Higher levels of melatonin in early stages of adolescent idiopathic scoliosis: toward a new scenario.

BACKGROUND: The melatonin deficiency hypothesis as a central mechanism in the pathogenesis of adolescent idiopathic scoliosis (AIS) is certainly intriguing. However, the actual role of melatonin remains unclear. The aim of this study was to assess the potential clinical value of melatonin serum level in the pathogenesis and the prognosis of AIS progression in patients who were treated nonoperatively. METHODS: Two groups of patients were enrolled. The study group consisted of patients with AIS aged below 14 years who were treated conservatively. In the second group, that is, the control group, age-matched, weight-matched, and height-matched healthy individuals were enrolled. Blood samples were collected from all patients on visit 1 and the serum levels of melatonin were evaluated with the enzyme-linked immunosorbent assay (ELISA) method. The blood sampling procedure was repeated exactly 1 year later (visit 2). RESULTS: Forty-two patients formed the study group (with AIS) and 29 served as the control group. The mean serum value of melatonin on visit 1 was 19.32 pg/mL for the AIS group and 12.23 pg/mL for the control group. This difference was statistically significant (P = 0.014). One year later, 34 patients from the AIS group and 23 from the control group were reevaluated and the mean serum levels of melatonin were 52.43 and 68.44 pg/mL, respectively. No statistically significant difference was found between the 2 groups (P = 0.235). Statistical analysis of the serum melatonin levels of patients with progressing AIS (>5 degrees of the Cobb angle in 1 y) when compared with patients with stable AIS (P = 0.387) or the control group (P = 0.727) failed to show that the deficiency of melatonin may be associated with the progression of AIS. CONCLUSIONS: Higher melatonin levels were observed in conservatively treated patients with AIS, whereas melatonin deficiency was not associated with AIS progression in this study. LEVEL OF EVIDENCE: Level III-case-control study.

Leflunomide addition in patients with articular manifestations of psoriatic arthritis resistant to methotrexate.

In contrast to rheumatoid arthritis, in psoriatic arthritis (PsA), the efficacy of disease-modifying antirheumatic drugs (DMARDs) combination has not been documented. We conducted a retrospective study to evaluate the effectiveness of leflunomide (LEF) addition in 11 PsA patients with articular manifestations that failed to respond to methotrexate (MTX) monotherapy [disease activity score in 28 joints (DAS28) > 3.2)]. Eight of them, all with moderate disease activity (DAS28 < 5.1) at baseline, tolerated the combination. A statistically significant improvement of the mean DAS28, based on erythrocyte sedimentation rate (ESR), and its variables, and C-reactive protein (CRP) at 12-16 weeks after LEF addition was observed. Mean change of DAS28 in patients with polyarticular disease did not differ compared with those with oligoarticular. Based on the European League Against Rheumatism (EULAR) response criteria, none of our patients achieved a good response, seven had a moderate response, and one was a non-responder. The two patients with the lower DAS28 at baseline attained low disease activity (LDA, DAS28 ≤ 3.2), while none reached remission (DAS28 ≤ 2.6). Achievement of clinical remission or at least LDA has been recently proposed as the goal of treatment in PsA. Our results imply that LEF addition may serve as an alternative therapeutic modality for patients with moderately active PsA and, as lower as possible, residual disease activity after the initial therapy with MTX alone.

Radial head replacement with the MoPyC pyrocarbon prosthesis.

BACKGROUND: Radial head fractures often pose therapeutic dilemmas. We present the early results of patients who underwent radial head replacement with the MoPyC prosthesis (Bioprofile, Tornier, Saint-Ismier, France). MATERIALS AND METHODS: We re-evaluated patients who underwent post-traumatic radial head resection and implantation of the MoPyC prosthesis due to pain and motion restriction. All patients underwent radiographic evaluation. Clinical evaluation was performed using the Broberg-Morrey and the Mayo Elbow Performance Score (MEPS) scales. RESULTS: Thirty-two patients (20 men, 12 women; mean age, 54 years; 22 dominant upper limbs) were evaluated. Twenty had a comminuted radial head fracture (Mason IV, 15; Mason III, 5), 2 from radial head fracture malunion, and 10 had complex elbow injuries (comminuted radial head fractures with ligamentous ruptures with or without coronoid process fractures). Mean follow-up was 27 months (range, 21-46 months). The mean results at the latest follow-up were flexion-extension, 130° (range, 105°-150°); pronation, 74° (range, 60°-80°); and supination, 72° (range, 60°-80°). No laxity was evident during valgus and varus stress tests. Mean grip strength was 96% of the contralateral side. Broberg-Morrey scores were excellent in 33%, good in 44%, and fair in 23%. MEPS results were excellent in 80%, good in 17%, and fair in 3%. There were 6 cases of periprosthetic lucencies or osteolysis of the radius without any clinical signs of loosening. CONCLUSIONS: Radial head replacement with the MoPyC pyrocarbon prosthesis (when performed in carefully selected patients) yields satisfactory results regarding range of motion and function of the elbow joint.

Percutaneous anterolateral balloon kyphoplasty for metastatic lytic lesions of the cervical spine.

The purpose of our report is to describe a new application of kyphoplasty, the percutaneous anterolateral balloon kyphoplasty that we performed in two cases of metastatic osteolytic lesions in cervical spine. The first patient, aged 48 years, with primary malignancy in lungs had two metastatic lesions in C2 and C6 vertebrae. Patient's complaints were about pain and restriction of movements (due to the pain) in the cervical spine. The second patient, aged 70 years, with primary malignancy in stomach, had multiple metastatic lesions in thoracolumbar spine and C3, C4 and C5 vertebrae without neurological symptoms. The main symptoms were from cervical spine with severe pain even in bed rest and systematic use of opiate-base analgesic. The preoperative status was evaluated with X-rays, CT scan, MRI scan and with Karnofsky score and visual analogue pain (VAS) scale. Both patients underwent percutaneous anterolateral balloon kyphoplasty via the anterolateral approach in cervical spine under general anaesthesia. No clinical complications occurred during or after the procedure. Both patients experienced pain relief immediately after balloon kyphoplasty and during the following days. The stiffness also resolved rapidly and cervical collars were removed. VAS score significantly improved from 85 and 95 preoperatively to 30 in both patients. Karnofsky score showed also improvement from 40 and 30 preoperatively to 80 and 70, respectively, at the final follow-up (7 months after the procedure). Fluoroscopy-guided percutaneous anterolateral balloon kyphoplasty proved to be safe and effective minimally invasive procedure for metastatic osteolytic lesions of the cervical spine, reducing pain and avoiding vertebral collapse. Experience and attention are necessary in order to avoid complications.

Histomorphologic study of discoid meniscus.

PURPOSE: The purpose of this study was to investigate the matrix collagen network of the discoid lateral meniscus in comparison with normal lateral meniscus. METHODS: Discoid meniscus samples obtained arthroscopically from 10 patients with a diagnosis of intact complete-type discoid lateral meniscus by a technique of excision in 1 piece were examined histomorphologically regarding the integrity of both main collagen fiber systems, radial and circular, because they have been described in the structure of normal knee meniscus. As a control group, intact lateral menisci excised during knee arthroplasty procedures were used. RESULTS: Histomorphologic scoring showed statistically significant disorganization of the circular collagen network in the discoid meniscus group compared with the normal meniscus group, especially along the posterior third of the specimen (P < .001). In addition, a heterogeneous course of the circumferentially arranged collagen fibers was shown in the discoid meniscus structure. CONCLUSIONS: Findings of discontinuity and inhomogeneity of the circumferential collagen network in the discoid meniscus in comparison with normal meniscus indicate that the discoid lesion represents a structural lesion rather than a morphologic variant. CLINICAL RELEVANCE: Disorganization of the circular collagen fiber system in the discoid meniscus matrix may contribute to the pathogenesis of the high tear and degenerative lesion rate observed among menisci with discoid configuration.

Epidemiologic, clinical and arthroscopic study of the discoid meniscus variant in Greek population.

This retrospective study was aimed to investigate the epidemiologic, clinical and arthroscopic features of discoid meniscus variant in Greek population. We reviewed the cases of 2,132 patients who underwent knee arthroscopy between 1986 and 2004 and diagnosis of discoid lateral meniscus was established in 39 patients with mean age of 31.7 +/- 9.4 years old. Incidence of the discoid lateral meniscus variant was recorded at rate of 1.8% presenting no significant differences according to patient gender or lesion body side. Regarding the type of discoid dysmorphy, 23 cases attributed to complete type, 15 were incomplete and in one case, Wrisberg type was observed. Predictive values of the most commonly recorded physical signs in the clinical diagnosis of the discoid meniscus were analysed. Comparative evaluation of the long-term results of arthroscopic partial meniscectomy performed in patients with intact or torn discoid lateral meniscus and torn normally shaped lateral meniscus was carried out using Lysholm and IKDC scoring systems. Also, we investigated any correlation between dysmorphy type and tear pattern analysing the arthroscopic findings. Results demonstrated that the discoid meniscus lesion represents an atypical clinical entity in adults and no significant predictive value of the signs encountered in the clinical examination of the patients with discoid meniscus was observed. Clinical outcome after arthroscopic partial meniscectomy regarding the intact discoid meniscus group was superior in comparison with that of torn discoid meniscus cases. On other hand, no difference in the result of partial meniscectomy between discoid and normal lateral meniscus tear groups was found. No statistically significant relationship between the type of discoid menisci and tear pattern or incidence rate of concomitant intraarticular lesions was confirmed.

The Effectiveness of the Burch-Schneider antiprotrusio cage for acetabular bone deficiency: five to twenty-one years' follow-up.

From 1985 to 2001, the Burch-Schneider antiprotrusio cage (B-S APC) was implanted in 57 cases (55 patients) with massive acetabular deficiency. The B-S APC survived until the last review 5 to 21 years after operation in 89.5% of the cases, produced substantial pain relief, and increased range of hip motion and walking capacity. The 10.5% failure rate was due to aseptic loosening in 2 cases and mechanical failure in 4 cases. It appears that application of the B-S APC in extensive acetabular deficiency presents a durable solution provided that proper indications and technique are used.

[Simultaneous existence of unicameral bone cysts involving the femur and ischium]. / Femur ve iskiyumda eszamanli basit kemik kistleri.

We report a 30-year-old male patient with two unicameral bone cysts (UBC) simultaneously located in the proximal third of the right femur and ipsilateral ischium ramus, respectively. Fine needle biopsies were attempted for both lesions. Biopsy of the femoral lesion under local anesthesia was unsuccessful, so an open biopsy was performed which confirmed the diagnosis of UBC. Biopsy of the ischial lesion was not sufficient for diagnosis. Cytological examination of both specimens showed no other benign or malignant pathology. The femoral lesion was treated with intralesional (due to its large size) excision-curettage, bone grafting, and the introduction of a long gamma locking intramedullary nail to prevent the occurrence of a pathological fracture. The ischial lesion was left untreated and followed conservatively. The patient was free of any symptoms and complications three years postoperatively. This is the first report of an adult patient with UBCs simultaneously located both in a long tubular bone (femur) and a flat bone (ischium ramus).

Recurrent spontaneous hemarthrosis after total knee arthroplasty successfully treated with synoviorthesis.

A case of spontaneous recurrent hemarthrosis--due to developed hypertrophied synovium--after total knee arthroplasty is reported. The patient was successfully treated with radiosynovectomy. The first hemorrhage occurred 18 months after the total knee arthroplasty. Several similar episodes followed over a period of 4 years. Because conservative treatment failed to control the bleeding, an arthroscopic lavage was performed, which revealed the existence of proliferative synovium. A significant part of the hypertrophic tissue was excised with the use of a thermocoagulator. However, 1 month later, another episode of hemarthrosis occurred. As a final step before reoperation, the patient was treated with intra-articular injection of ytrium 90. Eighteen months later, she remains symptom-free, is very satisfied with the result, and reports no new episode of hemarthrosis.

The long-term effects of hip fusion on the adjacent joints.

Hip fusion has served well for many years as the surgical procedure of choice to treat painful joints with severe osteoarthritis or tuberculous arthritis. This retrospective study evaluates the long-term results of hip fusion, as far as its impact on the adjacent joints is concerned. Thirty-three patients that underwent hip arthrodesis 26-52 years previously were evaluated. All patients reported being satisfied with the fusion and being able to adequately work and perform everyday activities. Twenty-five reported episodes of low back-pain, 18 reported pain in the ipsilateral knee, four in the contralateral knee and five in the contralateral hip. Back pain started after an average time interval of 24 years, and pain in the ipsilateral knee appeared 24.6 years after the fusion. Hip fusion, a procedure which is now hardly ever performed, appears to offer a painless, strong and stable hip. However, the adjacent joints, mainly the lumbosacral spine and the ipsilateral knee, will probably develop secondary degenerative arthritis.

Potential influence of hormones in the development of slipped capital femoral epiphysis: a preliminary study.

The potential influence of hormonal imbalance on the development of slipped capital femoral epiphysis was assessed through a prospective clinical study. The serum levels of T3, T4, thyroid-stimulating hormone, testosterone, estradiol, dehydroepiandrosterone-sulfate, follicle-stimulating hormone, luteinizing hormone, human growth hormone, adrenal cortex hormone and cortisol were evaluated in seven boys and seven girls. Forty-three out of 154 hormonal determinations (27.9%) were abnormal. The results showed increased incidence of pathological values mainly in the levels of follicle-stimulating-hormone, luteinizing-hormone and testosterone. No patient had clinical findings of endocrinopathy. A (possibly) temporary hormonal disorder may play a potentially significant role in the development of slipped capital femoral epiphysis.

Bursal osteochondromatosis overlaying an osteochondroma in the immature skeleton.

A rare case of bursal osteochondromatosis overlying an osteochondroma located at the proximal third of the left tibia in a 10-year-old boy is described. The treatment was operative by marginal resection of the affected bursa and marginal en bloc resection of the osteochondroma. The patient remains symptom and complication free 8 years postoperatively with no sign of recurrence of both lesions. This is the first reported case of a bursal osteochondromatosis overlying an osteochondroma in a developing skeleton, thus rendering this type of lesion one among the possible differential diagnoses that should be considered when dealing with relative diagnostic dilemmas in immature patients.

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.

Thoracic cord compression caused by disk herniation in Scheuermann's disease: a case report and review of the literature.

We present the case of a 14-year-old male with Scheuermann's disease and significant neurological deficit due to thoracic disk herniation at the apex of kyphosis. He was treated with an anterior decompression, anterior and posterior fusion in the same setting using plate, cage and a segmental instrumentation system. The patient had an excellent outcome with complete neurological recovery.

Stress fractures of the lesser metatarsals after a Wilson osteotomy for correction of hallux valgus deformity.

This article describes a patient with lesser-metatarsal stress fractures resulting from an oblique Wilson displacement first metatarsal osteotomy. The shortening of the first metatarsal forces the lesser metatarsals to bear the weight previously borne by the first ray and increases the compression stress on the adjacent metatarsal heads. The proximal displacement of the osteotomy must be minimized in order to limit the risk of stress fracture of the lesser metatarsals.

Curve progression 25 years after bracing for adolescent idiopathic scoliosis: long term comparative results between two matched groups of 18 versus 23 hours daily bracing.

BACKGROUND: Scoliotic curves do not necessarily stop progressing at skeletal maturity. The factors that influence curve behavior following bracing are not fully determined. Our objectives were to evaluate the loss of the scoliotic curve correction in a cohort of patients treated with bracing during adolescence and to compare the outcomes of 18 versus 23 h of bracing at a mean of 25 years post brace removal. METHODS: Seventy-seven patients, who were successfully treated for Adolescent Idiopathic Scoliosis with Βoston brace, were re-evaluated 25 years after the end of their treatment. Patients were further divided in 2 matched groups; those wearing the brace for 23 h and those not wearing the brace at school-time, limiting the application of the brace to 18 h. The mean scoliotic curve was compared between groups before, during, just after bracing and 25 years post bracing. Validated in patients' native language forms of Short Form 36 and Oswestry Disability Index questionnaires were used to compare the quality of life between groups 25 years post bracing. RESULTS: The mean age of the cohort was 40.4 (±3.2) years. They underwent long term follow up at a mean of 25.16 (±2.69) years after brace removal. The mean cohort scoliotic curve increased by 3.9 (±6.69) at 25 years since brace removal. There was however no significant difference in the mean Cobb angle of the cohort between pre brace and long term follow up period (p = 0.307). The 18 and 23 h application groups were comparable according to demographics and several bracing and scoliotic curve parameters. There was no significant difference in the mean curve magnitude between 18 and 23 h application groups at brace removal (p = 0.512) and at 25 years follow-up (p = 0.878). There was also no significant difference in the mean score of Quality of Life questionnaires between groups at long term follow up. CONCLUSION: Scoliotic curves do not necessarily stop progressing after bracing. Bracing is effective treatment method with good long term results in appropriate patients. Since compliance was not objectively measured, we don't feel confident to give any indication about everyday dosage.

Disc-like herniation in association with gas collection in the spinal canal: CT evaluation.

Gas production as a part of disk degeneration can occur but rarely causes nerve compression syndromes. Few cases have been reported in which lumbar intraspinal epidural gas cause nerve root compression symptoms. We present 12 cases of gas collection in the spinal canal that were presented to the orthopaedic out-patient department with symptoms of low back pain and sciatica. CT showed the presence of free epidural gas collections adjacent to or over the affected nerve roots. Relief of symptoms was noted with the change of positions, lying down or sleeping. In this study, we conclude that the presence of lumbar intraspinal epidural gas that causes radicular compressing phenomena, can be easily detected with the use of CT.

Intrapelvic migration of a guide pin during fixation of a hip fracture: who and what is to blame?

The authors report the case of a 61-year-old patient who underwent internal fixation with a dynamic hip screw for a stable intertrochanteric fracture of the right hip. The immediate postoperative radiograph showed complete intrapelvic migration of the threaded guide pin, which has gone unnoticed during operation. The pin was removed by laparotomy, and was found to have damaged no pelvic viscera; the patient made an uneventful recovery. The authors analyse the mechanism of such iatrogenic complications and the possible means to avoid them.