The Outcome of 69 Recemented Hip Femoral Prostheses Performed by One Surgeon 22-40 Years Ago.

BACKGROUND: There is a lack of long-term data on cement-in-cement technique in revision of failed hip femoral stem. METHODS: We present the outcome of 69 consecutive recemented femoral prostheses, performed by one surgeon (GH) 22-40 years ago. Four patients (4 hips) were lost to follow-up. Sixty-three patients (65 hips) were followed for their lifetime or until the time of the preparation of the study. The study population consisted of 18 failed hemiarthroplasties and 47 failed total hip arthroplasties. RESULTS: The 23-year probability of survival for the recemented femoral components, with re-revision for any reason and resection arthroplasty as the end point, was 73.6% (61.8%-85.4%) and, with re-revision for aseptic loosening as the end point, was 82.2% (71.4%-93%). CONCLUSION: Our follow-up study at 22-40 years, after recemented hip femoral prostheses, shows that recementing works well in selected cases.

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.

Bone and cartilage regeneration with the use of umbilical cord mesenchymal stem cells.

INTRODUCTION: The production of functional alternatives to bone autografts and the development new treatment strategies for cartilage defects are great challenges that could be addressed by the field of tissue engineering. Umbilical cord mesenchymal stem cells (MSCs) can be used to produce cost-effective, atraumatic and possibly autologous bone and cartilage grafts. AREAS COVERED: MSCs can be isolated from umbilical cord Wharton's jelly, perivascular tissue and blood using various techniques. Those cells have been characterized and phenotypic similarities with bone marrow-derived MSCs (BM-MSCs) and embryonic stem cells have been found. Findings on their differentiation into the osteogenic and chondrogenic lineage differ between studies and are not as consistent as for BM-MSCs. EXPERT OPINION: MSCs from umbilical cords have to be more extensively studied and the mechanisms underlying their differentiation have to be clarified. To date, they seem to be an attractive alternative to BM-MSCs. However, further research with suitable scaffolds and growth factors as well as with novel scaffold fabrication and culture technology should be conducted before they are introduced to clinical practice and replace BM-MSCs.

Measured resection versus gap balancing technique for femoral rotational alignment: a prospective study.

PURPOSE: To compare the measured resection technique and the gap balancing technique for correction of the femoral rotational alignment. METHODS: 57 women and 6 men (mean age, 70 years) with end-stage osteoarthritis and <15º malalignment and <10º flexion contracture of the knee underwent primary total knee arthroplasty through the medial approach using the measured resection technique (n=34) or the gap balancing technique (n=29). Femoral rotational alignment was evaluated before and 7 days after surgery using computed tomography by referencing the 2 posterior condyles to the transepicondylar axis. RESULTS: The 2 groups did not differ significantly in terms of correction of the femoral rotational alignment (3.4º ± 1.4º vs. 3.5º ± 3.1º, p=0.817). CONCLUSION: The measured resection and the gap balancing techniques achieved comparable correction of femoral rotational alignment.

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.

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.

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.

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.