A new method for intraoperative assessment of leg length, sizing and placement of the components in total hip replacement.

BACKGROUND: Intraoperative radiograph of the pelvis is a well-established way to avoid misplacement/undersizing of the components and leg length discrepancy (LLD) in total hip replacement (THR). We describe a method for the obtainment and the evaluation of intraoperative radiographs with a sophisticated wireless radiographic system and a computerized digital tool originally used for preoperative templating. METHODS: In this retrospective case-control study, 60 patients with unilateral hip osteoarthritis who underwent THR with intraoperative radiographic check with the conventional method (n = 30, control group) or the new method (AGFA flat panel DR14eG™/Orthosize™, n = 30, case group) were evaluated and compared for operation time, intraoperative changes in size/placement of the components and final radiological outcome (LLD, acetabular inclination and femoral offset) based on postoperative radiographs of the pelvis. RESULTS: Mean operation time was lower in case group (85.3 min vs. 103.3 min, p value < 0.005), as well as mean absolute LLD (1.93 mm vs. 2.94 mm, p value = 0.242). There was a higher percentage of intraoperative changes in the offset of the prostheses' head (70% vs. 40%, p value = 0.018) and a significantly lower percentage of patients with LLD > 5 mm in the case group (0% vs. 27%, p value = 0.002). CONCLUSIONS: This new method for the obtainment and assessment of intraoperative radiographs proved to be fast and assuring for keeping LLD below 5 mm in all patients.

Unusual Complete Isolated Scaphoid Dislocation, Report of a Case.

Isolated scaphoid dislocations are extremely rare injuries and are commonly associated with significant ligamentous disruptions. A dorsiflexion-supination force upon the hand is considered as the most common mechanism of injury. Different treatment options have been proposed for the management of this uncommon entity, ranging from conservative treatment with closed reduction and casting to a wide range of open or percutaneous surgical techniques. In this article, we reported ona case of this rare injury managed with open reduction and pinning along with ligamentous reconstruction.

Revision total knee arthroplasty due to bone cement and metal hypersensitivity.

INTRODUCTION: Hypersensitivity to implants is a rare complication of total knee arthroplasty (TKA). Metal and, less frequently, bone cement can produce allergic symptomatology that if unresponsive to conservative treatment could lead to revision. MATERIALS AND METHODS: We present the case of a patient with generalized pruritus and metal taste starting during the first postoperative month after TKA. Dermal allergy exams revealed that the patient had hypersensitivity to nickel sulphate and cobalt chloride and bone cement. Conservative treatment with antihistamine medication and corticosteroids failed to control the symptoms. The patient underwent revision TKA with a hypoallergic prosthesis 8 months after the primary procedure. RESULTS: Full disappearance of the symptoms occurred 3 months after revision. The latest follow-up evaluation (3 years post-revision) was unremarkable. CONCLUSIONS: In our opinion, an exhaustive medical history should be obtained from every candidate for total joint replacement and in cases of prior severe allergic reactions to metals, plastics or glues, patch testing of the components of the future prosthesis should be done. When an already implanted prosthesis causes symptoms like pain, edema, pruritus, erythema, limited range of motion and increase in joint's temperature, the possibility of allergy to metals and/or bone cement (in case of cemented prosthesis) should be checked after the exclusion of other reasons like infection. If symptoms cannot be controlled by conservative measures, revision should be decided and carried out with hypoallergic prosthesis.

Recurrent Dislocation of The Extensor Carpi Ulnaris Tendon in a Water-Polo Athlete.

INTRODUCTION: Dislocation/subluxation of the Extensor Carpi Ulnaris (ECU) tendon is a rare condition in the general population, but is a common problem among athletes that subject their wrists to forceful rotational movements. Pain and snapping sensation at the dorsoulnar aspect of the wrist especially during supination are the predominant symptoms that often necessitate surgical intervention. CASE PRESENTATION: We present a case of a professional water-polo athlete with recurrent ECU tendon dislocation, in whom a combination of direct repair of the tendon's subsheath and reinforcement with an extensor retinaculum graft led to definitive resolution of her symptoms and resulted in her uneventful return to high-level sport activities 4 months postoperatively. CONCLUSIONS: The treatment of symptomatic ECU instability is still controversial, especially for acute dislocations. Depending on the type of injury many surgical techniques have been proposed. Combination of direct repair of the tendon's subsheath and reinforcement with an extensor retinaculum graft is a reliable option.

A Two-stage procedure for the treatment of a neglected posterolateral knee dislocation: Gradual reduction with an Ilizarov external fixator followed by arthroscopic anterior and posterior cruciate ligament reconstruction.

BACKGROUND: Neglected knee dislocations are extremely uncommon and their management cannot be evidence-based since only a few case reports have been published describing different treatment methods. We present the case of a young man with a neglected posterolateral knee dislocation and a concomitant sciatic nerve injury. METHODS: A two-stage treatment strategy with gradual reduction using the Ilizarov technique and subsequent arthroscopic anterior and posterior cruciate ligament reconstruction was followed. RESULTS: The two-stage treatment approach led to a satisfactory clinical outcome. At the latest follow-up evaluation the patient was fully ambulatory and the knee was painless with no anteroposterior instability. CONCLUSIONS: In neglected knee dislocations treatment optios are guided by the severity of the concomitant injuries and the status of articulating surfaces. Gradual reduction with the Ilizarov technique and subsequent arthroscopic ligamentous reconstruction is a reliable alternative to open surgical procedures.

Differentiating between Traumatic Pathology and Congenital Variant: A Case Report of Butterfly Vertebra.

Butterfly vertebra is a rare congenital malformation of the spine, which is usually reported in the literature as an isolated finding. We describe a 40-year-old woman that presented to our emergency department with back pain and sciatica. Initial radiological evaluation revealed an incidental finding of a L4 butterfly vertebra in the anteroposterior and lateral view radiographs. The patient presented with no neurological deficit. This rare congenital anomaly is usually asymptomatic, and awareness of its non-traumatic nature is critical in order to establish a correct diagnosis. Further evaluation of the patient is necessary to exclude pathologic fracture, infection, or associated vertebral anomalies and syndromes, such as Alagille, Jarcho-Levin, Crouzon, and Pfeiffer syndromes. Furthermore, in the emergency setting, awareness of this entity is needed so that a correct diagnosis can be established.

The Outcome of 241 Charnley Total Hip Arthroplasties Performed by One Surgeon 30 to 40 Years Ago.

We present the outcome of 241 consecutive low friction arthroplasties (LFAs) performed by one surgeon (GH) 30 to 40 years ago. The overall survival rate at 30 years with revision for any reason or removal of the components as the end point was 53% (43.2-62.8%) when 40 hips remained in the study. Cox regression analysis for the possible risk factors of age, gender and diagnosis revealed higher risk of the overall failure in younger patients, and higher risk of failure due to loosening in younger patients and in those with congenital hip disease. Our follow-up study at 30 to 40 years following Charnley LFA can be used as a benchmark for comparison with the newer methods of total hip arthroplasty.

Strategies for managing bone defects of the lower extremity.

Management of posttraumatic segmental bone loss as a result of severe open injuries of the lower extremity, high-energy closed injuries, and following failed initial treatment of complex fractures that develop pseudarthrosis continues to challenge reconstructive surgeons. There are numerous strategies for dealing with such injuries but the outcome is unpredictable. The procedure is rarely only one stage and complications frequently arise. In most cases the reconstruction process is long and difficult and amputation must be part of the decision-making process. All traditional treatment strategies have advantages and major drawbacks. To overcome some limitations, biologic treatments have been developed based on specific pathways of bone physiology and healing.

Chondroprotective effect of high-dose zoledronic acid: An experimental study in a rabbit model of osteoarthritis.

To address the need to impact the subchondral bone-articular cartilage interaction for the treatment of degenerative osteoarthritis (OA), bisphosphonates may be used as a means to inhibit the subchondral bone resorption. The purpose of the present study is to evaluate the chondroprotective effect of zoledronic acid (ZOL) in a model of OA. Eighteen adult male rabbits underwent an anterior cruciate ligament transection and were separated into two groups: ZOL group (n=10) received 0.6 mg/kg intravenous injection of ZOL on day 1, 15, and 29 and placebo group (n=8) received saline. The animals were euthanized at 8 weeks. Macroscopically, the ZOL group had significantly milder ulcerations, cartilage softening and fibrillation compared to the placebo group. Microscopically, morphology of the articular cartilage was better in the ZOL treated group compared with the placebo group, without complete disorganization in any section of the ZOL group. Furthermore, the chondrocytes in the ZOL treated group were mainly cloning, indicating cartilage repairing and regeneration process, while in the placebo group hypocellularity predominated. Additionally, subchondral necrosis was evident in some specimens of the placebo group. Zoledronic acid, in a high-dose regimen, proved to be chondroprotective in a well-established animal model of OA.

One-component revision in total hip arthroplasty: the fate of the retained component.

The purpose of the present study was to evaluate the long-term outcome of the unrevised part in one-component total hip arthroplasty revision (index operation). Forty-four patients (46 hips) with a mean age of 58years at the time of the index operation were included. At the final follow-up, 4 of the 19 (21%) unrevised acetabular components and 6 of the 27 (22%) unrevised femoral components were subsequently revised at a mean time of 14 and 11years from the index operation, and 22 and 24years from the primary operation, respectively. We concluded that revision of a stable component is not justifiable on the basis of its long duration in use or non-ideal position or possible loosening on radiographs.

Severe osteoporosis and mutation in NOTCH2 gene in a woman with Hajdu-Cheney syndrome.

Hajdu-Cheney syndrome (HCS) is a rare genetic disorder characterised by acro-osteolysis, skull deformation and generalised osteoporosis. Recently, truncating mutations in the last exon of NOTCH2, a protein-coding gene, were found to be responsible. We present the case of a young woman with HCS in whom clinical and radiologic diagnosis was confirmed with DNA tests.

Sequential treatment with teriparatide and strontium ranelate in a postmenopausal woman with atypical femoral fractures after long-term bisphosphonate administration.

OBJECTIVE: Despite the existence of numerous case series, no evidenced-based medical management for atypical fractures associated with bisphosphonate (BP) treatment has been established. DESIGN: We report the outcome of teriparatide (TRP) administration followed by strontium ranelate (SR) in a woman with a complete and an incomplete contralateral atypical fracture of the femoral diaphysis (AFF) associated with BP treatment. The spontaneous complete AFF was managed with intramedullary nailing, discontinuation of BP and initiation TRP. RESULTS: Eleven months later, she suffered a contralateral incomplete AFF. At the completion of the TRP treatment, she had only slight discomfort in the femur with the incomplete AFF. BMD testing revealed increase of 7.61% at the lumbar spine (LS) and 0.8% at the hip. Following TRP, 1-year SR treatment resulted in further BMD increase of 9.2% at the LS and 1.4% in the hip, while she does not report any pain. Bone markers remain within the normal range. CONCLUSION: Our case indicates that sequential therapy with TRP and SR in cases of AFF might be a rational treatment option. However, there is a need for additional information concerning the effect of TRP and SR, given alone or sequentially, in these patients in order to incorporate these drugs into the management of AFF.

Conservative treatment of an anterior-lateral ankle dislocation without an associated fracture in a diabetic patient: a case report.

Anterior or anterior-lateral dislocation of the ankle is a rare condition that can be treated conservatively as well as any other similar types of ankle dislocations without associated fractures. We present a case report of an anterior-lateral ankle dislocation with a concomitant avulsion injury of the ankle's anterior capsule in a diabetic patient that was treated conservatively. At the patient's visit 12 months after the initial injury, he was asymptomatic with full range of motion of the ankle joint. To our knowledge, we could not identify this type of an injury in a diabetic patient that was treated successfully with conservative treatment in the existing literature.

Case report: Teriparatide treatment in a case of severe pregnancy -and lactation- associated osteoporosis.

OBJECTIVE: Pregnancy- and lactation-associated osteoporosis (PLO) is an uncommon disease. The majority of cases are seen in the third trimester or early post-partum in primagravid women and the prominent clinical feature of PLO is severe and prolonged back pain and height loss. The prevalence and aetiology of this disorder are as yet unclear and there are no guidelines for its treatment. CASE REPORT: We report the outcomes of teriparatide (TRP) treatment in a woman suffering from severe PLO with 6 vertebral fragility fractures, severe back pain and very low BMD. RESULTS: Thirteen months after the initiation of therapy, the patient was almost free of back pain. There was no new clinical vertebral fracture. Her laboratory tests were all normal. BMD increased by 24.4% at the lumbar spine, 9.9% and 4.6% at the left and the right total hip and 12.6% and 7.8% at the left and right femur neck, respectively. CONCLUSION: TRP treatment simultaneously with weaning and calcium and vitamin D supplementation seems to considerably increase BMD, improve severe back pain and quality of life and prevent further occurrence of vertebral fractures, making TRP a helpful tool in restoring bone strength in PLO patients.

The use of bisphosphonates in women prior to or during pregnancy and lactation.

OBJECTIVE: The unique pharmacokinetics of bisphosphonates (BPs) in conjunction with their use by an increasing number of women at reproductive age has raised serious concerns about their safety during pregnancy and lactation. Bisphosphonates cross the placenta. Animal studies have shown adverse effects on both the fetus and the mother, mostly at doses much higher than those commonly used in humans. Protracted parturition, maternal mortality, embryolethality, severe general underdevelopment and marked skeletal retardation of the fetuses (increased amount of diaphyseal bone trabeculae, decreased diaphyseal length), small fetal weight and abnormal tooth growth have been observed. DESIGN: We conducted a thorough research of the literature in order to identify human studies concerning this issue. RESULTS: We identified a total of 78 cases involving fetuses whose mothers had been exposed to BPs before conception or during pregnancy, along with 7 cases of BPs exposure prior to or during lactation. The vast majority of mothers and infants did not demonstrate serious adverse effects. However, there were cases of shortened gestational age, low neonatal birth weight and transient hypocalcaemia of the newborns, while the very few reported cases of spontaneous abortions and congenital anomalies probably resulted from maternal underlying diseases and concomitant medication. CONCLUSION: The administration of bisphosphonates in pregnancy should be assessed in view of their potential hazardous effects on both mother and fetus. In cases of absolute or relative indications of BPs prior to pregnancy, close observation of the mother and the infant, especially during the first two weeks of life, is imperative for the successful outcome of pregnancy.