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.

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.

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.

Quadratus Femoris Partial Tear Secondary to Occult Ischiofemoral Impingement.

Introduction: Hip pain in children and adolescents may become a diagnostic challenge. A wide range of causes must be considered in the deferential diagnosis. Ischiofemoral impingement (IFI) is a pathological condition defined by hip pain associated with narrowing of the ischiofemoral (IF) space. We report the case of an adolescent patient with non-traumatic quadratus femoris (QF) tear secondary to an occult IFI syndrome. To the best of our knowledge, this is the first such case reported in the literature. Case Report: A 15-year-old girl reported persisting hip pain for a month following increased physical activity. The symptoms had started a couple of days following a weekend of increased activity due to her participating in a dancing contest. Physical examination and imaging studies (standard anterior pelvis radiograph and MRI-scan) failed to reveal any pathology apart from an area of diffused edema in the IF space. Standard hematology and biochemistry laboratory tests were all within normal range. Conservative treatment for 6 months with rest and modification of physical activities failed. A new MRI scan showed partial edema resolution and marked reduction in the IF and QF spaces (12 mm and 8 mm, respectively), thus suggesting IFI, which, in turn, led to a partial rupture of the QF. The patient underwent a local infiltration of the QF with betamethasone sodium phosphate and betamethasone acetate (6+6 mg/2 ml) under CT guidance, which led to the complete resolution of all her symptoms. She remains symptoms free for 24 months. Conclusion: IFI is a rather uncommon condition in the developing skeleton. As in adults, in adolescents as well, MRI is the study of choice in cases of IFI, since it shows QF pathology and allows measurement of the IF and QF spaces, assisting physicians in establishing the right diagnosis. However, the coexistence of a QF hematoma and/or edema, may temper with the initial MRI measurements and render the diagnosis of the primary condition rather difficult. Conservative treatment (with local infiltration of the QF) was proven to be successful in the hereby described case.

[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.

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.

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.

Coracoclavicular joint degeneration, an unusual cause of painful shoulder: a case report.

A case of painful shoulder in a 42-year old right-hand dominant Caucasian female due to degeneration of the coracoclavicular joint is described. The pain was aggravated by weight lifting. The diagnosis was confirmed radiographically with simple plain films and clinically by the injection of local anaesthetic (xylocaine 2%) that lead to the exclusion of any other concomitant pathology of the acromioclavicular joint and the anterior subacromial space. The patient was treated successfully with an intraarticular steroid injection, and 30 months later she remains free of symptoms.

Postoperative re-perfusion of drained blood in patients undergoing total knee arthroplasty: is it effective and cost-efficient?

The value of postoperative salvage and re-infusion of drained blood was assessed in 155 patients undergoing total knee arthroplasty for primary knee osteoarthritis. In group A (n = 77), standard vacuum drains were used. In group B (n = 78), an auto-transfusion system was used and the blood drained within 6 hours postoperatively was re-infused. Group B patients were further distributed into 2 subgroups, in one of which methylprednisolone was administered before blood re-perfusion. Patients who received autologous blood had higher levels of haemoglobin at 8 hours (p < 0.05) and 24 hours postoperatively (p < 0.01) and needed less allogeneic blood transfusion (p < 0.01). Methylprednisolone administration was found to attenuate the postoperative febrile reaction (p = 0.01).

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.

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.

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.

The serum levels of Receptor Activator of Nuclear Factor-κB Ligand, bone-specific alkaline phosphatase, osteocalcin and osteoprotegerin do not correlate with the radiographically assessed severity of idiopathic hip and knee osteoarthritis.

OBJECTIVES: Determination of the serum levels of Receptor Activator of Nuclear Factor-Κb Ligand, bone-specific alkaline phosphatase, osteocalcin and osteoprotegerin in patients suffering from osteoarthritis of varying severity and healthy controls and correlation of these results with the patients' age and the radiographically assessed severity of the disease. DESIGN AND METHODS: Patients suffering from hip (n=58) or knee (n=117) osteoarthritis and matched controls (n=19) were enrolled in this study. Patients underwent physical examination and standard radiographic evaluation before blood sampling. RESULTS: The serum levels of osteoprotegerin were positively correlated with age in all groups, whereas those of osteocalcin in the 'knee' group only. Osteoarthritis' severity and location did not have a statistically significant impact on the mean serum level of any marker in both groups. CONCLUSIONS: Based on our results, none of the studied markers can serve as a surrogate for radiographic imaging in patients suffering from hip and knee osteoarthritis.

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.

Primary cementless total hip arthroplasty with an alumina ceramic-on-ceramic bearing: results after a minimum of twenty years of follow-up.

BACKGROUND: The biological problems related to wear debris after total hip arthroplasty have stimulated renewed interest in alternatives to metal-on-polyethylene bearing surfaces. METHODS: We retrospectively evaluated the clinical and radiographic results of 100 patients who had undergone a total of 109 primary total hip arthroplasties with a cementless alumina ceramic-on-ceramic prosthesis between January 1985 and December 1989. The mean age of the patients at the time of the index arthroplasty was forty-six years. Clinical evaluation was performed with use of the Charnley modification of the Merle d'Aubigné-Postel scale. Seventy-eight patients who had had a total of eighty-five arthroplasties were available for follow-up evaluation at an average of 20.8 years. The patients' average age at the time of the latest follow-up was 66.8 years. RESULTS: Six hips (six acetabular cups and one femoral stem) in six patients underwent revision. Aseptic loosening of the cup combined with focal osteolysis was the cause of all six revisions. In one patient, the stem was also revised because of aseptic loosening. At the time of final follow-up, the result was excellent (according to the Merle d'Aubigné-Postel scale) in 68% of the hips, good in 19%, fair in 9%, and poor in 4%. The mean Merle d'Aubigné-Postel score improved from 7.9 points preoperatively to 16.9 points postoperatively (p < 0.001). The cumulative rate of survival of the prostheses was 84.4% at 20.8 years. CONCLUSIONS: The results of these cementless ceramic-on-ceramic total hip arthroplasties continued to be satisfactory at a minimum of twenty years postoperatively. The improved design of contemporary prostheses and the new generation of ceramic-on-ceramic bearing surfaces may lead to even better long-term results.

The role of pantalar arthrodesis in the treatment of paralytic foot deformities. Surgical technique.

BACKGROUND: Pantalar arthrodesis is considered by many to be the final operative option before amputation for the treatment of paralytic foot deformities. The aim of the present study was to evaluate the long-term results of pantalar arthrodesis with regard to its impact on the adjacent joints and the walking ability of patients with paralytic foot deformities. METHODS: Twenty-four patients (seventeen men and seven women) who underwent a one-stage pantalar arthrodesis between 1953 and 1973 for the treatment of sequelae of poliomyelitis were reevaluated. All patients underwent a physical and radiographic examination, and all completed the Short Form-36 questionnaire and a pantalar arthrodesis specific questionnaire. RESULTS: The average age of the patients was twenty years at the time of the operation and 57.2 years at the time of the latest evaluation. The average duration of follow-up was 37.2 years. Eleven patients had development of immediate postoperative complications, including wound-healing problems (nine) and infections (two). The long-term results,however, were good (mean Short Form-36 scores, 73 of 100 points [overall], 51.5 points [physical functioning], and >70 points [all other domains]). Sixteen patients experienced repeated episodes of ipsilateral knee pain; most (fifteen) of these patients experienced a gradual onset of this pain, starting at an average of 20.8 years (range, fifteen to thirty years) postoperatively. The position of the fused ankle did not appear to have a significant impact on the development of ipsilateral knee pain or the time interval between the pantalar arthrodesis and the onset of ipsilateral knee pain. CONCLUSIONS: Pantalar arthrodesis effectively stabilizes the ankle, hindfoot, and midfoot in patients with severe paralytic deformities. Even though most patients can be expected to have development of osteoarthritis of the ipsilateral knee, it seems that a successfully performed pantalar arthrodesis in carefully selected cases is a reliable operative option offering a strong and stable foot that will function well for many years.