Participation in athletic activities may be associated with later development of hip and knee osteoarthritis.

Participation in physical activity and recreational sports is critical for maintaining overall health; athletic activities and reduction in the incidence of several "lifestyle" diseases seem to have a dose-dependent relationship. Also, quality of life is enhanced in people who are active and regularly participate in sports. However, sports-related joint loading and strenuous occupational loading have been shown to increase the risk of osteoarthritis (OA), which seems to have a multifactorial etiology. This article reviews the literature on known connections between participation in sports and athletic activities and development of secondary OA in the joints of the major upper and lower limbs (ie, knee, hip, elbow, and shoulder) in athletes without injury. Most studies examining the connection between participation in sports and later development of OA usually provide low-level evidence and have many methodological weaknesses. Based on the literature reviewed in this article, it may be concluded that the connection between participation in athletic activities and development of OA has not been proven; however, the condition is highly likely to occur in the hip and knee joints. Definite conclusions regarding the connection between development of glenohumeral and/or elbow OA and participation in athletic activities cannot be drawn.

Aortic Endovascular Stent IIIb Endoleak Combined With Sealed Aneurysm Rupture Mimicking a Paravertebral Retroperitoneal Tumor.

The aim of this paper is to present the unique case of a sealed ruptured abdominal aortic aneurysm (AAA) with simultaneous type IIIb endoleak of an endovascular stent, mimicking a paravertebral retroperitoneal tumor. A 75-year-old male was referred to the tumor service of our tertiary orthopaedic department suffering from intractable low back pain with an onset of six months. He had undergone repair of an infrarenal AAA with an endovascular stent 5 years ago. Imaging studies depicted a large retroperitoneal mass adjacent to L2 and L3 vertebrae. The stent's metal cage had no signs of wear or migration. The pathology report of a CT-guided core-needle biopsy he had undergone before his referral raised suspicion about possible AAA rupture. CT-angiography confirmed the existence of a ruptured AAA, accompanied by retroperitoneal blood loss and a (possibly) failed stent. The IIIb eroded stent was openly removed and a Y-type allograft was used to repair the defect. The patient reported immediate relief and was uneventfully discharged. He demised 4 years later due to reasons unrelated to the hereby reported condition. Increased awareness is warranted when dealing with anterior lumbar spine or retroperitoneal lesions. A close cooperation between a vascular and an orthopaedic/spine surgeon must always be sought.

A Rare Case of Traumatic Bilateral Elbow Dislocation Without a Fracture in a Seven-Year-Old Female Child.

Pediatric bilateral elbow dislocation is an infrequent injury. This is a report of a seven-year-old girl, the youngest patient ever reported, with simultaneous isolated bilateral traumatic elbow dislocation without fracture, treated with closed reduction under sedation.

Organizing an Orthopaedic Department During COVID-19 Pandemic to Mitigate In-Hospital Transmission: Experience From Greece.

The new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerging in Wuhan city of China, was the cause of a rare type of pneumonia evolving rapidly in pandemic early at the beginning of 2020. The rapid human-to-human transmission of SARS-CoV-2 increases the risk of in-hospital transmission, requiring re-definement of musculoskeletal trauma management and postoperative care. Following the review of the existing literature on COVID-19 and similar infectious diseases, National and Hospital Board instructions for Infectious Diseases, as well as the consensus for surgical care by the consortium of the Orthopaedic Department Directors, we present the outline of the implemented principles in the orthopaedic departments of a tertiary academic hospital in Greece to operate during COVID-19 pandemic. Our overall objectives were to decrease the admission load and mitigate the risk of in-hospital transmission of SARS-CoV-2. The principles involve the management of the Orthopaedic medical and nursing personnel, alterations of the workflow in the wards, operating rooms and outpatient clinics from the admission to the discharge of an orthopaedic patient. In addition, we present the recommended principles of management of traumatic orthopaedic injuries highlighting those deserving admission and in-hospital care and those that can be treated in the outpatient setting or day surgery clinics.

The effect of a new oral anticoagulant (Rivaroxaban) on implants pull-out strength. An experimental study in rats.

OBJECTIVES: Thromboprophylaxis reduces the risk of surgery related deep venous thrombosis and pulmonary embolism. The classical anticoagulants (heparin and LWMH) were associated with systemic osteoporosis, poor bone healing and materials' osseointegration. There is a lack of data concerning the effect of the new orally administered anticoagulants on osseointegration. The aim of this study is to investigate the possible effect of rivaroxaban, a direct anti-Xa factor, on osseointegration. METHODS: Twenty eight white, male, Wistar rats were divided into two groups: Group A, study group (n=14) and group B, control group (n=14). In all animals under general anesthesia one screw was inserted on the right tibia. For twenty eight days the animals of group A received intraperitoneal rivaroxaban injections 5mgr/kgr every day. The animals of group B received intraperitoneal equal amount of normal saline injections. At the end of the four weeks all animals were sacrificed and their right tibias were excised and underwent the pull-out test. RESULTS: The mean values of pull-out test were 92,10±19,12N for the control group and 95,46±21,02N for the study group. The statistical analysis using t-test showed no significant difference (p=0,665) for the pull-out test. CONCLUSIONS: These results indicate that Rivaroxaban hasn't got any deleterious effect on the osseointegration of implants on rats.

Promoting Undergraduate Surgical Education: Current Evidence and Students' Views on ESMSC International Wet Lab Course.

BACKGROUND: Undergraduate Surgical Education is becoming an essential element in the training of the future generation of safe and efficient surgeons. Essential Skills in the Management of Surgical Cases (ESMSC), is an international, joint applied surgical science and simulation-based learning wet lab course. METHODS: We performed a review of the existing literature on the topic of undergraduate surgical education. Following that, we analyzed the feedback questionnaire received 480 from 2 recent series of ESMSC courses (May 2015, n = 49 and November 2015, n = 40), in order to evaluate European Union students' (UK, Germany, Greece) views on the ESMSC course, as well as on the undergraduate surgical education. Results Using a 10 point graded scale, the overall ESMSC concept was positively evaluated, with a mean score of 9.41 ± 0.72 (range: 8-10) and 8.94 ± 1.1 (range: 7-10). The majority of delegates from both series [9.86 ± 0.43 (range: 8-10) and 9.58 ± 0.91 (range: 6-10), respectively] believed that ESMSC should be incorporated in the undergraduate surgical curriculum. Comparison of responses from the UK to the Greek Medical Student, as well as the findings from the third and fourth year versus the fifth and sixth year Medical Students, revealed no statistically significant differences pertaining to any of the questions (p > 0.05). CONCLUSIONS: Current evidence in the literature supports the enhancement of surgical education through the systematic use of various modalities that provide Simulation-Based Training (SBT) hands-on experience, starting from the early undergraduate level. The findings of the present study are in agreement with these previous reports.

Investigational drugs for fracture healing: preclinical & clinical data.

INTRODUCTION: The need for fracture healing enhancement for the management of fracture complications such as non-union and for the achievement of early function in fracture patients is constantly increasing. Therefore, the development and evaluation of novel pharmaceutical agents is mandatory in order to accelerate the process and increase bone union rates. AREAS COVERED: This review summarizes the most recent knowledge on the pharmacological enhancement of fracture repair. It provides a synopsis of the most important preclinical and clinical studies published over the past five years on long bone fracture healing. EXPERT OPINION: To date, limited drugs seem to have the potential for clinical use in fracture healing enhancement and the field is progressing very slowly. Among anti-osteoporotic drugs, only PTH and anti-sclerostin antibodies have such a potential but further research is needed before clinical use. The same applies also to BMPs, the use of which still carries major drawbacks that should be overcome before their widespread clinical utilization. Other drugs and growth factors, such as statins, VEGF, FGF, EPO, could be future key players in fracture healing but evidence is still lacking. Further in depth understanding of the healing process is essential in order to identify novel effective pharmacological agents.

Management of glucocorticoid-induced osteoporosis: clinical data in relation to disease demographics, bone mineral density and fracture risk.

INTRODUCTION: Glucocorticoid-induced osteoporosis (GIOP) is the most common type of secondary osteoporosis. Patient selection and the treatment choice remain to be controversial. None of the proposed management guidelines are widely accepted. We evaluate the available clinical data, the efficacy of current medication and we propose an overall algorithm for managing GIOP. AREAS COVERED: This article provides a critical review of in vivo and clinical evidence regarding GIOP and developing evidence-based algorithm of treatment. Data base used includes MEDLINE® (1950 to May 2014). EXPERT OPINION: Patient-specific treatment is the gold standard of care. Glucocorticoid (GC)-treated patients must comply with a healthy lifestyle and receive 1000 mg of calcium and at least 800 mg of Vitamin D daily. Bisphosphonate (BP) therapy is the current standard of care for prevention and treatment of GIOP. Most of bisphosphonates demonstrated benefit in lumbar bone mineral density (BMD) and some in hip BMD. Alendronate, risedronate and zoledronate showed vertebral anti-fracture efficacy in postmenopausal women and men. Scarce data however when compared head to head with BP efficacy. In post-menopausal women, early antiresorptive BP treatment appears to be efficient and safe. In premenopausal women and patients at high risk of fracture receiving long-term GC therapy however, teriparitide may be advised alternatively.

Reduction of Acute Anterior Dislocation with the FARES Method.

INTRODUCTION: The FARES (Fast, Reliable, and Safe) method is a new way to reduce acute anterior glenohumeral dislocations that combines the application of gentle longitudinal traction, vertical oscillation movements, and abduction and external rotation of the arm. STEP 1 POSITION THE PATIENT: Place the patient supine on a stretcher, with his/her elbow extended, and advise him/her to hold the stretcher with the opposite hand. STEP 2 BRIEF THE PATIENT: Convince the patient that his/her cooperation is necessary for a better outcome. STEP 3 HOLD THE ARM: Holding the patient's hand with both of your hands, with his/her elbow extended and forearm in neutral rotation, start the procedure at 30° of shoulder abduction. STEP 4 APPLY TRACTION AND ADD OSCILLATIONS: Applying gentle longitudinal traction to keep the arm extended, add gentle vertical oscillating movements. STEP 5 ABDUCT AND EXTERNALLY ROTATE THE ARM: Gradually abduct the arm to 90° and then gradually externally rotate the arm to achieve full external rotation. STEP 6 ACHIEVE REDUCTION: The dislocation is usually reduced once 120° to 150° of shoulder abduction has been achieved. RESULTS: In our previously published prospective randomized study, the FARES method was compared with the Hippocratic and the Kocher methods12. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Serum intact-parathyroid hormone level following total knee arthroplasty.

PURPOSE: To evaluate short-term parathyroid hormone (PTH) secretion following total knee arthroplasty (TKA). METHODS: 119 Caucasian postmenopausal women aged 49 to 81 (mean, 69.8) years who underwent TKA for end-stage knee osteoarthritis were included. Serum levels of intact-PTH, calcium, phosphorus, and creatinine were evaluated pre- and post-operatively (on days -1 and 7). Creatinine clearance was also calculated. RESULTS: In 67 of the patients, serum intact-PTH levels decreased after TKA; this sample proportion was not significant (p=0.82). In 16 of the patients, such levels elevated abnormally (above normal range). In the remaining 36 patients, such levels elevated within the normal range. Therefore, the mean serum intact- PTH level of all patients increased slightly after TKA (45.4 vs. 45.3, p=0.162). The serum intact-PTH level did not correlate to body weight (r=-0.045, p=0.624), patient age (r=-0.061, p=0.508), serum creatinine level (r=0.084, p=0.366), and clearance of creatinine (r=-0.037, p=0.692). CONCLUSION: In most postmenopausal women, the serum intact-PTH level decreased moderately following TKA, but in some, the level was abnormally elevated. This may interfere the prosthesis incorporation process.

The serum levels of Receptor Activator of Nuclear Factor-κB Ligand, bone-specific alkaline phosphatase, osteocalcin and osteoprotegerin do not correlate with the radiographically assessed severity of idiopathic hip and knee osteoarthritis.

OBJECTIVES: Determination of the serum levels of Receptor Activator of Nuclear Factor-Κb Ligand, bone-specific alkaline phosphatase, osteocalcin and osteoprotegerin in patients suffering from osteoarthritis of varying severity and healthy controls and correlation of these results with the patients' age and the radiographically assessed severity of the disease. DESIGN AND METHODS: Patients suffering from hip (n=58) or knee (n=117) osteoarthritis and matched controls (n=19) were enrolled in this study. Patients underwent physical examination and standard radiographic evaluation before blood sampling. RESULTS: The serum levels of osteoprotegerin were positively correlated with age in all groups, whereas those of osteocalcin in the 'knee' group only. Osteoarthritis' severity and location did not have a statistically significant impact on the mean serum level of any marker in both groups. CONCLUSIONS: Based on our results, none of the studied markers can serve as a surrogate for radiographic imaging in patients suffering from hip and knee osteoarthritis.

Serum levels of bone turnover markers following total joint arthroplasty.

PURPOSE: To evaluate changes in serum levels of bone turnover markers during the first year following a total hip or knee arthroplasty (THA or TKA, respectively). METHODS: 34 women and 13 men (mean age, 68 years) with idiopathic hip or knee osteoarthritis underwent elective THA or TKA. The serum levels of (1) osteoprotegerin, (2) nuclear factor-kappa B ligand (RANKL), (3) osteocalcin, and (4) bone-specific alkaline phosphatase (b-ALP) were determined in each patient on preoperative day 1 and postoperative day 3 and 7, and month 2, 4, 6, 8, 10, and 12. RESULTS: All 4 markers changed significantly over the 12-month period. At month 12, values of all markers did not return to their preoperative levels uniformly. At month 8, the serum levels of osteoprotegerin, osteocalcin, and b-ALP remained higher than their respective preoperative values. The serum levels of RANKL gradually decreased after month 2, rendering this marker a potential index for fixation. CONCLUSIONS: Bone turnover markers change following arthroplasties. Postoperative month 8 seems to be a milestone in the normal course of these markers.

Adolescent idiopathic scoliosis in athletes: is there a connection?

The potential relationship between adolescent idiopathic scoliosis (AIS) and sports is rather vague. Sports have often been considered to be a causative factor of, or a treatment option for the former, particularly among adolescent athletes who are engaged in certain athletic activities. The highly repetitive nature of sports, amenorrhea, exercise-related exerted stress on the immature spine of professional adolescent athletes, and the joint laxity that may coexist during adolescence, have also been associated with an increased incidence of AIS. The purpose of this article is to discuss the potential connection between sports and AIS by reviewing the existing literature.

Severe axial vertebral rotation treated with a modified Boston brace: a case report.

We report the case of a 13-year-old Caucasian girl suffering from severe axial rotation of the T5 to L4 vertebrae. The patient (initially examined during a school screening study) was at first considered to be suspicious of suffering from scoliosis due to a highly positive Adam's forward bending test. However, her radiographic evaluation revealed the existence of axial rotation in 12 of her vertebrae, without inclination in the sagittal and coronal planes. After an observation period of 12 months and due to the fact that both her physical appearance and the measured vertebral rotation deteriorated, the patient was given a modified thoracolumbar Boston brace that had an immediate positive derotational effect on all but two vertebrae. Twenty four months later, the progress of the vertebral rotation(s) seems to have been halted and most affected vertebrae appear to be stabilized in their new, 'post-brace', reduced position, with better results shown when the Boston brace is worn. The patient remains under constant medical observation. The application of a modified Boston brace seems to have served well (so far) a useful purpose for reducing and stabilizing this case of severe axial vertebral rotation, providing less deformity and (possibly) offering a better final cosmetic result.

Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods.

BACKGROUND: There are several methods to reduce anterior shoulder dislocations, but few studies have compared the efficacy, safety, and reliability of the different techniques. As a result, deciding which technique to use is seldom based on objective criteria. The aim of the present study was to introduce a new method to reduce an anterior shoulder dislocation, which we have termed "FARES" (Fast, Reliable, and Safe), and to compare it with the Hippocratic and Kocher methods in terms of efficacy, safety, and the intensity of pain felt by the patient during reduction. METHODS: Between September 2006 and June 2008, a total of 173 patients with an acute anterior shoulder dislocation (with or without a fracture of the greater tuberosity) were enrolled in the study. One hundred and fifty-four patients, who met all inclusion criteria, were randomly assigned to one of the three study groups (FARES, Hippocratic, and Kocher) and underwent reduction of the dislocation by first or second-year orthopaedic surgery residents. A visual analog scale was used to determine the intensity of the pain felt by the patient during reduction. RESULTS: Demographically, the groups were comparable in terms of age, male:female ratio, the mechanism of dislocation, and the mean time between the injury and the first attempt at reduction. Reduction was achieved with the FARES method in 88.7% of the patients, with the Hippocratic method in 72.5%, and with the Kocher method in 68%. This difference was significant, in favor of the FARES method (p = 0.033). The mean duration of the reduction maneuver was significantly shorter for the FARES method (2.36 +/- 1.24 minutes for the FARES method, 5.55 +/- 1.58 minutes for the Hippocratic method, and 4.32 +/- 2.12 minutes for the Kocher method; p < 0.001), and the mean visual analog pain score was significantly lower for the FARES method (1.57 +/- 1.43 for the FARES method, 4.88 +/- 2.17 for the Hippocratic method, and 5.44 +/- 1.92 for the Kocher method; p < 0.001). No complications were noted in any group. CONCLUSIONS: The FARES method is a significantly more effective, faster, and less painful method of reduction of an anterior shoulder dislocation in comparison with the Hippocratic and Kocher methods. It is easily performed by only one physician, it is applicable to anterior shoulder dislocations as well as simple fracture-dislocations, and its use is associated with no more morbidity than that associated with the other two methods.

Efficacy of steroid and nonsteroid caudal epidural injections for low back pain and sciatica: a prospective, randomized, double-blind clinical trial.

STUDY DESIGN: Prospective, double-blind, randomized, case-control study. OBJECTIVE: To evaluate the efficacy of caudal epidural injections (CEI) containing steroid versus nonsteroid preparations when treating patients suffering from low back pain (LBP) and sciatica. SUMMARY OF BACKGROUND DATA: Literature seems to be deprived of well-designed randomized, controlled studies that evaluate the effectiveness of CEI in the treatment of chronic LBP; hence the value of CEI remains still the subject of controversy. METHODS: Patients suffering from severe chronic LBP and sciatica were randomly allocated into 2 groups. Steroid-group's patients (n = 93) underwent CEI containing 12 mL of xylocaine 2% and 1 mL of betamethasone dipropionate and betamethasone phosphate (2 + 5) mg/dL. Water for Injection (WFI)-group's patients (n = 90) underwent CEI containing 12 mL of xylocaine 2% and 8 mL of WFI. Both groups were statistically comparable as far as their demographic data and the cause and duration of symptoms were concerned. Patients answered the Oswestry Disability Index questionnaire and underwent physical examination, before and at 1 week, 1 month, 6 months, and 1 year following the CEI. RESULTS: Symptoms improved in 132 patients (72.1%) following CEI. The mean Oswestry Disability Index questionnaire score of steroid-group's patients was statistically significant lower than that of the WFI-group at all postinjection re-evaluations. Patients receiving steroid CEI experienced faster relief during the first postinjection week. The Straight Leg Rising test improved in both groups following CEI; this improvement was faster among steroid-group's patients. Fifty-one patients (27.8%), noticed no improvement 1 week post-CEI and underwent a second CEI (with the same preparation) 7 to 14 days later. Nineteen of them reported improvement; 32 (steroid-group:13, WFI-group:19) did not respond well and underwent operative decompression (n = 15) or spinal fusion (n = 17). CONCLUSION: CEI containing local anesthetic and steroids or WFI seems to be effective when treating patients with LBP and sciatica. CEI containing steroid preparations demonstrated better and faster efficacy.

Incidence of secondary hyperparathyroidism among postmenopausal women with end-stage knee osteoarthritis.

PURPOSE: To evaluate the incidence of secondary hyperparathyroidism (SH) among postmenopausal women with end-stage knee osteoarthritis scheduled for total knee replacement (TKR). METHODS: 283 Caucasian postmenopausal women aged 49 to 81 (mean, 70) years with end-stage idiopathic knee osteoarthritis were scheduled to undergo primary TKR. They had been menopausal for 7 to 31 (mean, 19) years. Their preoperative serum levels of intact parathyroid hormone (I-PTH), calcium, phosphorus, creatinine, and the clearance of creatinine were evaluated. RESULTS: 100 patients had abnormally elevated serum I-PTH. The overall incidence of SH was 35%. Serum levels of calcium and phosphorus were elevated in 33 and 12 patients, respectively. The serum level of I-PTH correlated positively with patient age (r=0.158, p=0.008) and serum creatinine level (r=0.138, p=0.021) and negatively with clearance of creatinine (r= -0.169, p=0.004). CONCLUSION: SH is common among elderly postmenopausal women and may affect bone healing and implant fixation. Preoperative screening/evaluation of the serum PTH level in postmenopausal women scheduled for TKR is recommended.

The role of exercising in a pair of female monozygotic (high-class athletes) twins discordant for adolescent idiopathic scoliosis.

STUDY DESIGN: The report of 2 cases and review of the literature. OBJECTIVE: To report the cases of a pair of female monozygotic (high-class athletes) twins discordant for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: The relation between scoliosis and exercising is rather unclear. The latter has often been considered both as a therapeutic means and a causative factor of the former. The existence of genetic predisposition in the development of adolescent idiopathic scoliosis is commonly accepted. According to the best of our knowledge, this is the first report of a pair of female monozygotic (high-class athletes) twins, discordant for adolescent idiopathic scoliosis. METHODS.: A pair of 13.5-year-old female monozygotic twins, high-class level athletes of synchronized swimming, was clinically examined during a school screening program. Both girls were observed in the standing erect position for asymmetries of the lateral contours of the trunk, shoulders, and scapulas and their limb's length was measured. The "forward bending test" was performed to determine the existence of rib hump asymmetry. RESULTS: One of the sisters was considered to be suspicious of suffering from scoliosis. The radiologic evaluation that followed confirmed the existence of adolescent idiopathic scoliosis (left thoracolumbar curve of 32 degrees as measured by the Cobb angle). The clinical and radiologic evaluation of her sibling failed to reveal the existence of any spinal deformity. CONCLUSION: Adolescent idiopathic scoliosis seems to be a multifactorial skeletal disorder. The role of exercising and heredity in its development remain controversial.

Adolescent idiopathic scoliosis and exercising: is there truly a liaison?

STUDY DESIGN: Cross-sectional observational study. OBJECTIVE: Evaluation and comparison of the prevalence of adolescent idiopathic scoliosis (AIS) among 2 groups of patients (athletes and nonathletes) to determine whether athletic activities are related to the development of AIS. SUMMARY OF BACKGROUND DATA: The potential association between AIS and exercising remains uncertain. The latter has often been considered as a therapeutic means and a causative factor of the former. METHODS: A group of 2387 adolescents (boys: 1177, girls: 1210, mean age: 13.4 years) was evaluated. All completed a questionnaire concerning personal, somatometric, and secondary sex characteristics, type, duration and character of daily-performed physical activities, and existing cases of AIS among relatives. Patients were classified into 2 groups according to their answers; "athletes" and "nonathletes." The groups were comparable as far as age, height, weight, onset of menstruation, family history of scoliosis, and side of handedness were concerned. Children underwent physical examination by 3 orthopedic surgeons who were unaware of their level of athletic activities. Children considered, by all, to be suspicious of suffering from scoliosis, underwent further radiographic evaluation. RESULTS: In 99 cases (athletes: 48, nonathletes: 51), AIS was radiographically confirmed (Cobb angle >10 degrees). No statistically significant difference was found between athlete and nonathlete adolescents (P = 0.842), athlete and nonathlete boys (P = 0.757), and athlete and nonathlete girls (P = 0.705), as far as the prevalence of AIS was concerned. The mean value of the Cobb angle of the main scoliotic curve was not statistically different between male athletes and nonathletes (P = 0.45) and female athletes and nonathletes (P = 0.707). With the Cobb threshold reset at 20 degrees, no statistically significant differences were detected either. CONCLUSION: Our results demonstrate that systematic exercising is probably not associated with the development of AIS. Actively participating in sports activities doesn't seem to affect the degree of the main scoliotic curve either.