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.

Actinobaculum schaalii, a new cause of knee prosthetic joint infection in elderly.

Actinobaculum schaalii is an emerging pathogen particularly involved in urinary tract infection of elderly people and/or patient with urological risk factors of urinary tract infection. This microorganism is a difficult-to-diagnose pathogen and is rarely involved in systemic or deep infections. Here, we report the first case of prosthetic joint infection due to A. schaalii in an 84-year-old man with a benign prostatic hyperplasia associated with chronic retention of urine. This case underlines the importance to optimize the diagnosis of emerging uropathogens as A. schaalii, to prevent systemic infections, particularly in patients with orthopaedic implants.

Meniscal biomechanical alterations in an ACLT rabbit model of early osteoarthritis.

OBJECTIVE: The purpose of this study was to analyze the early biomechanical alterations of menisci during the early stage of osteoarthritis (OA) development and to correlate them with the chemical composition and matrix alteration. A particular focus was paid to pathological changes in glycosaminoglycan (GAG) content and collagen fiber architecture. DESIGN: Menisci (n = 24) were removed from rabbits' knee joints 6 weeks following surgical anterior cruciate ligament transection (ACLT). Both the anterior and posterior regions of medial and lateral menisci were characterized using indentation tests, Raman microspectroscopy (RM), biphotonic confocal microscopy (BCM) and histology. RESULTS: Mechanical and matrix alterations occurred in both regions of medial and lateral menisci. A significant decrease in the mechanical properties was observed in OA menisci, with a mean reduced modulus from 2.3 to 1.1 MPa. Microstructural observations revealed less organized and less compact collagen bundles in operated menisci than in contralateral menisci, as well as a loss of fiber tension. GAG content was increased in OA menisci, especially in the damaged areas. Neither changes in the secondary structure of collagen nor mineralization were detected through RM at this stage of OA. CONCLUSION: ACLT led to a disorganization of the collagen framework at the early stage of OA development, which decreases the mechanical resistance of the menisci. GAG content increases in response to this degradation. All of these results demonstrate the strong correlation between matrix and mechanical alterations.

How is quality of life after total hip replacement related to the reconstructed anatomy? A study with low-dose stereoradiography.

PURPOSE: The purpose of this study was to evaluate the relationships between the three-dimensional anatomy of operated hip in standing position using low-dose stereo-radiography imaging system and postoperative hip disability and osteoarthritis outcome score (HOOS) after total hip arthroplasty (THA). MATERIAL AND METHODS: A total of 123 patients who underwent THA during a one-year period were included. There were 50 men and 73 women with a mean age of 67.3±13.6 (SD) years (range: 19-89 years). All patients underwent pre- and postoperative low-dose stereo-radiography examination and completed a HOOS form (score from 0 to 100, 100 for full satisfaction). We recorded 16 anatomical parameters before THA, and 15 after THA. After binary transformation of HOOS score using 70 as threshold value, outcome was assessed using logistic or generalised linear models. RESULTS: A total of 103 patients (103/123; 83.7%) had a HOOS score≥70 and were considered as the satisfied group. A significant difference in pelvic incidence (the angle between a line perpendicular to the sacral plate at its midpoint and a line connecting the same point to the centre of the bicoxofemoral axis) was found between the satisfied 56.4±10.4 (SD)° (range: 31-85°) and the unsatisfied group 48.7±8.9 (SD)° (range: 40-65) (P=0.006). The relative variation of offset (distance from the centre of rotation of the femoral head to a line bisecting the long axis of the femur) compared to the contralateral hip was -7% in the satisfied group and 7.2% in the unsatisfied group (P=0.01). CONCLUSION: Pelvic incidence, a parameter independent of the reconstructed anatomy, probably influences the quality of life of patients with THA, via pelvic compensatory capabilities. A loss of femoral offset negatively influences the satisfaction of patients.

Embedding of bone samples in methylmethacrylate: a suitable method for tracking LacZ mesenchymal stem cells in skeletal tissues.

Considerable research has been focused on the use of bone marrow-derived mesenchymal stem cells (MSCs) for the repair of non-unions and bone defects. To date, the question of whether transplanted MSCs survive and engraft within newly formed tissue remains unresolved. The development of an easy and reliable method that would allow cell fate monitoring in transplant recipients is a pressing concern for the field of tissue engineering. To demonstrate the presence of transplanted cells in newly formed bone, we established a xenograft nude rat model allowing the detection of murine LacZ MSCs in vivo. MSCs were isolated from transgenic lacZ mice, seeded onto bioabsorbable collagen sponges, and transplanted to repair a calvarial defect in nude rats. As a preliminary step, the histological procedure was adapted to optimize the detection of LacZ cells in bone tissue embedded in methylmethacrylate (MMA). Four fixatives and four fixation times were evaluated. Among all the fixatives tested, 2% formaldehyde/0.2% glutaraldehyde at 4C for 4 days gave the best results for X-gal staining at pH 7.4 on both cell cultures and bone explants. All fixatives were effective for immunodetection of beta-gal. In the chimeric LacZ/nude rat animal model, MSCs were detected in vivo for up to 4 weeks after implantation and contributed to the repair and the neovascularization of the bone defect. LacZ is a suitable phenotypic marker to track MSCs in skeletal tissues embedded in MMA.

Engineering of implantable cartilaginous structures from bone marrow-derived mesenchymal stem cells.

Fabrication of implantable cartilaginous structures that could be secured in the joint defect could provide an alternative therapeutic approach to prosthetic joint replacement. Herein we explored the possibility of using biodegradable hydrogels in combination with a polyglycolic acid (PGA) scaffold to provide an environment propitious to mesenchymal stem cells (MSCs) chondrogenic differentiation. We examined the influence of type I collagen gel and alginate combined with PGA meshes on the extracellular matrix composition of tissue-engineered transplants. MSCs were isolated from young rabbits, expanded in monolayers, suspended in each hydrogel, and loaded on PGA scaffolds. All constructs (n=48) were cultured in serum-free medium containing transforming growth factor beta-1, under dynamic conditions in specially designed bioreactors for 3-6 weeks. All cell-polymer constructs had a white, shiny aspect, and retained their initial size and shape over the culture period. Their thickness increased substantially over time, and no shrinkage was observed. All specimens developed a hyalin-like extracellular matrix containing glycosaminoglycans (GAGs) and type II collagen, but significant differences were observed among the three different groups. In PGA/MSCs and collagen-PGA/MSCs constructs, the cell growth phase and the chondrogenic differentiation phase of MSCs occurred during the first 3 weeks. In alginate-PGA/MSCs constructs, cells remained round in the hydrogel and cartilage extracellular matrix deposition was delayed. However, at 6 weeks, alginate-PGA/MSCs constructs exhibited higher contents of GAGs and lower contents of type I collagen. These results suggest that the implied time for the transplantation of in vitro engineered constructs depends, among other factors, on the nature of the scaffold envisioned. In this study, we demonstrated that the use of a composite hydrogel-PGA scaffold supported the in vitro growth of implantable cartilaginous structures cultured in a bioreactor system.

Allograft integration in a rabbit transgenic model for anterior cruciate ligament reconstruction.

BACKGROUND: Tissue engineering strategies include both cell-based and cell homing therapies. Ligamentous tissues are highly specialized and constitute vital components of the musculoskeletal system. Their damage causes significant morbidity and loss in function. HYPOTHESIS: The aim of this study is to analyze tendinous graft integration, cell repopulation and ligamentization by using GFP+/- allografts in GFP+/- transgenic New Zealand white (NZW) rabbits. MATERIAL AND METHODS: Graft implantation was designed to closely mimic anterior cruciate ligament (ACL) repair surgery. Allografts were implanted in 8 NZW rabbits and assessed at 5 days, 3 weeks and 6 weeks through: (1) arthroCT imaging, (2) morphological analysis of the transplanted allograft, (3) histological analysis, (4) collagen type I immunochemistry, and (5) GFP cell tracking. Collagen remodeling was appreciated at 3 and 6 weeks. RESULTS: Graft repopulation with host cells, chondrocyte-like cells at the tendon-bone interface and graft corticalization in the bone tunnels were noticed at 3 weeks. By contrast we noticed a central necrosis aspect in the allografts intra-articularly at 6 weeks with a cell migration towards the graft edge near the synovium. DISCUSSION: Our study has served to gain a better understanding of tendinous allograft bone integration, ligamentization and allograft repopulation. We believe that both cell-based therapies and cell homing therapies are beneficial in ligament tissue engineering. Future studies may elucidate whether cell repopulation occurs with pre-differentiated or progenitor cells. We believe that both cell-based therapies and cell homing therapies are beneficial in ligament tissue engineering. LEVEL OF EVIDENCE: Level V (animal study).

Ocular involvement in Epstein-Barr virus-associated T-cell lymphoma.

PURPOSE: To determine if serous retinal detachment may occur in a case of Epstein-Barr virus-associated T-cell lymphoma. METHODS: We examined a 51-year-old man who had recent loss of vision and poor general health. RESULTS: Ocular involvement consisted of bilateral serous retinal detachment and choroidal infiltrates. The diagnosis of lymphoma was made by liver biopsy. The course of the disease was fulminant. Postmortem histologic examination disclosed a massive infiltration of the choroid and hematopoietic organs by pleomorphic large T cells. Epstein-Barr virus was detected by in situ hybridization. CONCLUSION: Ocular involvement, including choroidal infiltrates and serous retinal detachment, may occur in Epstein-Barr virus-associated T-cell lymphoma.

Hybrid alumina total hip arthroplasty using a press-fit metal-backed socket in patients younger than 55 years. A six- to 11-year evaluation.

Between 1990 and 1992, we implanted 71 hybrid alumina-on-alumina hip arthroplasties in 62 consecutive patients under the age of 55 years, with a mean age of 46 years at surgery. There were 56 primary and 15 secondary procedures. The prostheses involved a cemented titanium alloy stem, a 32 mm alumina head, and a press-fit metal-backed socket with an alumina insert. Three patients (four hips) died from unrelated causes. Four hips had revision surgery for either deep infection, unexplained persistent pain, fracture of the alumina head, or aseptic loosening of the socket. The nine-year survival rate was 93.7% with revision for any cause as the end-point and 98.4% with revision for aseptic loosening as the end-point. The outcome in the surviving patients (50 patients, 57 hips) with a minimum five-year follow-up (mean eight years) was excellent in 47 hips (82.5%), very good in eight (14%), good in one and fair in one. A thin, partial, lucent line, mainly in zone III was present in 38% of the sockets and one socket had a complete lucency less than 1 mm thick. One stem had isolated femoral osteolysis. There was no detectable component migration nor acetabular osteolysis. This hybrid arthroplasty gave satisfactory medium-term results in active patients. The press-fit metal-backed socket appeared to have reliable fixation in alumina-on-alumina hip arthroplasty. The excellent results using cemented fixation of the stem may be related to the low production of wear debris.

Trigger finger treatment by ulnar superficialis slip resection (U.S.S.R.).

Surgical release of the A1 pulley for treatment of trigger finger normally produces excellent results. However, in patients with long-standing disease, there may be a persistent fixed flexion deformity of the proximal interphalangeal joint. This is sometimes due to a degenerative thickening of the flexor tendons and may be treated by resection of the ulnar slip of flexor digitorum superficialis tendon. One hundred seventy-two patients (228 fingers) who had undergone this procedure were reviewed at a mean follow-up of 66 months. Mean pre-operative fixed flexion deformity of the proximal interphalangeal joint was 33 degrees. All but eight fingers were improved by surgery and there was an average gain of 26 degrees in passive extension (7 degrees residual fixed flexion deformity) of the proximal interphalangeal joint. Full extension was attained in 141 of the 228 fingers, and in all 101 fingers with a pre-operative loss of passive extension of 30 degrees or less. This technique is indicated for patients with loss passive extension in the proximal interphalangeal joint and a long history of triggering.

Management of silicone-induced cataract in AIDS patients treated for viral retinitis-associated retinal detachment.

BACKGROUND AND OBJECTIVE: To evaluate the outcome of cataract surgery for patients with acquired immunodeficiency syndrome (AIDS) who underwent vitrectomy and silicone tamponade for viral retinitis-associated retinal detachment. PATIENTS AND METHODS: The authors retrospectively reviewed the data of five AIDS patients (five eyes) who had cataract within a mean period of 4 months following vitrectomy and silicone oil tamponade for viral retinitis-associated retinal detachment. Phacoemulsification and implantation of a poly-methylmethacrylate posterior chamber intraocular lens were performed. The mean postoperative follow-up was 3 months. RESULTS: Neither silicone oil loss nor retinal redetachment were reported postoperatively. Visual acuity improved in two eyes and remained unchanged in one eye. Total blindness occurred in two eyes. CONCLUSION: Although cataract surgery in these eyes is a relative easy procedure and does not interfere with the retinal status, visual outcome remains poor because of possible postoperative optic atrophy.

[Medical treatment of ocular burns]. / Brûlures oculaires: traitement médical.

Chemical burns, especially alkali burns, can induce severe damage to the eye, not only of its surface, but also of its deep structures. Ocular chemical burns require urgent medical care and sometimes surgery. Medical management of chemical burns of the ocular surface includes controlling the inflammation of the underlying corneal stroma, preserving limbal vasculature, and restoring the limbal stem cell population if necessary, as early as the 3rd week following the injury, which sometimes also requires surgery consisting for the most part of amniotic membrane and/or limbal stem cell transplantation.

[Triple procedure with phacoemulsification prior to grafting]. / Triple procédure avec phacoémulsification précédant la greffe.

We report a surgical technique which combines phacoemulsification and posterior chamber in the bag intra-ocular lens implantation before penetrating keratoplasty. This combined technique can only be performed in eyes with clear cornea. This technique seems to be safer during cataract extraction. We compared this combined procedure with the classical technique which associates manual extracapsular extraction and posterior chamber intra-ocular lens implantation and penetrating keratoplasty.

[Technique of peribulbar anesthesia]. / Technique d'anesthésie péribulbaire.

A new technique of peribulbar anesthesia using a short needle has been applied on 3,691 patients. Complications previously reported with the use of a long needle are thus avoided.

[Value of posterior capsulorrhexis during combined phacoemulsification and silicone oil removal]. / Intérêt du capsulorhexis postérieur au cours de l'intervention combinée phakoemulsification et ablation de l'huile de silicone.

Combined surgery with silicone oil removal, phacoemulsification and intraocular lens implantation was retrospectively evaluated in 9 eyes of 9 patients. Visual acuity was better after surgery in 7 eyes, and 8 eyes did not required further posterior capsulotomy during follow-up (10 months). In 2 eyes post-op intraocular inflammation was observed. Redetachment of the retina occurred in one eye. Posterior capsulorrhexis can be done during cataract surgery and silicone oil removal in a vitrectomised eye, without inducing direct complications.

[Self-sealing sclerotomies in pars plana vitrectomy]. / Sclérotomies autoétanches lors de la vitrectomie par la pars plana.

PURPOSE: To study a technique of self-sealing sclerotomies, recently described. METHODS: After conjunctival peritomy, a tunnel incision is performed with a crescent knife, 2 mm posterior to the intended site of entry. Then a 20G microvitreoretinal blade is used to enter the vitreous cavity. From November 1996 to April 1997, 99 primary vitrectomies were prospectively studied. RESULTS: 292 sclerotomies were performed with this technique. Self-sealing sclerotomies were observed in 270 cases (92.5%). In 22 cases, leakage of fluid required closure with 8-0 nylon sutures. Leakage was related to multiple instruments used through the sclerotomy, or more frequently to a thin scleral wall. In 1 case, transient hypotony was observed. Ocular pressure spontaneously returned to normal. CONCLUSIONS: Self-sealing sclerotomies are difficult to perform if the sclera is thin, and leakage can be observed if multiple instruments have to be used through the same sclerotomy. But this technique prevents vitreous and retinal herniation through the sclerotomy, and ocular hypotony. It also reduces the operative time, and prevents irritation related to nonabsorbable sutures.

[Orbital Erdheim-Chester disease]. / Maladie d'Erdheim-Chester orbitaire.

Erdheim-Chester disease is related to a tissue infiltration of foamy histiocytes. Results of immunoperoxydase stains for S-100 and T6 protein, the Langerhans cells antigen, is negative. It is a multisystemic disease, and it particularly involves bones and orbit. The visual prognosis is threatened, and the disease may lead to a fatal issue. Treatments have poor effects on the disease. Patients sometimes have good symptomatic response to corticotherapy. This case was revealed by headaches and diabetes insipidus. The orbital infiltration was asymptomatic.

[Uveitis with hypopyon in patients with acquired immunodeficiency syndrome, treated with Rifabutin]. / Uvéite à hypopion chez des patients présentant un syndrome d'immunodéficience acquise et traités par Rifabutine.

BACKGROUND: Iridocyclitis has been identified as a dosage-dependent side effect in patients with the acquired immunodeficiency syndrome who are treated for Mycobacterium avium complex infections with systemic Rifabutin. We reviewed cases of acute hypopyon uveitis occurring in patients with AIDS to establish whether there was an association or not. METHODS: All patients were referred by an infection disease specialty service for complete ophthamological evaluation and ancillary laboratory. Six patients with AIDS, aged from 29 to 65 years, presented with acute unilateral hypopion. RESULTS: At the time of presentation, all six patients were receiving treatment for MAC infection with Rifabutin (dosage range, 300-600 mg/d) and four received Fluconazol. Results of microbiological investigations were negative. Hypopyon developed in the second eye of two patients. Hypopion resolved rapidly with intensive antibiotherapy without corticosteroids. CONCLUSION: Concomitant use of Rifabutin and Fluconazol may precipitate hypopyon uveitis. The cause of the uveitis is less certain, but the possible role of a microbiological agent cannot be ruled out.

[Surgical treatment of retrofoveal choroid neovascularization in multifocal choroiditis]. / Traitement chirurgical des néovaisseaux choroïdiens rétrofovéolaires au cours de la choroïdite multifocale.

BACKGROUND: Surgical removal of subfoveal choroidal neovascularization allows visual improvement, especially in young patients. METHODS: Three eyes of 3 patients were prospectively studied. Subfoveal choroidal neovascularization was related to presumed ocular histoplasmosis syndrome. The surgical procedure included vitrectomy, surgical excision of the neovascular membrane, and air tamponnade. RESULTS: Follow-up was 6, 12 and 20 months. Vision improved in 2 eyes. In one case, recurrent extrafoveal neovascularization was treated with laser photocoagulation. DISCUSSION: Surgery seems to be an alternative to photocoagulation in subfoveal choroidal neovascularization in presumed ocular histoplasmosis.