Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study.

OBJECTIVE: To evaluate the discriminatory ability of ultrasound in calcium pyrophosphate deposition disease (CPPD), using microscopic analysis of menisci and knee hyaline cartilage (HC) as reference standard. METHODS: Consecutive patients scheduled for knee replacement surgery, due to osteoarthritis (OA), were enrolled. Each patient underwent ultrasound examination of the menisci and HC of the knee, scoring each site for presence/absence of CPPD. Ultrasound signs of inflammation (effusion, synovial proliferation and power Doppler) were assessed semiquantitatively (0-3). The menisci and condyles, retrieved during surgery, were examined microscopically by optical light microscopy and by compensated polarised microscopy. CPPs were scored as present/absent in six different samples from the surface and from the internal part of menisci and cartilage. Ultrasound and microscopic analysis were performed by different operators, blinded to each other's findings. RESULTS: 11 researchers from seven countries participated in the study. Of 101 enrolled patients, 68 were included in the analysis. In 38 patients, the surgical specimens were insufficient. The overall diagnostic accuracy of ultrasound for CPPD was of 75%-sensitivity of 91% (range 71%-87% in single sites) and specificity of 59% (range 68%-92%). The best sensitivity and specificity were obtained by assessing in combination by ultrasound the medial meniscus and the medial condyle HC (88% and 76%, respectively). No differences were found between patients with and without CPPD regarding ultrasound signs of inflammation. CONCLUSION: Ultrasound demonstrated to be an accurate tool for discriminating CPPD. No differences were found between patents with OA alone and CPPD plus OA regarding inflammation.

Do not hallow until you are out of the wood! Ultrasonographic detection of CPP crystal deposits in menisci: facts and pitfalls.

PURPOSE: Ultrasonography (US) has been demonstrated to be an important tool in the diagnosis of calcium pyrophosphate (CPP) crystal deposition disease. The aim of our study was to individuate and describe possible pitfalls in US detection of such deposits in menisci. PATIENTS AND METHODS: We enrolled all patients waiting to undergo knee replacement surgery due to osteoarthritis, for one-month period. Each patient underwent US examination of the knee, focusing on the menisci. After surgery, the menisci were examined by US, macroscopically and microscopically, using the microscopic analysis as the gold standard for CPP deposition. RESULTS: 11 menisci of 6 patients have been studied. Ex vivo examination of menisci performed better in CPP identification than in vivo examination. The possible reasons of misinterpretation or misdiagnosis of the in vivo exam were identified and are extensively described in the paper. Also a new sign of CPP crystal deposits was found. CONCLUSIONS: This study permitted to highlight some difficulties in CPP crystal detection by US in menisci. Further studies are needed to define completely US CPP crystal aspect and to improve the sensibility and specificity of US in CPP deposition diagnosis.

The "Cascade" membrane: a new PRP device for tendon ruptures. Description and case report on rotator cuff tendon.

Rotator cuff tears are common soft-tissue injuries that often require surgical treatment. Initial efforts to better tendon healing centered on improving the strength of repair. More recent studies have focused on abiologic enhancement of the healing process. Platelet rich plasma (PRP) is a fraction of plasma that has been isolated and used to enhance regeneration in bone and soft tissues. The healing potential of PRP has been attributed to the release of multiple growth factors from the highly concentrated platelets. The "Cascade" membrane is a thin layer of autologous fibrine that is very rich in platelets and is obtained by high speed centrifugation of a small quantity of PRP. The Authors present the case of C.U., a right-handed 53 year-old male that came to our attention complaining of severe right shoulder pain and ROM reduction. The MRI showed a thick tear of the sovraspinatus tendon with retraction of the muscle. The patient underwent surgical repair with arthroscopy and mini-open approach with acromionplasty, subacromial decompression, cuff repair by trans-bone suture and application of the "Cascade" membrane (A.T. Grade Milano, Italy) that was sutured side-to-side to close the 10 mm tear. A standard rehabilitation protocol for rotator cuff tears was performed. A MRI 6 months after surgical repair showed the complete integrity of the cuff under the membrane. Currently no widely accepted treatment for massive, irreparable rotator cuff tears is available. Allograft reconstruction to span the remaining defect in massive rotator cuff tears will lead to increase functional results; we believe that further studies are needed to describe and evaluate its potential in tendon healing; multiple MRI studies will demonstrate healing of the tendon with the graft.

Osteogenic growth peptide effects on primary human osteoblast cultures: potential relevance for the treatment of glucocorticoid-induced osteoporosis.

The osteogenic growth peptide (OGP) is a naturally occurring tetradecapeptide that has attracted considerable clinical interest as a bone anabolic agent and hematopoietic stimulator. In vivo studies on animals have demonstrated that the synthetic peptide OGP (10-14), reproducing the OGP C-terminal active portion [H-Tyr-Gly-Phe-Gly-Gly-OH] increases bone formation, trabecular bone density and fracture healing. In vitro studies performed on cellular systems based on osteoblastic-like cell lines or mouse stromal cells, have demonstrated that OGP (10-14) increases osteoblast proliferation, alkaline phosphatase (ALKP) activity and matrix synthesis and mineralization. In view of a potential application of OGP (10-14) in clinical therapy, we have tested different concentrations of OGP (10-14) on primary human osteoblast (hOB) cultures. We have observed significant increases of hOB proliferation (+35%), ALKP activity (+60%), osteocalcin secretion (+50%), and mineralized nodules formation (+49%). Our experimental model based on mature hOBs was used to investigate if OGP (10-14) could prevent the effects on bone loss induced by sustained glucocorticoid (GC) treatments. A strong decrease in bone formation has been attributed to the effects of GCs on osteoblastogenesis and osteocyte apoptosis, while an increase in bone resorption was due to a transient osteoblastic stimulation, mediated by the OPG/RANKL/RANK system, of osteoclasts recruitment and activation. Moreover, GCs act on hOBs decreasing the release of osteoprotegerin (OPG) a regulator of the RANKL/RANK interaction. Here, we provide evidences that OGP (10-14) inhibits hOB apoptosis induced by an excess of dexamethasone (-48% of apoptotic cells). Furthermore, we show that OGP (10-14) can increase OPG secretion (+20%) and can restore the altered expression of OPG induced by GCs to physiological levels. Our results support the employment of OGP (10-14) in clinical trials addressed to the treatment of different bone remodeling alterations including the GC-induced osteoporosis.

Recovery of physical function and patient's satisfaction after total hip replacement (THR) surgery supported by a tailored guide-book.

BACKGROUND AND AIM OF THE WORK: The purpose of this prospective study was to give a customized guide, describing the hospitalization period and the postoperative exercise program, to patients scheduled for total hip arthroplasty (THA) and to show its effectiveness on functional recovery and on patient's satisfaction with the rehabilitation care and with the in-hospital discharge planning after surgery. METHODS: This trial included 365 consecutive subjects with osteoarthritis who underwent THA at the Orthopaedic and Traumatology Clinic of Siena (Italy). The Harris Hip Score (HHS), a disease specific measure, was determined before and after surgery. Postoperative evaluations, associated with a Satisfaction Questionnaire, were carried out at the time of discharge and after 3 months. RESULTS: The overall satisfaction level was very high, both at discharge (81+/-28) and at follow-up (90+/-17). The HHS results showed a significant (p< or =0.05) improvement over time in patients with higher scores 3 months after surgery in comparison with baseline. CONCLUSIONS: Patients reported high levels of satisfaction at the 3 month postoperative follow-up and good levels at discharge. After surgery, the highest improvements were shown in bodly pain and physical function scores. The current study showed that a customized guide was well accepted by patients with THA and satisfie their need of information. It was also effective in improving patient's satisfaction and early recovery of physical function after surgery.

Long-term effects of neridronate on human osteoblastic cell cultures.

UNLABELLED: Bisphosphonates (BPs) are widely used in the treatment of a variety of bone-related diseases, particularly where the bone turnover is skewed in favor of osteolysis. The mechanisms by which BPs reduce bone resorption directly acting on osteoclasts are now largely clarified even at molecular level. Researches concerning the BP's effects on osteoblast have instead shown variable results. Many in vitro studies have reported positive effects on osteoblasts proliferation and mineralization for several BPs; however, the observed effects differ, depending on the variety of different model system that has been used. OBJECTIVES: We have investigated if neridronate, an aminobisphosphonate suitable for pulsatory parenteral administration, could have an effect on human osteoblastic proliferation and differentiation in vitro. METHODS: We have investigated whether prolonged addition of neridronate (from 10(-3) to 10(-11) M) to different human osteoblasts cultures, obtained from 14 different bone specimens, could affect the cells number, the endogenous cellular alkaline phosphatase (ALKP) activity, and the formation of mineralized nodules. RESULTS: Our results show that neridronate does not negatively affect in vitro the viability, proliferation, and cellular activity of normal human osteoblasts even after a long period addition of the drug (20 days) at concentrations equal or lower than 10(-5) mol/l (therapeutic dose). In addition, neridronate seems to enhance the differentiation of cultured osteoblasts in mature bone-forming cells. A maximum increase of alkaline phosphatase activity (+50% after 10 days; P < 0.01) and mineralized nodules (+48% after 20 days; P < 0.05) was observed in cultures treated with neridronate 10(-8) M. CONCLUSIONS: These results encourage the use of neridronate in long-term therapy of demineralizing metabolic bone disorders.

Vitamin D status and bone turnover in women with acute hip fracture.

Hypovitaminosis D is common in elderly women. Few data are available on vitamin D status and bone turnover in women with acute hip fracture. The aims of this study were to determine whether elderly Italian women with an acute hip fracture also had low vitamin D levels and an increase of bone turnover compared with elderly women with osteoporosis but without fractures. Seventy-four women with acute osteoporotic hip fracture and 73 women with postmenopausal osteoporosis were studied. All women were self-sufficient and had adequate sunlight exposure. To exclude the effect of trauma on serum 25-hydroxycolecalciferol levels and bone markers (bone alkaline phosphatase and C-terminal telopeptides of Type I collagen as indices of bone formation and bone resorption), blood samples were drawn within 24 hours of the fracture. Current data indicated that in our patients the prevalence of hypovitaminosis D is common although to a lesser extent than in women who are housebound. Women with acute hip fractures had a higher prevalence of vitamin deficiency defined as serum 25-hydroxycolecalciferol lower than 12 ng/mL, compared with women with osteoporosis. Moreover, the presence of fracture did not influence the rate of bone formation, whereas the increase in bone resorption could be attributed to an older age of women with acute hip fracture because of similar values of parathyroid hormone levels in the two groups.

Healing of fresh tibial fractures with OP-1. A preliminary report.

Osteogenic proteins (OP) are elements of a class of natural growth factors called Bone Morphogenetic Proteins (BMP). A specific member of this class is OP-1, a human recombinant protein that has osteogenic properties. The osteoinductive and osteoconductive properties of OP-1, with its specific collagen matrix, promote the generation of new functionally active, biologically and biomechanically mature bone. We carried out a clinical study to verify the potential of this protein in fresh tibial closed fractures, using OP-1 associated with osteosynthesis by means of a monolateral external fixator.

Low-velocity gunshot fractures of the tibia.

A gunshot-related fracture is a unique type of open fracture. Bullet-induced fractures of the tibia may be encountered in any urban or rural setting as a result of hunting or cleaning mishaps or, perhaps more frequently, of criminal activity. For surgeons with limited experience, there is a bewildering range of apparently contradictory advice concerning their management. This article reports a case of a 53-year-old man with a highly comminuted bullet-induced shaft fracture of the tibia received during hunting activity. The patient was treated with a unilateral external fixator and vascularized flap for skin reconstruction. Six months after surgery, the external fixator was removed at clinical and radiological evidence of healing. At 1 year follow-up, the patient obtained complete healing and returned to normal activity.

Metallosis due to impingement between the socket and the femoral head in a total hip prosthesis. A case report.

Metallosis is usually defined as aseptic fibrosis, local necrosis, or loosening of a device secondary to metallic corrosion and release of wear debris. It is an occasional but characteristic clinical finding in patients who have a metal-on-metal design of total hip replacement, or when metal surfaces contact after a failure or erosion of the polyethylene component. We report the case of a patient who had severe metallosis caused by wear of the femoral head with the titanium socket, after the complete erosion and destruction of the polyethylene cup, with failure of the accetabular component. Breakage of the acetabular cup constitutes one of the possible long-term complications occurring as a result of a total hip replacement. This extremely rare complication can occur at any time postoperatively and may not be associated with symptoms or other problems for a long time.