Composite ceramic bone graft substitute in the treatment of locally aggressive benign bone tumours.

PURPOSE: To report the use of a composite ceramic bone graft substitute containing calcium sulphate and hydroxyapatite (HA) in the treatment of large expansive osteolytic benign bone tumours. METHODS: 4 women and 9 men aged 8 to 49 (mean, 22) years with aneurysmal bone cysts (n=6) or giant cell tumours (n=7) in the epi- or meta-physeal areas of the lower limbs underwent curettage, phenolisation, and filling with bone graft substitute containing calcium sulphate and HA. The mean tumour size was 38.5 (range, 18-65) ml. The patients were followed up for a mean of 41 (range, 33-52) months. Range of movement, Musculoskeletal Tumor Society Rating Score (MTSRS), and haematological and blood biochemical parameters were measured. RESULTS: Two patients had recurrence at 7 and 9 months, both progressed to grade-III giant cell tumours. One underwent revision with an iliac crest autograft, whereas the other underwent en bloc excision and prosthetic replacement. The 11 other lesions displayed clinical and radiological consolidation at a mean of 4.6 (range, 3-7) months. No restriction of range of movement was observed, except in the patient undergoing prosthetic replacement. The mean MTSRS was 96% (range, 83-100%) of that expected for normal function. During the follow-up period, haematological and blood biochemical parameters stayed within normal limits. CONCLUSION: Composite bioceramic osteoconductive grafts, which combine porous HA with calcium sulphate, provide a framework for human osteogenesis and avoid donor-site morbidity (autologous bone graft harvesting). Tumour recurrence remains a major concern especially in young patients, as revision invariably requires removal of additional bone, potentially compromising joint integrity.

Sacral insufficiency fractures.

PURPOSE: To highlight difficulties in the diagnostic process and the validity of imaging techniques for sacral insufficiency fractures. METHODS: Records of 25 women aged 68 to 95 years with sacral insufficiency fractures were reviewed. Baseline blood biochemistry and haematology test results were obtained. Pelvic anterior/posterior radiography was undertaken for all patients; additional computed tomography, technetium bone scanning, and magnetic resonance imaging were used in some. Treatments were based on the severity of the injury and the patient's mobility and cooperativeness. RESULTS: Among the 25 women, 11 had bilateral and 14 had unilateral vertical sacral fractures. Associated fractures included horizontal sacral fracture, fractures of the os pubis and ilium. Symptoms included lower back or buttock pain, abdominal pain, and those emulating radiculopathy and myelopathy, including leg weakness, sciatica, and urinary retention. The mean delay in diagnosis was 9 (range, 1-28) days. The mean recovery time between bilateral and unilateral fractures was significantly different (22 [range, 12-33] vs 14 [range, 8-36] weeks, p=0.01). No patient with bilateral fractures regained her pre-injury mobility, compared to 43% among those with unilateral fractures (p=0.02, Fisher's exact test). Computed tomography was the most reliable imaging technique; technetium bone scanning was highly sensitive but non-specific; magnetic resonance images of the fractures may mimic metastatic disease. CONCLUSION: With the increase in the elderly population, sacral insufficiency fractures may become epidemic in future. Primary and secondary osteoporoses are common causes. Once a diagnosis is established, in most cases treatment is simple but recovery may be protracted and full mobility curtailed.

Should we use a separate knife for the skin?

The aim of this study was to re-assess whether the use of a 'one-knife technique' can be considered as safe as the alternative practice of using separate skin and inside knives for elective orthopaedic surgery. A total of 609 knife blades from 203 elective orthopaedic operations, with equal numbers of skin, inside and control blades, were cultured using direct and enrichment media. We found 31 skin blades (15.3%), 22 inside blades (10.8%), and 13 control blades (6.4%) gave bacterial growth. Of the 31 contaminated skin blades only three (9.7%) had growth of the same organism as found on the corresponding inside blade. It is not known whether contamination of deeper layers in the remaining 90% was prevented by changing the knife after the skin incision. The organisms cultured were predominantly coagulase-negative staphylococci and proprionibacterium species; both are known to be the major culprits in peri-prosthetic infection. Our study suggests that the use of separate skin and inside knives should be maintained as good medical practice, since the cost of a single deep infection in human and financial terms can be considerable.

Osteonecrosis of the medial tibial plateau: a case report.

Medial tibial plateau osteonecrosis is a disease that lacks distinguishing signs and symptoms, especially in the early stage, and requires clinicians to exercise a high degree of suspicion to prevent disease progression. We present a case of spontaneous osteonecrosis of the medial tibial plateau in a 59-year-old woman. Within 5 months of the onset of symptoms, the entire medial tibial plateau collapsed down into the metaphyseal region, causing severe varus deformity, instability, and inability to walk without crutches and a hinged knee brace. Initial symptoms of medial joint line pain and generalised swelling of the knee were attributed to early degenerative changes. Subsequent radiographs were misinterpreted as simple medial compartment arthritis. Due to severe bone loss and significant lateral collateral ligament attenuation, a total joint arthroplasty was required, using a stemmed tibial component with medial metal block and bone graft augmentation. The speed of bone collapse and the extension into the metaphysis, requiring complex joint arthroplasty, makes this case unique.

Post-thrombotic syndrome after total hip or knee arthroplasty: incidence in patients with asymptomatic deep venous thrombosis.

PURPOSE: To measure the risk of developing signs of post-thrombotic syndrome 15 to 24 months after total hip or knee arthroplasty in patients with asymptomatic deep venous thrombosis (DVT). METHODS: A total of 85 total knee arthroplasty patients and 47 total hip arthroplasty patients were postoperatively screened for asymptomatic DVT using colour duplex ultrasound. RESULTS: The rate of asymptomatic DVT was 37.6% (n = 32) in knee patients and 34.0% (n = 16) in hip patients. All 32 DVT cases in the knee group had thrombi located below the knee, whereas 6 of the 16 DVT cases in the hip group had thrombi located above the knee, the remaining 10 were below the knee. Patients with proximal thrombi were treated with warfarin for 3 months, whereas patients with distal DVT received 300 mg aspirin daily for the same period. All DVT cases were monitored for up to 12 weeks using repeated colour duplex scans. Signs of thrombus resolution were present at around 6 weeks (range, 4-12 weeks). Clot propagation was observed in 3 cases. In a mean of postoperative 18 months (range, 15-24 months), 28 of the 32 knee patients with asymptomatic DVT were available for follow-up: 11 had transient calf and ankle swelling, 6 had persistent oedema, and the remaining 11 were symptom free. 14 of the 16 hip patients with asymptomatic DVT were available for follow-up: 6 had transient calf and ankle swelling, 4 had persistent oedema, and 4 remained symptom free. 17 patients reported ongoing problems and were re-examined. Signs of mild-to-moderate post-thrombotic syndrome were recorded in 4 knee patients and 3 hip patients. CONCLUSIONS: Patients with above-knee DVT were much more likely to have post-thrombotic syndrome. Despite thromboprophylaxis with low-molecular-weight heparin, asymptomatic DVT is common after total joint arthroplasty and is responsible for the development of post-thrombotic venous insufficiency and post-thrombotic syndrome in a considerable proportion of patients. Once symptomatic or asymptomatic DVT is established, treatment appears incapable of preventing the occurrence of post-thrombotic syndrome, especially in cases of above-knee DVT. Efforts should hence concentrate on combating DVT propagation and improving DVT prevention.

Bilateral capitellum humeri fracture: a case report and review of the literature.

We report a case of a 37-year-old woman who sustained a bilateral Hahn-Steinthal type fracture of her capitellum humeri. Open reduction and internal fixation, using extra-articular insertion of Herbert screws, were performed. Both elbows were immobilised for 3 weeks postoperatively. Radiographic signs of union were present at week 8. Within the observation period of 18 months, no signs of avascular necrosis were detected. At the end of the recovery period, despite intensive physiotherapy, the patient was left with a 20 degrees loss of flexion in her right elbow and a 15 degrees loss of extension in her left elbow. We found the use of Herbert screws particularly suitable for this type of injury: it allows good inter-fragmentary compression due to the sub-articular positioning that avoids the risk of damaging the articular surface. Mobilisation should start early to prevent joint stiffness and long-term disability.

Medial meniscal cyst of the knee--an unusual presentation: a case report.

We report an unusual case of a large, asymptomatic, medial meniscal cyst of the knee. Medial meniscal cysts are relatively uncommon, are usually symptomatic and in most cases are so small that only magnetic resonance imaging can confirm the diagnosis.

Use of extendable total femoral replacements in children with malignant bone tumors.

Although rarely required, extendable reconstruction devices for replacing the entire femur offer children with malignant bone tumors the opportunity of a nearly normal development by overcoming an expected leg length discrepancy. Femoral integrity can be restored, allowing most patients to walk without the use of aids. There are no data available to provide evidence regarding long term results and morbidity in such patients. Six patients (range 2-12 years of age), three with osteogenic osteosarcoma and three with Ewing's sarcoma, were treated between 1988 and 1996 with custom made Stanmore extendable prosthetic total femoral replacements. One patient died 12 months after surgery because of complications relating to pulmonary metastasis. The remaining five patients were observed between 2.7 and 8.9 years (average, 5 years). No tumor recurrence has been recorded and no amputation has been performed. All surviving patients underwent an average of 9.4 operative procedures (range, 4-16 procedures) including 6.4 extension procedures (range, 3-10 procedures), and one prosthetic revision (range, 0-3 procedures). Five revisions in two patients were necessary because of infection, loosening of the prosthesis, mismatch between femoral head and acetabulum, or full extension of the extending mechanism. The functional results were measured in accordance with the Musculoskeletal Tumor Society rating score, with an average result of 77.3%. Total femoral replacement in a growing individual achieves good functional results yet has various risks for an uncertain outcome. Careful selection of the patient and realistic appraisal of the long term prospects are essential for successful treatment.

Stanmore custom-made extendible distal femoral replacements. Clinical experience in children with primary malignant bone tumours.

The use of extendible distal femoral replacements is a relatively new treatment alternative for malignant bone tumours in growing individuals. Although their appearance was widely appreciated, questions about functional practicality and longevity remain unclear. With longer follow-up, advantages of immediate functional restoration and beneficial psychological aspects seem to be overshadowed by an increase in complications such as aseptic loosening, infection or prosthetic failure. We have reviewed 18 children with such tumours who were treated between 1983 and 1990 by custom-made Stanmore extendible distal femoral replacements. Four died from metastatic disease within 2.5 years of operation and two required amputation for local recurrence or chronic infection. The remaining 12 patients were followed for a mean of 8.7 years (6 to 13.2). A mean total lengthening of 5.2 cm was achieved, requiring, on average, 4.3 operations. Using the Musculoskeletal Tumor Society rating score the functional result at review was, on average, 77% of the expected normal function, with seven patients achieving > or = 80%. Revision of the prosthesis was required in ten patients, in six for aseptic loosening, at a mean of 6.2 years after the initial procedure.

Bilateral demyelinating neuropathy in a solitary lytic and sclerotic myeloma of the proximal humerus: a case report.

Mixed lytic and sclerotic myeloma are uncommon and occur at an earlier age than multiple myeloma in areas of persistent haemopoiesis. Their characteristic symptoms are pain, swelling and pathological fractures and they are usually detected at an early stage. We report a case of a mixed sclerotic/lytic myeloma of the humerus presenting at an unusually advanced stage and associated with a bilateral progressive demyelinating peripheral sensory and motor polyneuropathy resembling polyradiculitis. The neurological changes partly disappeared after the tumour had been resected which suggests that nerve reconstitution may occur due to reversal of the demyelination.

[Effect of low dose omega-3 fatty acid supplementation on plasma lipids and lipoproteins in coronary patients with dyslipoproteinemia]. / Wirkung niedrig dosierter Omega-3-Fettsäuresupplementationen auf Plasmalipide und Lipoproteine bei Koronarpatienten mit Dyslipoproteinämie.

In a prospective study, 20 patients (aged 48-67 years) with primary hyperlipoproteinaemia of phenotypes IIa, IIb, IV and with proven coronary sclerosis received four different doses of long-chain polyunsaturated omega-3 fatty acids. 0.18 to 1.1 g per day were administered in the form of fish oil capsules over four 2-week periods. The aim was to study the effect of different low dose supplementations of n-3 fatty acids on the plasmalipid- and lipoprotein composition and to determine a threshold of effectiveness. Significant reduction of the triglyceride level was registered in all subjects with the greatest decrease in those patients who presented with the highest base levels. The cholesterol and LDL-cholesterol values on average remained almost unchanged, apart from a significant increase of LDL-cholesterol in patients with type IV hyperlipoproteinaemia. The HDL-cholesterol fraction also showed a significant increase in type IIb patients which was related to alterations of the HDL-3 subfraction. The minimal effective dose of a daily administration of omega-3 fatty acids can be expected between 0.18 g and 0.35 g. The observed changes of plasmalipids and lipoproteins reflect the beneficial effect of long-chain polyunsaturated omega-3 fatty acids in respect to plasma-triglyceride reduction and HDL-cholesterol increase as seen in other studies, despite the use of supplementations far below 1 g per day.

Two-level intervertebral disc herniation in an adolescent.

A two-level intervertebral disc prolapse is a rare circumstance in adolescents. We describe the case of a 19-year-old man who suffered a deceleration traum and developed simultaneous large intervertebral disc herniations at L4/5 and L5/S1. The aetiology is discussed and, in accordance with the current literature, it is pointed out that clinical findings due to intervertebral disc herniations in young people do not necessarily correspond with the extent of the disease.

Acute MRI changes in infectious discitis: report on two cases.

Previous reports suggest that MRI changes should be seen within 48h of symptoms arising. We report on two patients with proven discitis at the L5/S1 disc. MRI performed within 60h of the onset of symptoms did not demonstrate evidence of infection and therefore did not confirm the diagnosis of discitis. The reliability of early MRI to confirm infective discitis is questionable. The cases we report on did not display any of the typical changes of discitis on MRI within the first 48h after the onset of symptoms. Absence of typical infective changes on MRI does not necessarily exclude an infection within the disc space.