Phlebotomy: a treatment of ischaemic necrosis of the femoral head? Analysis of a hypothesis.

The treatment of non-traumatic ischaemic osteonecrosis of the femoral head (ONFH) remains problematical and there is evidently scope to seek for a medical treatment of this disease which often leads to a surgical procedure for hip prosthesis. If we exclude the context of hemoglobin disorders, necrosis appears mainly in adults, when their limb bones contain a fatty marrow. Investigations such as intramedullary pressure measurement and transosseous phlebography suggest a disorder of the intraosseous blood circulation. Various studies in animals and man have provided arguments indicating that a kind of intraosseous 'obesity' due to hyperplasia and/or hypertrophy of the fatty tissue of the femoral marrow play a role in the development of necrosis. In this respect, the blood flow of the yellow marrow is close to ischemia, whereas red marrow flow can be very high. In various conditions, mainly hemolytic anemias, the femoral yellow marrow can convert to red marrow, which has also been described in anemias induced by blood loss. If it is not thought unreasonable to consider ONFH an 'ischemic' disease, these observations are an encouragement to attempt treatment by repeated phlebotomies. This procedure may locally restore red marrow, and then an adequate blood flow which could stabilize or even reverse the lesions if they are diagnosed early.

How and what kind of bone is made by metastatic cells of prostatic cancer.

In 14 patients with densifying bone metastases of prostatic cancer, the analysis of blood and urine P-Ca parameters, serum 25 OH D3, Ca infusion test, and histomorphometry with measure of calcification rate shows that: - hypocalcemia is common in such patients, sometimes associated to a lack of vitamin D with hypocalciuria and increased Ca retention at the infusion test, and sometimes unexplained; - from a histological point of view, this osteopathy is characterized by a hyperosteoidosis, often an important one, around and only around the metastasis foci, the malignant cells being indispensable to induce the osteoidosis. The entire mineralization of the osteoid matrix may happen but rarely because the hyperosteoidosis is most often increased by a vitamin D deficiency.

[Keratosis lichenoides chronica with mucous membrane involvement and ocular pseudo-pemphigus. Follow-up study over 18 years. Retinoid therapy (author's transl)]. / Kératose lichénoïde chronique avec atteinte muqueuse synéchiante sévère. Etude évolutive sur 18 ans. Thérapeutique par le rétinoíde aromatique.

A very uncommon ocular and mucocutaneous syndrome is reported. Cutaneous manifestations include keratotic plugs occasionally disposed into verrucous plaques (in mountainous chain), lichenoid lesions on face, neck and hand's back, and nail's involvement. Histologically three types of lesions are observed: marked hyperkeratosis, lichenoid aspect, and follicular pustulosis. Mucous membranes alterations, present for almost as long as 20 years, include stomatitis, chronic balanitis with ulcerative and keratotic lesions leading to synechiae; ocular abnormalities has had a follow up into lesions similar to those of cicatricial pemphigoid; direct immunofluorescence study in the vicinity of a buccal erosion showed a complement deposit on basement membrane; immunofluorescence studies on involved and uninvolved skin, and indirect immunofluorescence were negative. Several diagnosis were considered, in first place an atypical Reiter's syndrome. A part the possibility of a new entity, the most attractive hypothesis is this of a keratosis lichenoides chronica with severe mucous cicatrical lesions. A large number of treatment had been inefficacious but a clear improvement of keratotic lesions was noted with oral retinoid therapy.

[Osteomyelitis in the pagetic tibia]. / Ostéomyélite sur tibia pagétique.

Osteomyelitis developing in pagetic bone is a very rare event, of which only one instance has been reported to date, in a patient with mandibular disease. We have managed three patients with osteomyelitis of a pagetic tibia. The portal of entry was a skin lesion in all three cases. A Gram-negative organism was found in all three cases and was associated with the anaerobe Bacteroides melaninogenicus in one case. One of the patients was lost to follow up before eradication of the infection. Amputation was required in the other two after unsuccessful antimicrobial therapy for 23 and four years, respectively.

Acute neck pain and fever as the first manifestation of chondrocalcinosis with calcification of the transverse ligament of the atlas. Five case-reports with a literature review.

We report five cases of acute neck pain with fever in patients with diffuse articular chondrocalcinosis and computed tomography evidence of calcification of the transverse ligament of the atlas. A review of the relevant literature illustrated the high frequency of this condition, the variability of clinical presentations ranging from episodes of acute neck pain with fever to compression of the proximal spinal cord, the value of computed tomography for determining the site of the calcific deposits and assessing the lesions, and the possibility of deposition of both calcium pyrophosphate dihydrate and hydroxyapatite crystals in the same patient.

[D-penicillamine in rheumatoid arthritis : hematological incidents and accidents (author's transl)]. / La D-pénicillamine dans la polyarthrite rhumatoide : incidents et accidents hématologiques.

From literature data and their own experience, the authors comment hematological complications, related to the use of D-penicillamine, mainly in theumatoïd arthritis. Hypereosinophilia is more common than thrombopenia, but, both complications are usually benign. Anemia alone is very rare. Leukopenia appears in 6% of treated patients, but pancytopenia is rare. Leukopenia and pancytopenia are the most severe complications, even fatal in some cases. The safest dose of D-penicillamine seems to be between 600 and 900 mg per day, provided that, however, regular hematological controls may be achieved.

Is osteonecrosis of the femoral head avascular? Bone blood flow measurements after long-term treatment with corticosteroids.

Since nontraumatic osteonecrosis of the femoral head is usually considered primarily as an ischemic disease, blood flow has been studied in femoral segments in two groups of geese, one control group and the other treated with a high dose of corticosteroids for 5 months. There was no histologic evidence of osteonecrosis in femoral heads, and mean bone blood flow in any femoral segments was not reduced in the treated group. These results suggest that osteonecrosis of the femoral head is not caused primarily by ischemia, even if ischemia may play a secondary role in the evolution of the disorder.

[Histopathology of bone lesions in 9 cases of algodystrophy of the hip]. / Histopathologie des lésions osseuses dans 9 cas d'algodystrophie de la hanche.

The authors present the results of histo-pathological observations made in 9 cases of sympatic algodystrophy reflex of the hip, subjected to a punch biopsy of the head and neck of the femur. The punch biopsy was decided upon, either because of difficult diagnosis, or because of the abnormally long duration of the pain syndrome. In all cases, there were bone lesions. The most common were in the marrow tissue, with stasis (9 cases), fibrosis (7 cases) and necrosis at small, isolated points (5 cases). There was osteoclastic resorption in the bones in 3 cases, and rapid osteogenesis in 6 cases. The latter anomaly revealed the rapid reconstruction characterizing the syndrome. Finally, the authors comment on the relationship between algodystrophy and necrosis of the hip, and the advantages of punch biopsy.

[Painful polyarticular syndrome probably induced by cyclosporin in three patients with a kidney transplant and one with a heart transplant]. / Syndrome algique polyarticulaire probablement induit par la ciclosporine (SAPPIC) chez trois transplantes renaux et un transplanté cardiaque.

Among others, ciclosporin had the advantage of decreasing appreciably the incidence of osteonecrosis after renal transplantation. However, the authors have isolated, in three renal transplant patients and one heart transplant patient, treated with ciclosporin, a new syndrome consisting of bilateral and symmetrical joint pain, affecting the lower extremities and lasting almost one year. Subsiding of the radiological aspect and the isotopic hyperfixation of the affected joints, at the end of the evolution, as well as the histological aspect of the bone surrounding the joints, remind somehow of algodystrophy. In both cases, the severity of the pain seemed to depend on the doses of ciclosporin, indicating that this molecule could play a role in the occurrence of this syndrome.

Calcification of the transverse ligament of the atlas in chondrocalcinosis: computed tomography study.

OBJECTIVE: To seek an association between articular chondrocalcinosis (AC) and calcification of the transverse ligament of the atlas (TLA), and to evaluate the frequency and the main computed tomography appearances of such calcification. METHODS: Axial computed tomography slices of the cervico-occipital hinge were performed routinely in 21 patients with AC (three men, 18 women; mean age 79 years, range 67-87) and compared with those from a control group of 21 age and gender matched patients without AC. RESULTS: Calcification of the TLA was present in 14 of the 21 patients (66%) in the AC group and in none of the 21 patients (0%) in the control group (chi 2 test: p < 0.001). Calcification was localised behind the odontoid process, inserted upon the osseous tubercles of the lateral masses of C1, and had a curvilinear profile; it varied in height (1.5 to 9 mm) and appearance (thin = < 1 mm; thick = > 1 mm) and formed either a single or a double band. CONCLUSION: This study has demonstrated a relationship between AC and calcification of the TLA. Although such calcification often remains asymptomatic (nine of 14 patients in our study), it may be associated with attacks of acute neck pain with segmentary stiffness, fever, and an increased erythrocyte sedimentation rate, sometimes revealing AC.

[Bone scintigraphy in Paget's disease]. / La scintigraphie osseuse dans la maladie de Paget.

Sixty patients with Paget's disease underwent bone scintigraphy and a radiological and biological exam. The use of scintigraphy in this disease is of double importance: it allows the spread of the disease to be diagnosed without doing X-rays of the entire skeleton. In twenty per cent of cases this disease cannot be located using X-rays and is detected by scintigraphy. It also supplies an additional objective criteria for judging the development of this disease, especially under treatment. The authors study the different hypotheses concerning the fixation to the bone of the isotope tracer in the Paget zone.

[Biological and histological profile of osteomalacia in condensing prostatic osteosis. Apropos of 4 cases]. / Profil biologique et histologique d'ostéomalacie dans l'ostéose condensante prostatique. A propos de 4 observations.

The authors report on 4 cases of condensating prostatic osteosis, whose biological picture and histomorphometric lesions in the involved area indicate osteomalacia. They discuss the individual nature of such a syndrome, the links between vitamin D deficiency and hyperosteoidosis at a very slow noted speed of calcification, and the usefulness of investigating and treating the syndrome.

[Marrow scintigraphy in Paget's disease of bone (author's transl)]. / La scintigraphie médullaire dans la maladie osseuse de Paget.

Marrow scintigraphy using 99mTc colloids was performed in 20 patients with Paget's disease of bone and compared with skeletal scanning in each of them. As long as the regions explored were haematopoietically active, despite the advanced age of the patients, there was decreased marrow uptake in regions of increased uptake on the skeletal scan. Whilst increased uptake of pyrophosphate reflects bone hyperosteogenesis, decreased uptake of colloids reflects marrow fibrosis, and early histological sign of the disease. This scanning technique could be a new criterion in the surveillance of the therapeutic effectiveness of calcitonins or of diphosphonates.

[Pubic and ischio-pubic osteitis. Bacteriological and histopathological study of the pubic bone]. / Ostéites pubiennes et ischiopubiennes. Etude bactériologique et histopathologique de l'os pubien.

The authors present 11 cases of pubic or ischio-pubic osteitis of which ten had undergone bone biopsy by aspiration, needle biopsy, or surgery. In 7 cases, a germ was isolated by culture of the bone sample. In 2 cases, there were purulent and necrotic lesions on pathological examination of the fragment. In 6 cases, the bony lesions were mainly of the marrow with fibrosis and lymphocyte-plasma cell infiltration. In 5 of these 6 biopsies, the bacterial culture was positive. This subacute mononuclear osteitis may thus be a variety of bacterial osteitis. All the patients were treated with antibiotics which seemed necessary.

[Local osseous blood flow measured with radioactive microspheres: correlations with intra-medullary pressures]. / Débits osseux locaux mesurés par microsphères radioactives: corrélations avec les pressions intra-médullaires.

The authors studied in the dog, using radioactive microspheres, the blood bone outputs of the trochanter, the femoral diaphysis and the tibial diaphysis, and measured, in a simultaneous fashion, the intra-medullar pressures in these bone regions. A same hierarchy of outputs is consistently found in all animals : the trochentarian outputs are always the highest, and next come, in decreasing order, the outputs of the femoral diaphyses and the tibias. On the other hand, the intra-medullar pressures, although differing according to the bone regions, always have rather superposable rates, so that the neighboring intra-medullar pressures always correspond to radically different outputs. It is thereby demonstrated that the intra-medullar pressures, as an isolated parameter, cannot accurately reflect the rate of bone output.

Regional femur blood flow measurements with radiolabelled microspheres in fatty liver-induced or corticosteroid treated animals: preliminary report.

Using radio-labelled microspheres, the authors studied bone blood flows in various segments of goose femurs (femoral head, trochanter, condyles). Experiments were conducted on three groups of geese: control, fatty liver induced and corticosteroid-treated animals. The preliminary results suggest that hyperlipemia and fatty liver conditions do not seem to obviously disturb intra osseous blood circulation in fatty geese, although corticosteroids might affect bone blood flows in condyles.