Osteoid Osteoma - Diagnostic and Therapeutic Difficulties. A. Single-centre Experience.

BACKGROUND: Osteoid osteoma is a primary, benign bone tumour. The characteristic clinical symptom is nocturnal pain at the tumour site that decreases or resolves completely with salicylates and non-steroidal antiinflammatory drugs (NSAIDs). The typical radiological features include a radiolucent area with an osteosclerotic rim. An unusual location or absence of visible abnormalities on conventional radiographs may pose a diagnostic challenge. MATERIAL AND METHODS: We report our clinical experience with osteoid osteoma in 15 patients, with special regard to diagnostic and therapeutic difficulties in two cases. RESULTS: All patients reported the characteristic pattern of nocturnal pain that was reduced or resolved after administration of aspirin or NSAIDs. A typical radiological appearance of osteoid osteoma was observed in 13 patients, with radiological studies showing no changes in two patients, who required extended imaging workup to establish the diagnosis. CONCLUSIONS: 1. Osteoid osteoma may be a diagnostic and therapeutic problem. 2. Lack of visible abnormalities on conventional radiographs in the presence of typical clinical symptoms does not rule out osteoid osteoma. 3. Bone scintigraphy and magnetic resonance imaging are helpful methods in the imaging of radiologically silent pathological lesions.

Osteochondral lesions of the knee reconstructed with mesenchymal stem cells - results.

BACKGROUND: We present the results of the treatment of osteochondral lesions with the modified sandwich technique with a collagen membrane. The aim of the study was to assess and compare clinical outcomes following the reconstruction of osteochondral lesions in two groups of patients treated with stem cells obtained from blood and with bone marrow concentrate. MATERIAL AND METHODS: The study group comprised 46 patients with MRI-confirmed osteochondral lesions of various aetiology. A group of 21 patients was treated with bone marrow concentrate and 25 patients were treated with mesenchymal cells obtained from peripheral blood. Patients were assessed with the use of KOOS, Lysholm and VAS scales at 6 months, and at 1 and 5 years following the reconstruction. RESULTS: We noted a significant improvement across all scales in 40 patients (86%). A poor outcome was noted in 6 patients. There was a statistically significant superiority of the group treated with stem cells obtained from blood. The analysis of MRI evidence in patients with good and excellent results showed satisfactory reconstruction of the cartilaginous surface and good regenerate integration. At 5 years, a slight decrease in mean clinical assessment scores was seen in both groups of patients. CONCLUSIONS: 1. The modified sandwich reconstruction is an effective modality in the treatment of severe osteochondral lesions of the knee. 2. Slightly poorer outcomes in the group treated with bone marrow concentrate may have resulted from the number of injected stem cells.

Large cartilage lesions of the knee treated with bone marrow concentrate and collagen membrane--results.

BACKGROUND: The study presents to assess the clinical results of cartilage lesion treatment with bone marrow concentrate and collagen membrane. MATERIAL AND METHODS: The study group comprised 54 patients with ICRS grade III or IV lesions. Lesion sizes ranged from 4 to 12 cm(2). The assessment was carried out at one and five years following the surgery with the use of KOOS and Lysholm functional scales and VAS and KOOS Pain scales. RESULTS: A significant improvement was obtained in 52 out of 54 patients across all scales. No complicating infections were noted. The average improvement at one year was 25 points in the KOOS scale and 35 points in the Lysholm scale. After 5 years an insignificant deterioration was noted in three patients. CONCLUSIONS: 1. One-stage reconstruction of large cartilage lesions with bone marrow concentrate is an effective treatment modality. 2. Due to its lower cost it is a valuable alternative to autologous chondrocyte transplantation. 3. The study group requires 2-3 years of further monitoring to clinically verify this treatment modality.

Cartilage lesions of the knee treated with blood mesenchymal stem cells - results.

BACKGROUND: The study aimed to assess long-term clinical outcomes of cartilage lesion treatment with blood stem cells. The analysis of complications of this method was an additional aim. MATERIAL AND METHODS: The study group comprised 52 patients with ICRS grade III or IV lesions of 4 to 12 cm2. The assessment was carried out at one and six years following the surgery with the use of KOOS and Lysholm scales and VAS and KOOS Pain scales. RESULTS: No postoperative infections were reported. Poor outcomes were noted in 2 patients at 12 months following the surgery. Scores improved in across all scales with an average improvement of 23 points in the KOOS scale and 35 points in the Lysholm scale at one year. At 6 years, minor deterioration was reported in 2 more patients. CONCLUSIONS: 1. The reconstruction of large cartilage lesions with peripheral blood stem cells is an effective treatment modality. 2. This method is a valuable alternative to autologous chondrocyte transplantation.

Custom made tumor-prosthesis as a primary treatment for giant cell tumor of femur--case report.

The article presents the case of a 41-year-old patient with a tumor of the distal third of left femur. Following extended radiological diagnostic work-up, MR, and an open biopsy, the diagnosis of a giant cell tumor was made. In view of the patient's clinical status, diagnostic work-up, and considerable tumor size, the decision was made to resect the tumour and use a primary custom-made endoprosthesis. A good clinical outcome was achieved. Even with the extended diagnostic work-up, the determination of tumor malignancy still posed a diagnostic problem.

A double-blind, randomized, multicenter study of MP4OX for treatment of perioperative hypotension in patients undergoing primary hip arthroplasty under spinal anesthesia.

BACKGROUND: MP4OX (oxygenated polyethylene glycol-modified hemoglobin) is a novel oxygen therapeutic agent specifically developed to perfuse and oxygenate tissue at risk for ischemia and hypoxia. In this study, we investigated the ability of MP4OX to treat hypotensive episodes. In addition, the tolerability profile of MP4OX in a large surgical population was established. METHODS: Patients from 21 study sites in 5 countries, scheduled to undergo primary hip arthroplasty under spinal anesthesia, were randomized in a double-blind manner to receive MP4OX or hydroxyethyl starch (HES) solution (Voluven®; HES 130/0.4). Patients received the first 250-mL dose of investigational product when systolic blood pressure decreased to the predefined dosing trigger. A second 250-mL dose was given only if the systolic blood pressure decreased to the same trigger level after administration of the first dose. The primary efficacy outcome was total duration of all hypotensive episodes during surgery and the first 6 hours after skin closure. RESULTS: Of the 474 patients randomized, 405 reached the dosing trigger and received at least 1 dose. The mean total duration of all hypotensive episodes was significantly shorter (P < 0.0001) in the MP4OX group (52.4 ± 71.50 minutes; range, 3-442 minutes) compared with the HES group (137.6 ± 120.21 minutes; range, 5-435 minutes). The overall incidence of adverse events (AEs) in the intent-to-treat population was similar between the MP4OX and HES groups (75.2% vs 73.4%; P = 0.733). Transient increases in laboratory values were reported in more patients in the MP4OX group versus HES controls for aspartate aminotransferase (13.4% vs 7.4%; P = 0.052), alanine aminotransferase (6.9% vs 4.9%; P = 0.409), lipase (9.7% vs 3.6%; P = 0.015), and troponin (8.1% vs 2.0%; P = 0.006). There was no significant difference in the incidence of serious AEs reported (6.4% in MP4OX group vs 3.0% in HES controls; P = 0.106). Certain AEs did occur more frequently in the MP4OX group, including nausea (23.8% vs 14.3%; P = 0.016), bradycardia (14.9% vs 5.9%; P = 0.003), hypertension (8.4% vs 2.5%; P = 0.009), and oliguria (5.9% vs 1.5%; P = 0.019). The composite morbidity and ischemia end points did not reveal any differences between the 2 treatment groups. CONCLUSIONS: Administration of MP4OX achieved the end point of treating perioperative hypotension in patients undergoing primary hip arthroplasty under spinal anesthesia. The study was not powered to demonstrate clinical benefit based on the composite morbidity or ischemia outcomes. Although efficacy end points with sufficient power were met, MP4OX is not being proposed for use in routine surgery where the risk-benefit profile would not be favorable based on the safety profile demonstrated in this study.

Diminished production of TWEAK by the peripheral blood mononuclear cells is associated with vascular involvement in patients with systemic sclerosis.

Widespread vasculopathy and profound fibrosis are key features of the pathogenesis of systemic sclerosis (SSc). We hypothesized that the TNF-like weak inducer of apoptosis (TWEAK), a recently recognized multifunctional cytokine which regulates angiogenesis and tissue remodeling, may play a role in the development of SSc. The production of TWEAK by the peripheral blood mononuclear cells (PBMC) was investigated, by means of ELISA, in 24 SSc patients and 14 healthy subjects. Moreover, production of TWEAK was correlated with clinical features of SSc. PBMC were isolated using density gradient centrifugation on Histopaque and were cultured in FCS supplemented RPMI medium at 37 degrees C under 5% CO2. Production of TWEAK by PBMC was significantly diminished in patients with more severe microvascular damage, as indicated by the presence of "active" capillaroscopic pattern, compared with SSc patients with less pronounced microangiopathy ("slow" pattern), and healthy subjects. Moreover production of TWEAK correlated inversely with duration of Raynaud's phenomenon. PBMC from patients with scleroderma-related interstitial lung disease tended to produce lower amounts of TWEAK compared with SSc patients without lung involvement but the difference was not significant. The results of our study suggest that diminished production of TWEAK might play a role in the pathogenesis of vascular injury in SSc patients. Whether TWEAK may represent a new therapeutic target in SSc requires further studies.

The effect of prophylactic doses of nadroparin and therapeutic doses of betamethasone on skin flap survival in rats.

Application of pedicle flaps is of great importance in orthopaedics and reconstructive surgery. It has been postulated that anticoagulants or anti-inflammatory treatments may have advantageous effect on pedicle flap survival. The aim of this study was to investigate whether: 1. low-molecular-weight heparin given at prophylactic doses or 2. steroids given at therapeutic doses improve survival of dorsal pedicle flap in rats. Thirty four animals divided into three groups were used for the experiments: Group I (N=12) was treated with low-molecular-weight heparin (nadroparin, 40 IU per kilogram of body mass/day). Group II (N=12) received single injection of betamethasone (intramuscularly, 0.1 mg per kilogram of body mass). Group III (N=10) received sterile saline (0.9% NaCl) subcutaneously as placebo. All animals were housed individually in an environmentally controlled room. After seven days from the operation, 51.7% of the dorsal flaps survived in group I and 48.3% in the group II. These results were comparable to those in the control animals. Our results indicate that neither low dose heparin (nadroparin) used at prophylactic doses nor steroids used at therapeutic doses had any effect on dorsal pedicle flap survival in rats.

[Applying the posterior fasciocutaneous thigh flap in bed sores treatment]. / Zastosowanie uszypulowanego powieziowo-skórnego plata tylnego uda w leczeniu odlezyn.

The paper presents the possibilities of applying the posterior thigh flap in the treatment of ischial pressure sores. Between 2000 and 2004 the flap was used in three cases treated in the Orthopaedics and Traumatology Department of the Medical Universtity in Bialystok. The indications, contraindications, operative technique and advantages of the posterior thigh flap are described. In all three cases the ischial bed sores healed well without recurrences. The posterior fasciocutaneous pedicled flap is a good method of treatment for not too extensive bed sores in the ischial region. This flap can be applied in recurrences found after primary bed sore treatment with another method. However the fasciocutaneous flap has a limited range of transposition as compared with cutaneous flaps.

Interbody fusion and transpedicular fixation in the treatment of spondylolisthesis.

BACKGROUND: This is a retrospective analysis of long-term results of treatment of dysplastic, isthmic and degenerative spondylolisthesis with interbody fusion and transpedicular screw fixation. MATERIAL AND METHODS: Twenty-one patients underwent interbody fusion with the "Bialstab" transpedicular system. Anterior lumbar interbody fusion (ALIF) was subsequently performed in 2 patients. In the remaining patients, posterior lumbar interbody fusion (PLIF) was performed following interbody fusion in the same session. Mean follow up was 22.4 months. Results were evaluated on the basis of a physical examination, the Oswestry questionnaire and the VAS back pain score. Radiologic assessment was based on targeted lateral radiographs to the stabilized segment. RESULTS: The post-operative wound healed without complications in all patients. Clinical outcomes at follow-up were rated as good (10), quite good (9) and poor (2). The average Oswestry score was 14 (range 0-30). The mean VAS score at follow-up was 2.9 (range 0-8). Anatomical slip reposition was performed in 2 patients, partial reposition in 11 patients, and 8 patients were treated with in situ fusion. Radiological evaluation revealed fusion in 17 patients. CONCLUSIONS: 1. Transpedicular fixation with interbody fusion is an effective technique for the treatment of spondylolisthesis. 2. Partial reposition of spondylolisthesis with neural decompression makes it possible to avoid neurological complications. 3. The "Bialstab" fixation system fulfills the criteria for good transpedicular stabilization.

[Sacral pressure sores and their treatment]. / Odlezyny okolicy krzyzowej i ich leczenie.

INTRODUCTION: Sacral bed sores still present a serious problem in most surgery departments. They occur mainly in elderly patients of limited mobility. The treatment of such sores extends over long periods of time and therefore involves considerable costs. MATERIAL AND METHODS: The material consisted of 11 sacral pressure ulcers treated surgically. The sores occurred in 4 severely disabled patients suffering from proximal third femur fractures, 4 patients with traumatic brain injury (treated in the Intensive Care Unit), and 3 patients suffering from bed sores after spinal cord injury. In 6 patients a fasciocutaneous flap was applied to the sores and in 5 cases a pedicled musculocutaneous gluteus maximus flap. The end results were assessed using Seiler's criteria. RESULTS: Complications of the "seroma" type were observed in 3 patients, and in 2 marginal necrosis. In all our patients complete healing was achieved within 2-4 weeks. CONCLUSIONS: On analysing our experience to date in surgical treatment of bed sores we are of the opinion that even extensive sacral sores can be covered with unilateral pedicled flaps provided that they are appropriately planned. Deep sores of the 4th degree sometimes with concomitant osteomyelitis require pedicled muscle flaps or in some cases musculocutaneous flaps to improve local circulation. The preparation of the patient for reconstruction surgery is just as important as the operation itself and therefore such preparation should never be neglected.

Distally based sural artery flap in soft tissue defects of the heel region.

Background. The coverage of tissue defects caused by decubitus ulcers in the remains a challenge for reconstructive surgery. In this article we describe our own experience with the use of the distally-based superficial sural artery flap. Material and methods. Between 1997 and 2004 we used distally-based superficial sural artery island flaps in 8 patients. In all cases the tissue was prepared as a fasciocutaneous flap. Results. All the flaps have survived. The advantages offered by this flap include constant and reliable blood supply, easy dissection, minimal morbidity of donor site, and preservation of the major arteries in the leg. We observed venous congestion and edema in three flaps, and marginal necrosis in one flap. Conclusions. The distally based sural artery flap is a good method for the treatment of soft tissue defects in the heel region. The procedure is short and can be performed in a single stage without microsurgery. This flap has the potential for reinnervation in demanding patients.

Histological patterns of synovitis and serum chemokines in patients with rheumatoid arthritis.

OBJECTIVE: Studies indicate the genetic, biological, and clinical heterogeneity of rheumatoid arthritis (RA). Recently the histological diversity of RA has been postulated. We investigated whether serum concentrations of interleukin 8 (IL-8), RANTES (regulated upon activation normal T cell expressed and secreted), and monocyte chemoattractant protein-1 (MCP-1) are correlated with histological appearance of the rheumatoid synovitis. METHODS: Using ELISA we assessed IL-8, RANTES, and MCP-1 concentrations in serum of 47 patients with RA and 30 patients with osteoarthritis (OA). RESULTS: Morphological analysis of synovial specimens distinguished 2 types of rheumatoid synovitis. Twenty-eight RA samples presented diffuse infiltrates of mononuclear cells with no specific microanatomical organization and were categorized as diffuse synovitis. In the remaining 19 specimens, classified as follicular synovitis, formation of lymphocytic follicles with germinal center-like structures was observed. Serum levels of studied chemokines were increased in patients with RA compared to the OA control group (p < 0.001 for all comparisons). Concentrations of IL-8, RANTES, and MCP-1 were highest in serum of RA patients with follicular synovitis in comparison with patients with diffuse synovitis (p < 0.01, p < 0.01, and p < 0.05, respectively) and could distinguish RA patients with these 2 histological disease patterns. Serum levels of chemokines correlated with markers of disease activity such as erythrocyte sedimentation rate, C-reactive protein concentrations, and Disease Activity Score. CONCLUSION: Distinct histological variants of rheumatoid synovitis associated with different serum levels of IL-8, RANTES, and MCP-1 reflect clinical activity of the disease and confirm the concept of RA heterogeneity.

The radiological outcomes of total knee arthroplasty using computer assisted navigation ORTHOPILOT.

Comprehensive radiographic analysis of total knee arthroplasty performed traditionally and with the use of Computer Assisted Navigation (CAN) is presented. The aim of this study was to compare the precision of implant alignment considering two operating techniques. The analyzed material consisted of 100 radiograms of patients operated on traditional way and 100 knee joint radiograms of patients operated on with a use of CAN. Assessment of postoperative radiograms was carried out in order to analyze coronal mechanical axis and sagittal orientation of both femoral and tibial components. Measurements were taken precisely up to 1 degrees and therefore results were classified as good (0-2 degrees deviation due to mechanical axis), satisfactory (2-4 degrees) and poor (over 4 degrees). The radiological outcome allows to present the following conclusions: CAN allows to minimize the risk of incorrect prosthesis alignment and therefore significantly improves the radiological outcome of total knee arthroplasty. This improvement can lead to better long time "survival" of implant components. The only price one pays for this improvement is 15-20 minute surgery delay, however it needs further studies to determine other possible disadvantages.

The Oxford II medial unicompartmental knee replacement. A minimum 10-year follow-up study.

Background. The first clinical results from unicondylar knee arthroplasty (UKA), which was introduced in the early seventies, were non-conclusive. The development and modernization of unicompartmental implants (mobile bearing models, such as Oxford II), and also stricter qualification criteria for UKA brought about significant improvement in long term outcome. The aim of our study was to assess the long-term outcome of UKA using Oxford II implants, and also to verify the inclusion criteria. Material and methods. The authors present an analysis of long-term outcome in unicompartmental knee arthroplasty in 42 patients, qualified for treatment according to the criteria of Kozin and Scott, and also the designers of the implant. The follow-up assessment was performed a minimum of 10 years after surgery (11.2 years average). Results. The results were assessed using the 100-point HSS scale. Excellent results were achieved in 10 cases, good results in 22 cases, fair results in 6 cases, and poor results in 4 cases. The implant survival rate was 86%. There were some complications related to surgical error or lack of strict compliance with the qualification criteria. Conclusion. UKA late results are comparable to those achieved in TKA, given proper qualification. Also, this procedure can be considered as a definitive solution in older patients.

Tactics in the treatment of fractures of the distal epiphysis of the radial bone.

This article presents the epidemiology, anatomical and clinical ramifications, and classification of distal radial fractures. The treatment methods used in different types of fractures are also presented, with discussion of their indications, limitations, advantages, and disadvantages, in terms of the selection of method and management tactics. Complications and ways to avoid them are also discussed.