim of this laboratory work was to study the compressive and flexural characteristics of various commercially available bone graft substitute (BGS) ceramic cements, in their initial as-mixed condition, and compare them to polymethylmethacrylate (PMMA). The tested biomaterials were two different calcium phosphate cements, two different calcium sulphate cements, one nanocrystalline hydroxyapatite and one PMMA cement. All biomaterials were prepared according to manufacturers instructions and the methodology described in ISO 5833 (2002) for acrylic bone cement was followed, as the one closest approaching in vivo requirements. All BGS cements had a brittle behaviour and when subjected to mechanical stress they all failed under sudden crack propagations in their bulk. Both in compression and bending, all BGS cements failed under loads lower than those of PMMA. In compression, the calcium sulphate extra strength cement showed a strength value of approximately 60% of PMMA, the other cements following at a distance. In bending, all BGS cements showed strengths below 22% of PMMA. However, due to limited number and fragility of specimens, calculated bending strengths can only be considered as indicative figures with limited comparative value. The results of this in vitro study showed a varying mechanical performance between tested BGS ceramic cements, whilst all of them exhibited lower compression and bending strength than the selected PMMA. These findings, of course, cannot be directly extrapolated to surgical or clinical implications, since the adopted in vitro context does not necessarily reflect the actual in vivo conditions met by such biomaterials.

Homocysteine and its relationship to deep venous thrombosis in patients undergoing total knee or hip arthroplasty.

UNLABELLED: Backround: The role of hyperhomocysteinemia as an independent risk factor for venous thrombosis after lower limb arthroplasty remains questionable. The objective of this study is to determine the relationship between hyperhomocysteinemia and postoperative thromboembolic events in patients undergoing total hip or knee arthroplasty. METHOD: Between September 2004 and June 2006, we studied 172 patients (41 male and 131 female) with mean age 70.2 years (48-85). Total plasma homocysteine as well as other thrombophilic agents (proteinC, protein S, Antithrombin III, Lupus anticoagulants, APC-Resistance) were measured preoperatively. Duplex sonography was performed twice postoperatively, on the 7(th) day (+/-2) and on the 42th day (+/- 2). Spiral CT was performed when pulmonary embolism was suspected. RESULTS: Four patients developed deep venous thrombosis from which two developed pulmonary embolism. Only one of these four patients had high levels of total plasma homocysteine. CONCLUSIONS: Total plasma homocysteine does not seem to affect the development of deep venous thrombosis in patients undergoing total knee or hip arthroplasty and receive low molecular weight heparine.

Experimental study of tendon healing early phase: is IGF-1 expression influenced by platelet rich plasma gel?

BACKGROUND: It is well established that growth factors play a critical role in the healing process of connective tissues. To our knowledge, there are no studies in literature concerning the influence of PRP on growth factors expression. HYPOTHESIS: The aim of this study was to assess the effect of a single application of platelet rich plasma (PRP) gel in a patellar tendon defect on the spatial and temporal expression of Insulin-like Growth Factor 1 (IGF-1) during tendon healing. MATERIALS AND METHODS: Twenty-four animals were randomized to receive PRP (PRPFast, Bioteck) in a gel form (PRP group) and 24 to serve as untreated controls (Control group). A defect of 3 mm x 10 mm was surgically created on the tendon under general anaesthetic and in the PRP group, PRP gel was applied to fill the tendon defect whereas no treatment was applied in the control group. Six animals (12 limbs) from each treatment-group were sacrificed after one, two, three and four weeks following treatment. Histological and immunohistochemical staining were performed. RESULTS: Histology revealed a faster healing process in the tendons of PRP group in comparison with the controls. In the first 2 weeks of healing, IGF-1 was found intracellularly in various type cells, whereas in the last 2 weeks of healing, IGF-1 was detected mainly in tenocytes. Both cytoplasmic and nuclear expressions were present, whereas the larger amounts of immunoexpression were localized in both epitenon and endotenon. A superior expression of IGF-1 was seen in PRP group compared with controls (p<0.0001) in both the epitenon and endotenon at each time point except at 4th week of healing where a superior expression of IGF-1 was shown in the endotenon of control group, compared to the PRP group (p<0.0001). CONCLUSION: PRP may improve tendon defect healing by overexpression of IGF-1. LEVEL OF EVIDENCE: Laboratory control animal study.

The use of autologous PRP gel as an aid in the management of acute trauma wounds.

Autologous platelet-rich plasma (PRP) gel is increasingly used in the treatment of a variety of soft and bony tissue defects, such as accelerating bone formation and in the management of chronic non-healing wounds. We performed this study to assess the benefits of using autologous PRP gel in the treatment of acute limb soft tissue wounds. 59 patients with acute wounds (open fractures, closed fractures with skin necrosis and friction burns) were randomised into two groups. Group A (32 patients) were treated with conventional dressings and Group B (27 patients) were managed with local application of PRP gel. Gustillo grade IIIb or IIIc open fractures were not included in this study, as these injuries required coverage with flap. The clinical endpoints were the healing rate and/or the time required to bring about adequate tissue regeneration in order to undergo reconstructive plastic surgery. The rate of wound healing rate was significantly faster in Group B at week 1, 2 and 3 (p=0.003, p<0.001 and p<0.001, respectively). The mean time to plastic reconstruction in Group B was 21.26 days, S.D.=1.35 vs 40.6 days in Group A, S.D.=5.27 (p<0.001). This study has shown that PRP gel treatment can be a valuable and effective aid in the management of acute trauma wounds.