Inflammatory bowel disease related osteonecrosis: report of a large series with a review of the literature.

BACKGROUND: Osteonecrosis is a major complication of inflammatory bowel disease usually associated with steroid use. There are few large series available detailing the specifics of affected patients. AIM: To identify any specific characteristics of osteonecrosis in this cohort. A major focus was placed on steroid dose, the average time between diagnosis of IBD and appearance of osteonecrosis and the frequency of multiple joint involvement. METHODS: Our study identified 23 patients in the practices of five gastroenterologists at the Mount Sinai Medical Center. We retrospectively reviewed their clinical history, as well as imaging studies. We classified osteonecrosis according to the Association Research Circulation Osseous (ARCO) staging system. RESULTS: Although our prednisone dosing data could not be used as an accurate predictor of onset or joint distribution, there was a tendency for correlation between the average daily dosing and the ARCO score. The ARCO scoring system was consistent for patients with bilateral hip involvement. The distribution of affected joints in IBD is similar to other conditions associated with osteonecrosis, with hips being the most frequently involved joints. Data showed bilateral involvement in most hips, but usually unilateral disease in the shoulders and knees. Treatment options include core decompression for early stages, whereas joint replacement surgery is required for stages 3 and 4. CONCLUSION: IBD predisposes patients to corticosteroid induced osteonecrosis. An exact threshold dose has not been determined. The data suggests that either long term therapy or short term high dose treatment increases the risk of osteonecrosis. Even if symptoms are limited to one joint, multiple joints are often involved and comprehensive testing with MRI is indicated in all cases.

Plant disease resistance: commonality and novelty in multicellular innate immunity.

Pathogen avirulence genes encode for effector molecules that play a crucial role in the process of pathogen colonization of plant tissue. Successful host defense requires rapid and efficient detection of the pathogen avirulence factors. In the last few years, much progress has been made in delineating the plant molecular sentinels that participate in pathogen identification. Because this ability is genetic information that is 'hard-wired' into the genome, it is called 'innate immunity' and it draws its origins from a phylogenetically ancient form of immunity common to plants and animals. Conservation is shown in many of the functional molecular motifs of innate genes such as the Toll/interleukin 1 receptor domains, nucleotide binding domains and structures that contain leucine rich repeats. Novel plant molecular surveillance domains also include pathogen pattern recognition by coiled-coil domains and specialized kinases. The rapid evolution of plant innate immunity genes is readily detected in their sequence polymorphism, by their massive amplification and appearance in the genome in a clustered organization. By comparative biology of highly diverged innate immunity systems we can enhance our appreciation of the truly basic forces that have shaped its evolution in mutlicellular organisms.

Does cost containment create conflict in the care of the elderly patient?

Ethical aspects of care of geriatric patients with orthopaedic disorders include patient autonomy, beneficence, and nonmaleficence. Advance directives and surrogate decision-makers are required if the patient has lost decisional capacity. Investor-owned health plans have captured the major share of the United States medical market, but have been shown to deliver lower quality of care than competing methods. A deeply imbedded fear of a government-run health plan with good intentions expressed as bad policy exists. Ageism is one example of how ethical principles may be trampled. The orthopaedic surgeon has a responsibility to maintain and fight for these ethical standards.

Outcome and long-term results following total hip replacement in elderly patients.

The authors reviewed the preoperative and postoperative charts and radiographs of 100 patients who were at least 80 years old when they underwent total hip arthroplasty. Seventy-six of these patients were available for further reexamination and evaluation. The average patient age was 85.2 years old (range, 80-97 years). The average followup period was 59.4 months (range, 26-146 months). The female to male ratio was 4 to 1. Osteoarthritis was the most common diagnosis. Hospital stay ranged from 12 to 39 days. Preoperative Charnley pain and walking scores averaged 5.1 points of a possible 12 points, and postoperative scores averaged 10.6 points. Eighty-eight percent of patients remained community walkers, and 60% used a cane. Four percent of the patients had 1 dislocation. There were no instances of mechanical loosening and no deaths. Subjective satisfaction was high. The level of independent living was maintained in 96% of patients at long-term followup. A satisfactory and cost-effective health outcome can be anticipated after total hip arthroplasty in octogenarian and nonagenarian patients.

Ethical aspects of care of the geriatric orthopaedic patient.

Ethical aspects of care of the geriatric orthopaedic patient include respecting patient self-determination as the primary standard of decision making; using advance directives or appropriate surrogate decision makers when patient decisional capacity is lost; and balancing the benefits and burdens of any intervention and its alternatives in arriving at a treatment decision. With an increase in managed care plans, questions of justice in care of the elderly will be raised. Physicians face fiscal incentives that encourage fewer surgical procedures and lower levels of health care particularly in the elderly, a group that notably has benefited from the functional enhancement permitted by modern orthopaedic techniques. Professional vigilance is required of physicians to ensure that appropriate health care services continue to be available to patients.

Comparison of three remission induction regimens and two postinduction strategies for the treatment of acute nonlymphocytic leukemia: a cancer and leukemia group B study.

Patients with acute nonlymphocytic leukemia were randomized to receive remission induction therapy consisting of seven days of cytosine arabinoside and three days of daunorubicin ("7 + 3") or to receive the same regimen intensified by either the addition of 6-thioguanine or by extension of the administration of cytosine arabinoside to ten days. Additionally, all patients were randomized to receive or not to receive cotrimoxazole antibacterial prophylaxis during the remission induction phase. Neither an increase in intensity of chemotherapy nor the antibacterial prophylaxis increased the remission rate above the 53% for patients treated with the standard "7 + 3" regimen. The second part of this study addressed the issue of the utility of long-term maintenance chemotherapy. To this end, patients were randomized to discontinue all treatment after 8 months of maintenance chemotherapy or to continue maintenance therapy for a total of 3 years. Although there was a transient increase in the relapse rate for patients who discontinued therapy, the proportion of long-term remitters was identical in the two patient groups. Additionally, there is a suggestion of a survival advantage for patients randomized to discontinue all therapy at 8 months.

Giant cell reaction of small bones.

A radiographically nonspecific lytic lesion in the middle phalanx of the index finger with microscopic evidence of a benign fibrous stroma with giant cells and osteoid was investigated in an 18-year-old man. Giant cell reaction is a rare, benign lesion of the small bones of the hands and feet. Trauma as the cause of a giant cell lesion poses an interesting question.

Gaucher's disease type 1: assessment of bone involvement by CT and scintigraphy.

The effectiveness of CT and technetium-99m sulfur colloid (99mTc SC) bone-marrow scans in determining the extent and severity of skeletal involvement in 23 patients with type 1 Gaucher's disease was compared with the effectiveness of conventional radiographic techniques and technetium-99m methylene diphosphonate (99mTc MDP) bone scintigrams. Density measurements obtained by CT proved sensitive in differentiating normal marrow (-50 to -120 H). Scintigrams with the sulfur colloid nuclide demonstrated three distinct patterns of uptake: peripheral expansion of normal marrow (profile B), greater marrow expansion with patchy areas lacking uptake (profile C), and greater loss of uptake with retention of the nuclide in other reticuloendothelial organs and circulation (profile D). CT scans provided greater sensitivity in resolving the extent of marrow involvement in affected areas, while the 99mTc SC scintigrams were more effective in overall assessment of the severity of bone-marrow involvement. Both conventional radiographic techniques and 99mTc MDP bone scans were useful primarily as screening procedures or for evaluating specific involved areas. 99mTc MDP scans were useful in evaluating regional defects (i.e., ischemic necrosis) in certain cases, but no consistent patterns were observed. CT and 99mTc SC scans are useful for determining the extent and severity of Gaucher's disease involvement of bone marrow.

Multiple myeloma in three siblings.

All three siblings of a family developed multiple myeloma. Two siblings had a history of monoclonal gammopathy; in one of these two siblings and in the third sibling, the disease progressed rapidly. A review of the literature shows that of 38 previously reported pairs of siblings with plasma cell disorders, eight families had a third affected sibling and four another affected relative. This clinical clustering suggests that some cases of multiple myeloma may have a hereditary basis and that other family members may be at risk for developing the disease.

Variations in treatment of postmenopausal osteoporosis.

The purpose of this study was to determine trends and differences between various medical specialties with regard to the treatment of postmenopausal osteoporosis. The method used was a cross-sectional survey, and the authors' sample was composed of 116 physicians. There was an overall lack of consensus on choice of treatment for postmenopausal osteoporosis. Treatment varies with the individual physician without any strict adherence to a formal therapeutic protocol. Calcium was the treatment modality most widely used by all the specialties. Gynecologists and endocrinologists show the greatest usage of estrogens, while orthopedic surgeons show the least. Fluoride was used significantly less than calcium, vitamin D, estrogen, diet, and exercise by all the specialties surveyed. One in three postmenopausal women in the United States has osteoporosis, and one in five will sustain a hip or vertebral fracture. Twelve to twenty percent of elderly patients die within six months of sustaining a hip fracture. There is an obvious need for carefully constructed clinical programs evaluating multiple agents and diagnostic techniques.

Efficacy of daunorubicin in the therapy of adult acute lymphocytic leukemia: a prospective randomized trial by cancer and leukemia group B.

The efficacy of the addition of intensive therapy with daunorubicin (45 mg/m2 IV on days 1, 2, 3) to an otherwise identical induction program consisting of vincristine, prednisone, and L-asparaginase was assessed in 177 previously untreated adults (greater than or equal to 20 years of age) with acute lymphocytic leukemia (ALL). In the prospectively randomized phase of the investigation, 46 patients received daunorubicin in induction, whereas 53 did not. The two groups were otherwise comparable for pretreatment variables. A complete response was observed in 38/46 patients (83%) treated with daunorubicin, compared to 25/53 (47%) induced with vincristine, prednisone, and L-asparaginase alone (P = .003). The high response rate attributable to the use of the anthracycline was confirmed by the nonrandomized treatment of 78 subsequent patients, in whom a complete response rate of 76% was attained. A common program for central nervous system therapy and for maintenance therapy was employed in 103 patients achieving complete response. Maintenance consisted of cycles of 6-mercaptopurine (6-MP) and methotrexate with periodic reinforcement with vincristine and prednisone. Maintenance therapy proved to be minimally toxic. The average duration of complete response was 15 months and was not affected by the induction program employed. Approximately 25% of responders are projected to remain in continuing complete response for 36 months. The failure of the daunorubicin-containing programs to produce a higher percentage of long-term survivors, despite the higher complete response rates achieved, was thought to be due to the use of a maintenance program that was weak in intensity and dependent on reinforcement with vincristine and prednisone. These data clearly establish the increased effectiveness of vincristine, prednisone, L-asparaginase, and daunorubicin, as compared to this combination without daunorubicin, in the induction of complete response in adults with ALL. The results support the concept of an intensive, rather than a conservative, chemotherapeutic approach as the most appropriate strategy for the treatment of adult ALL.

Complications of Ender-pin fixation in basicervical, intertrochanteric, and subtrochanteric fractures of the hip.

Two hundred patients with a basicervical, intertrochanteric, or subtrochanteric fracture were treated by Ender-pin fixation during a three-year period. Their median age was 73.5 years and there was a 10 per cent mortality rate. Early partial weight-bearing with some external support was allowed for most patients. Minimum shortening and one non-union occurred. However, there was a substantial incidence of complications. The fixation failed in all basicervical fractures. Distal pin migration of more than two centimeters occurred in 50 per cent of the unstable intertrochanteric fractures. Seventy-six per cent of the forty-two patients who were personally examined at follow-up had pain in the knee and 36 per cent had external malrotation. The incidence of pin migration increased in the more unstable fractures.

The location of the level of femoral neck transection for prosthetic hip arthroplasty.

The proper level of transection of the femoral neck for hip arthroplasty can be ascertained by using the proximal tip of the intact greater trochanter as a reference point. A transverse line projected medially from this point will cross the true level of the center of rotation of the femoral head for that hip. Placement of a trial prosthesis in accordance with this level will locate the point at which the femoral neck should be cut. By placing the femoral component so that its center of rotation is bisected by the same line, the level of the calcar flange can be marked on the neck of the femur. This is the level at which the femoral neck should be cut.

Surgical management of metastatic disease of bone at the hip.

Concordant advances in cancer chemotherapy, radiotherapy, and surgical technique have been of apparent benefit to many cancer patients suffering from skeletal involvement at the hip. Consideration of the effects of underlying disease and prior treatment must be evaluated prior to developing a surgical plan. Acetabular involvement can be treated by either conventional or augmented total hip arthroplasty using protrusio rings and acetabular meshes, depending upon minor or major degrees of tumor destruction. Girdlestone resection arthroplasty for massive degrees of acetabular involvement yields only modest results. Femoral neck fractures can be treated by endoprosthetic replacement. However, the association of acetabular disease should be considered, and if present, total hip arthroplasty should be performed. Intertrochanteric fractures can be stabilized with the use of a stout tubeplate nail device plus cement. Subtrochanteric fractures can be stabilized with a Zickel nail device plus cement. The goals of treatment are to relieve pain and restore function by using a device with an anticipated fatigue life which should exceed the patient's life expectancy.