Osteonecrosis bilateral de rodilla tratada con descompresión y concentrado de aspirado de médula ósea / Bilateral knee osteonecrosis with decompression and bone marrow concentrate

Descripta por Ahlbäck en 1968, la osteonecrosis de rodilla es una patología con un gran potencial de morbilidad. Está dividida en tres grandes grupos: primaria/espontánea, postoperatoria y secundaria/atraumática. Esta última podría estar directamente relacionada con el consumo prolongado de corticoides. Su tratamiento constituye un desafío para el cirujano ortopedista. Va a depender del estadio de la enfermedad y del colapso articular, y se intentará siempre preservar la superficie articular nativa. Dentro de las distintas opciones terapéuticas, las terapias biológicas constituyen una herramienta potencialmente valiosa como complemento al tratamiento quirúrgico, y muestran resultados clínicos esperanzadores. Presentamos el caso de una paciente con una osteonecrosis de rodilla bilateral, secundaria al consumo crónico de corticoides, tratada con una artroscopía bilateral asociada a perforaciones subcondrales descompresivas y aplicación subcondral de concentrado de médula ósea (CMO), con evolución satisfactoria de los síntomas a los treinta meses de seguimiento en la rodilla derecha, mientras que en la rodilla izquierda presentó una evolución tórpida de los síntomas a partir de los veinticuatro meses, por lo que está en plan de reemplazo articular.

Described by Ahlbäck in 1968, osteonecrosis of the knee is a pathology with great potential for morbidity. It is divided into three large groups: primary/spontaneous, postoperative, and secondary/atraumatic. The latter might be directly related to prolonged consumption of steroids. Its treatment is a challenge for the orthopedist. It will depend on the disease stage and articular collapse, always trying to preserve the native articular surface. Within the different therapeutic options, biological therapies are a potentially valuable tool as a complement to surgical treatment, showing encouraging clinical results. We present the case of a female patient with bilateral osteonecrosis of the knee, secondary to chronic consumption of steroids, treated with bilateral arthroscopy associated with decompressive subchondral perforations and subchondral application of bone marrow concentrate (BMC), with a satisfactory evolution of symptoms after thirty months of follow-up in the right knee. However, the left knee showed a torpid evolution of symptoms after twenty-four months of follow-up, so she is on a joint replacement plan

Robotic device-assisted knee extension training during the early postoperative period after opening wedge high tibial osteotomy: a case report.

BACKGROUND: Maintenance or restoration of a good range of motion of the knee is one of the most important outcomes following knee surgery. According to previous studies, opening wedge high tibial osteotomy enables better recovery of range of motion in knee flexion than that achievable after total knee arthroplasty or unicompartmental knee arthroplasty. However, few reports provide a detailed description of the postoperative recovery of knee extension range of motion after opening wedge high tibial osteotomy. We describe our experience with a knee extension training program using a single-joint hybrid assistive limb device (HAL-SJ; Cyberdyne Inc., Tsukuba, Japan) during the acute recovery phase after opening wedge high tibial osteotomy. The HAL-SJ is a wearable robotic device that facilitates voluntary control of knee joint motion. CASE PRESENTATION: A 67-year-old Japanese woman who underwent opening wedge high tibial osteotomy for spontaneous osteonecrosis of the left medial femoral condyle received HAL-SJ-based knee extension training postoperatively. Our experience with this patient revealed that knee extension training with the HAL-SJ during the acute phase following opening wedge high tibial osteotomy is feasible. Furthermore, the patient's knee extension range of motion improved to values similar to those seen during the preoperative stage, and her flexion range of motion was improved at 3 months after the surgery. CONCLUSIONS: HAL-SJ-based knee extension training could be used as a novel post-opening wedge high tibial osteotomy rehabilitation modality. Further exploration of individualized optimal settings of the HAL-SJ is required to improve its safety and efficacy.

A non-invasive, home-based biomechanical therapy for patients with spontaneous osteonecrosis of the knee.

BACKGROUND: The purpose of the current study was to examine the effect of a non-invasive, home-based biomechanical treatment program for patients with spontaneous osteonecrosis of the knee (SONK). METHODS: Seventeen patients with SONK, confirmed by MRI, participated in this retrospective analysis. Patients underwent a spatiotemporal gait analysis and completed the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the Short-Form-36 (SF-36). Following an initial assessment, patients commenced the biomechanical treatment (AposTherapy). All patients were reassessed after 3 and 6 months of treatment. RESULTS: A significant reduction in pain and improvement in function was seen after 3 months of therapy with additional improvement after 6 months of therapy. Pain was reduced by 53% and functional limitation reduced by 43%. Furthermore, a significant improvement was also found in the SF-36 subscales, including the summary of physical and mental scores. Significant improvements were found in most of the gait parameters including a 41% increase in gait velocity and a 22% increase in step length. Patients also demonstrated improvement in limb symmetry, especially by increasing the single limb support of the involved limb. CONCLUSIONS: Applying this therapy allowed patients to be active, while walking more symmetrically and with less pain. With time, the natural course of the disease alongside the activity of the patients with the unique biomechanical device led to a significant reduction in pain and improved gait patterns. Therefore, we believe AposTherapy should be considered as a treatment option for patients with SONK. TRIAL REGISTRATION: Assaf Harofeh Medical Center Institutional Helsinki Committee Registry, 141/08; ClinicalTrials.gov NCT00767780 .

Osteonecrosis en calcáneo en paciente con síndrome antifosfolípido / Osteonecrosis in calcaneus in a patient with antiphospholipid syndrome

Introducción. Aunque el síndrome antifosfolípido (SAF) es una entidad bien conocida, ciertas manifestaciones del síndrome tales como la osteonecrosis (ON) secundaria a eventos trombóticos han sido infradiagnosticadas. La necrosis avascular es la complicación ortopédica más frecuente. Caso clínico. Varón de 29 años con dolor en talón derecho de 13 meses de evolución, sin traumatismo, con SAF como antecedente personal. En las pruebas de imagen, se objetiva una ON en calcáneo. A la exploración destacaban múltiples lesiones maculares hemorrágicas dolorosas en la cara externa de pie hasta el talón, siendo normal el resto de la exploración. Fue tratado con magnetoterapia, mejorando la sintomatología. Discusión. Las manifestaciones ortopédicas del SAF son una característica relativamente nueva y poco conocida. Parece importante tener en cuenta esta entidad en los pacientes con SAF y dolor musculoesquelético, en ausencia de antecedente traumático, ya que se han descrito casos en los que esta enfermedad autoinmune debuta con una fractura a nivel del pie(AU)

Introduction. Although antiphospholipid syndrome (APS) is a well-known condition, certain manifestations of the syndrome such as osteonecrosis (ON) secondary to thrombotic events have been under-diagnosed. Avascular necrosis is the most common orthopedic complication. Case report. A 29 year-old man with a 13 month-course of pain in the right heel, without trauma, and with a personal history including antiphospholipid syndrome. In the imaging tests, ON in calcaneus is observed. On examination, multiple hemorrhagic macular painful lesions can be observed on the outer face of the foot up to the heel. The rest of the study examination is normal. He was treated with magnetic field therapy, with improvement of the symptoms. Discussion. Orthopedic manifestations of APS are relatively new and little known. It seems important to consider this condition in patients with APS and musculoskeletal pain in the absence of trauma, because cases have been reported where this autoimmune disease debuts with a fracture of the foot(AU)

A hand therapy protocol for the treatment of lunate overload or early Kienbock's disease.

We describe a hand therapy protocol aimed at unloading the wrist and increasing blood supply to the wrist, specifically to the lunate. The protocol was used in a series of patients with clinical radial wrist pain, dysfunction and changes on wrist imaging studies. The patients were not candidates for surgical treatment. Application of the therapy protocol improved objective and subjective parameters such as pain and motion, and may provide a viable treatment option for patients with lunate overload or early Kienbock's disease that are not candidates for surgery.

Enfermedad de Preiser. A propósito de un caso / Preiser's disease. A case study

La necrosis avascular idiopática del escafoides o enfermedad de Preiser es una entidad de la que se han descrito pocos casos. En algunas ocasiones es discutible si se trata de una osteonecrosis espontánea o representa un proceso patológico secundario a enfermedades sistémicas, tratamiento quimioterápico o está relacionada con el consumo de esteroides. Presentamos el caso de una mujer de 20 años de edad, sin traumatismo previo, con dolor en la muñeca derecha de 4 años de evolución. Había sido erróneamente diagnosticada de una tendinitis y tratada de forma conservadora sin mejoría. Se solicitaron estudios de imagen mediante radiología simple. Los hallazgos radiológicos presentaban una anomalía del polo proximal del escafoides que originaba una fragmentación del mismo, hecho que se confirmó posteriormente con la realización de una TC. A continuación se realizó una RMN en la que se observaron criterios de isquemia, fundamentalmente en polo proximal. En la RMN con contraste paramagnético aparecieron signos de viabilidad en el fragmento distal y de osteonecrosis en el proximal. Tras las pruebas de imagen se diagnosticó de necrosis avascular idiopática del escafoides. El tratamiento quirúrgico consistió en extirpar los fragmentos necróticos del polo proximal y practicar una neurectomía del nervio interóseo posterior. A los 2 años de la intervención, la paciente se encuentra asintomática y con un balance articular completo de la muñeca intervenida (AU)

The idiopathic avascular necrosis of the scaphoid or Preiser's disease is condition about which few cases have been described. In the majority of cases, it is debatable whether it is actually a spontaneous osteonecrosis, or a pathological process secondary to a systematic disease, or a result of chemotherapy treatment, or associated with taking steroids. We present the case of a 20-year old woman, with no previous trauma, with pain in her right wrist, which progressed over a period of four years. It was wrongly diagnosed as a tendinitis, and was treated conservatively without any improvement. A simple X-ray was requested that showed an abnormality of the proximal pole of the scaphoid that was beginning to fragment; a fact which was confirmed later by performing a CT scan. This was followed by nuclear magnetic resonance spectroscopy (NMR), which showed signs of ischaemia, mainly in the proximal pole. There were signs of viability in the distal fragment in the NMR using paramagnetic contrast. After the imaging tests, idiopathic avascular necrosis of the scaphoid was diagnosed. The surgical treatment consisted of the removal of necrotic fragments of the proximal pole and removal of the posterior interosseous-nerve. Two years after the intervention, the patient is asymptomatic and with a complete range of movement in the operated wrist (AU)

Bilateral pediatric Kienböck's disease: a case report.

Bilateral Kienböck's disease in pediatrics is extremely rare. We report a case of a 14-year-old boy with bilateral pediatric Kienböck's disease who was treated by temporary scaphotrapeziotrapezoidal joint fixation, with a good clinical result and radiographic results.

Complicaciones osteomusculares en el trasplante cardíaco / Musculoskeletal complications in heart transplant

Objetivo. Conocer la incidencia, etiología y tratamiento de las complicaciones osteomusculares más frecuentes que pueden surgir en los pacientes en la fase pre y postrasplante cardíaco. Estrategia de búsqueda. Se realiza búsqueda bibliográfica de los trabajos relevantes en las bases de datos: PubMed, PEDro, Cochrane, Tripdatabase. Las palabras clave para la búsqueda han sido: trasplante cardíaco, complicaciones, osteomuscular, osteoporosis, densidad mineral ósea, osteonecrosis, efectos secundarios, inmunosupresores. Selección de artículos. Se consideran los artículos escritos en castellano e inglés relativos a pacientes adultos. Síntesis de resultados y conclusiones Las complicaciones osteomusculares que más morbilidad ocasionan a los pacientes con trasplante cardíaco son la osteoporosis, fracturas vertebrales, osteonecrosis y complicaciones de los fármacos inmunosupresores. Se revisa la bibliografía actual sobre el diagnóstico y tratamiento de estas patologías en los pacientes con trasplante cardíaco (AU)

Aim. To know the incidence, etiology ant treatment of the most frequent osteomuscular complications in pre and post- transplant phase patients. Search strategy. A bibliographic search was performed in the following databases: PubMed, PEDro, Cochrane, Tripdatabase. Keywords used for the search were: Heart, cardiac, transplant, complications, osteoporosis, osteomuscular, bone mineral density, osteonecrosis, side effects, immunosupressants. Study selection. All articles found in Spanish or English regarding adult patients were considered. Results summary and conclusions. Musculoskeletal complications resulting in the most morbidity heart transplant patients are: osteoporosis, vertebral fractures, osteonecrosis and immunosuppressant-induced complications. The current bibliography on the diagnosis and treatment of these conditions in heart transplant patients has been reviewed (AU)

Lesiones osteocondrales tratadas con cilíndros bifásicos sintéticos (Truffit®) / Osteochondral lesions treated with synthetic biphasic cylinders (Truffit®)

Objetivo: Evaluar pacientes con lesiones osteocondrales intervenidos con cilindros bifásicos sintéticos. Pacientes y metodología: Se intervinieron, en el espacio de tres años, 60 pacientes, 42 hombres y 18 mujeres de entre 41 y 60 años en el 76,65% de los casos, con osteonecrosis de rodilla tratados con el cilindro bifásico Trufit BSG®. La rodilla derecha se vio afectada en el 58,20% y el cóndilo femoral interno en el 75%. A todos los pacientes se les realizó una RNM antes de la cirugía y se les evaluó con el cuestionario KOOS a los 6 meses, a los 18 meses, y en algunos casos a los 36 meses, en un tiempo medio de evolución de dos años. Hicimos un estudio de los porcentajes antes y después de la cirugía sin analizar la evolución personal de los pacientes. Resultados: un 30% de los pacientes presentaron a los 18 meses resultados regulares o malos. La sintomatología mejoró en todos los pacientes, si bien, la inflamación de la rodilla, los bloqueos o la inestabilidad persistían, después de la intervención, en un 25% de los pacientes. Un 25% señalaron dolor grave o muy grave. Las actividades cotidianas las realizaban con normalidad el 60% de los pacientes y casi la mitad señalaron haber modificado sus actividades o sentirse inseguros. Conclusión: los cilindros bifásicos en la osteonecrosis de rodilla mejoran la sintomatología y la función si bien, a corto plazo, persisten molestias en menor grado en un elevado porcentaje de los pacientes intervenidos (AU)

Objetive: To evaluate patients with osteochondral lesions operated upon with synthetic biphasic cylinders. Patients and methods: Sixty patients were operated upon over a three-year period: 42 males and 18 females, aged 41-60 years in 76.65% of the cases, with knee osteonecrosis treated with Trufit BSG® biphasic cylinders. The right knee was affected in 58.20% of the cases, and the internal femoral condyle in 75%. A magnetic resonance imaging study was carried out in all cases before surgery, and the KOOS questionnaire was administered after 6 and 18 months, and in some cases after 36 months, over a mean follow-up of two years. A percentage study was made before and after surgery, without analyzing the personal course of the patients. Results: Thirty percent of the patients presented regular or poor results after 18 months. The symptoms improved in all subjects, though inflammation of the knee, blocking or instability persisted after the operation in 25% of the cases. Intense or very intense pain was reported by 25% of the patients. Daily activities proved normal in 60% of the subjects, while almost one-half claimed to have changed their activities or feel insecure. Conclusion: Biphasic cylinders in knee osteonecrosis improve the symptoms and function, though modest discomfort persists over the short term in a high percentage of operated patients (AU)

Prosthodontic treatment of a patient with bisphosphonate-induced osteonecrosis of the jaw using a removable dental prosthesis with a heat-polymerized resilient liner: a clinical report.

Bisphosphonate-induced osteonecrosis of the jaws (BONJ) is reported frequently in patients receiving oral or intravenous bisphosphonates. To minimize potential complications, dental treatment must be performed with care. There are invasive and noninvasive treatment options for patients with active BONJ or a history of this complication. This clinical report describes the prosthodontic treatment of a patient who developed BONJ after receiving intravenous bisphosphonates (pamidronate). Because of the recurrent incidence of BONJ, noninvasive prosthetic therapy with telescopic overdentures and a heat-polymerized resilient liner was provided. After 2 years, there were no biological or technical complications.

Bilateral idiopathic avascular necrosis of the scaphoid: a rare case of Preiser's disease.

Whereas avascular necrosis of the scaphoid after a fracture is well-documented, idiopathic avascular necrosis of the scaphoid (Preiser's disease) is rare. Little is known of the aetiology of the condition and even less about the best course of management. We describe a rare case of bilateral Preiser's disease. Possible aetiological factors and a summary of the current concepts of management are discussed.

The benefit of modified rehabilitation and minimally invasive techniques in total hip replacement.

INTRODUCTION: We wished to assess if an intensive rehabilitation regimen alone, or one combined with modified anaesthetic and surgical techniques, can change the speed of rehabilitation or the length of hospital stay after total hip replacement. PATIENTS AND METHODS: We compared 44 patients who had followed a traditional care pathway, with 38 patients who had rehabilitated under a new rehabilitation protocol, with 40 patients who had also received modified, minimally invasive techniques. The speed of rehabilitation was measured in terms of three specific milestones accomplished on the day after surgery. RESULTS: We found a statistically significant improvement in the day after surgery each activity was possible. The length of hospital stay was reduced from 6.5 days to 5.4 days to 4.1 days, a difference which was also statistically significant. CONCLUSIONS: The data support the view that a new rehabilitation protocol alone can reduce the length of hospital stay and hasten rehabilitation. The combination of modified anaesthetic and minimally invasive surgical techniques with the new rehabilitation regimen can further improve short-term outcome after total hip replacement.

[Dieterich's Disease--the rare aseptic necrosis of the metacarpal head]. / Morbus Dieterich--die seltene aseptische Knochennekrose der Metakarpaleköpfe.

The rare diagnosis of the Dieterich's disease at the head of the metacarpal III is presented on the case of a 19-year-old female patient. While aseptic bone necroses at the hand skeleton in handsurgical special departments are not rare and diagnostics and choice of the right treatment are not difficult, there are quite rare findings, which are not commonly known. Dieterich's disease finds precipitation in the literature in a handful of articles, mostly case reports. Dieterich saw among 8 patients 7 women, with a distribution of 7 concerned metacarpal bone III and one metacarpal bone IV. A preference of the female sex or the metacarpal bone III cannot be derived from it. Aseptic necroses at the hand are rarer than at the foot skeleton. Clinically, a swelling at the extensor side of the finger basic joint can exist with movement restriction, occasionally is the hand over it slightly turned red. Mechanical load aggravates the complaints. The clinical aspect, X-ray and therapy options are differentially presented and discussed with consideration of the specific literature.

Artroplastia de recubrimiento de cabeza humeral en paciente joven con necrosis avascular bilateral / Humeral head surface replacement arthroplasty in young patient with bilateral avascular necrosis

La artroplastia de recubrimiento de la cabezahumeral está indicada en pacientes con una deformidad leve o moderada de la cabeza del húmero que presentan dolor e impotencia funcional. Presentamos el caso de una paciente joven afectada de necrosis avascular humeral bilateral a la que se le colocó dicha prótesis en ambos hombros. Tras completar el tratamiento rehabilitador, se le realizó una valoración funcional mediante la escala de Constant, obteniendo unos resultadosmuy favorables respecto a su situación previa a la cirugía. Dadas las ventajas que presenta la artroplastia de recubrimiento de cabeza humeral (menor incidencia de complicaciones, disminución del tiempo quirúrgico y reducción de la duración del programa rehabilitador) asociadas a los buenosresultados funcionales obtenidos, consideramos que este tipode prótesis puede ser una buena alternativa a la artroplastiacementada convencional de hombro en pacientes con deformidadleve o moderada de cabeza humeral

Humeral head surface replacement arthroplastyis indicated in patients with a slight or moderate deformity of the humeral head with pain and functional impotence. We present the case report of a young female patient with bilateral humeral avascular osteonecrosis in whom this prosthesis in placed both shoulders. After a rehabilitation program, we made a functional evaluation with the Constant score, obtaining favorable outcomes in relationship to her previous situation. Given the advantages of this arthroplasty(lower incidence of complications, less surgical time and reduction in the length of the rehabilitation program) and the good functional outcome, we consider this type prosthesis to be a good alternative choice to the conventional stemmed arthroplasty of the shoulder in patients with slight or moderate deformity of the humeral head

Conservative treatment versus scaphotrapeziotrapezoid arthrodesis for Kienbock's disease. A retrospective study.

Efficiency of surgical treatment in Kienböck's disease has never been proven in the long term. We retrospectively reviewed the charts of the 104 patients treated by various techniques for Kienböck's disease from 1981 to 1999 in our unit. A comparison was made between 19 cases treated conservatively (amongst 59) and 11 cases (amongst 25) treated by scaphotrapeziotrapezoid (STT) arthrodesis with a mean follow-up of 13 years. The two groups were statistically comparable in stage, age, sex ratio, number of manual workers. STT arthrodesis was responsible for an increased loss of mobility, an increase of barometric pain, a longer rehabilitation time and more fractures of lunatum than conservative treatment. Those results question about indications for STT in Kienböck's disease.

Case reports: osteonecrosis of the capitate: a pediatric case report.

We present what we think is the first documented occurrence of osteonecrosis of the capitate in a skeletally immature patient. Atraumatic osteonecrosis of the capitate is rare, and all reported cases have occurred in adults. Our pediatric patient was treated with observation and limited immobilization. He achieved a full recovery clinically and radiographically after 1 year. A review of the literature pertaining to osteonecrosis of the capitate also is provided.

Kienböck's disease in a 14-year-old gymnast: a case report.

Kienböck's disease is rare in children and there are few reports and therapeutic recommendations in the literature about this condition. We report a case of a 14-year-old female gymnast for whom nonsurgical treatment was followed by complete healing within 12 months. Repeated computed tomography scans provided a sequential coronal, sagittal, and transverse illustration of the progressive healing of the lunate.

Arthroscopic microfracture treatment for osteonecrosis of the knee.

PURPOSE: This study evaluated the results of arthroscopic subchondral microfracture performed on patients with spontaneous osteonecrosis (ON) (group 1) or secondary ON (group 2) of the knee joint. TYPE OF STUDY: Retrospective clinical study. METHODS: Group 1 included 26 patients (mean age, 48 years) who had spontaneous ON. Group 2 included 15 patients (mean age, 32 years) with ON secondary to inflammatory disease or steroid therapy. Seventy-six percent of the chondral defects were located in the medial femoral condyle. The average defect sizes in group 1 was 162 mm2 and in group 2 was 362 mm2. After debridement of the necrotic tissues, multiple perforations were placed into the subchondral bone to obtain revascularization. RESULTS: There was an increase in the average Lysholm scores from 57 to 90 in group 1 after 27 months of mean follow-up (P < .05); 71% of patients could participate in strenuous sports with no or minimal limitation. The mean activity level in group 1 according to Cincinnati Knee Rating System was 6 preoperatively and 13.54 postoperatively. For group 2, the average scores showed significant improvement and patient satisfaction after surgery (preoperative and postoperative average Lysholm scores were 41 and 75, respectively, with mean follow-up of 37 months). Average activity level in group 2 increased from 2.67 to 11.73. Control magnetic resonance imaging scans of the cases revealed the continuity of normal cartilage with cartilage-like tissue in the treated areas. However, an increase of the size of ON in the subchondral bone was detected in 27% of the knees. CONCLUSIONS: The microfracture technique is safe, simple, and cost-effective, and may be an alternative procedure for treatment of ON of the knee, especially in young patients, before possible subsequent replacement surgery. LEVEL OF EVIDENCE: Level IV.

Multiple avascular necrosis in a patient with systemic lupus erythematosus/systemic sclerosis overlap syndrome.

A white female patient developed overlapping features of systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) with severe pulmonary compromise. She was treated with steroids and azathioprine, which improved her clinical condition and spirometric status. In May 2002 she presented with continuous pain in her left ankle that continued even during rest and under treatment with nonsteroidal anti-inflammatory drugs (NSAIDs). Magnetic resonance imaging (MRI) showed multiple avascular necrosis (AVN). Rest and kinesitherapy were indicated for 1 year, and gradually an orthosis was introduced allowing the patient to walk normally.