The Effect of Strontium Ranelate on Fracture Healing: An Animal Study.

BACKGROUND: Strontium ranelate (StR) is an antiosteoporotic agent previously utilized for the enhancement of fracture union. We investigated the effects of StR on fracture healing using a rabbit model. METHODS: Forty adult female rabbits were included in the study and were divided in 2 equal groups, according to StR treatment or untreated controls. All animals were subjected to osteotomy of the ulna, while the contralateral ulna remained intact and served as a control for the biomechanical assessment of fracture healing. Animals in the study group received 600 mg/kg/day of StR orally. All animals received ordinary food. At 2 and 4 weeks, all animals were euthanatized and the osteotomy sites were evaluated for healing through radiological, biomechanical, and histopathological studies. RESULTS: The treatment group presented statistically significant higher callus diameter, total callus area, percentage of fibrous tissue (p < 0.001), vessels/mm2, number of total vessels, and lower osteoclast number/mm2 (p < 0.05) than the control group at 2 weeks. Additionally, the treatment group presented significantly higher percentages of new trabecular bone, vessels/mm2, osteoclast number/mm2, and lower values for callus diameter, as well as total callus area (p < 0.05), than the control group at 4 weeks. At 4 weeks, in the treatment group, force applied (p = 0.003), energy at failure (p = 0.004), and load at failure (p = 0.003) were all significantly higher in the forearm specimens with the osteotomized ulnae compared to those without. Radiological bone union was demonstrated for animals receiving StR at 4 weeks compared with controls (p = 0.045). CONCLUSION: StR appears to enhance fracture healing but further studies are warranted in order to better elucidate the mechanisms and benefits of StR treatment.

Simultaneous Periprosthetic Fractures of the Femur and the Acetabulum After Bipolar Hip Arthroplasty.

BACKGROUND Although periprosthetic fractures of the femur are a recognized complication of total hip arthroplasty, periprosthetic fractures of the acetabulum are rare. Simultaneous periprosthetic fractures of both the acetabulum and the femur have not been reported, to our knowledge. CASE REPORT We report a simultaneous fracture of the acetabulum and the femur in a 68-year-old female patient who had previously sustained a subcapital fracture of the femur, treated with a bipolar uncemented prosthesis. We discuss the possible mechanism of this combination of fractures. CONCLUSIONS Simultaneous periprosthetic fractures of the femur and the acetabulum can occur if, in the presence of osteoporotic bone, the metallic femoral head has migrated medially in the acetabulum while the femoral stem is not loose.

Small diameter acetabulum and femoral head in total hip arthroplasty for developmental dysplasia of the hip, with no femoral osteotomy.

We present the results of 66 total hip arthroplasties in 62 patients of mean age 46 years (24-74 years), with developmental dysplasia of the hip. In all cases the centre of rotation of the new hip was positioned at the site of the true acetabulum. In all patients cementless press fit acetabular components of small diameter (42-44 mm) were used, articulating exclusively with a 22.25 mm modular metal femoral head, without the use of bone grafts or shortening osteotomies of the femur. Despite the use of small diameter femoral heads the rate of dislocation was 3%. After an average follow-up period of 9 years (4-18 years), no revisions were required for infection, loosening or wear or implant migration. Osteolytic lesions were seen in the periacetabular region in 3 patients who were symptom free. A total of 2 revisions were required for instability and 2 patients had the wires of their trochanteric osteotomy removed because of bursitis. Leg length inequality was improved in 55% of the patients and one postoperative transient sciatic nerve lesion settled within 4 months. We believe that in patients with painful dysplastic hips, the use of small diameter implants with the centre of rotation at the true acetabulum, can give very satisfactory results, without any supplementary procedures.

The association of adipokine levels in plasma and synovial fluid with the severity of knee osteoarthritis.

OBJECTIVE: We sought to determine the association between plasma and SF levels of leptin and adiponectin in patients with knee OA. METHODS: Plasma and SF levels of adipokines and soluble leptin receptor (sOB-R) were determined by ELISA in 96 patients with knee OA at different stages, according to Ahlback's classification. RESULTS: Levels of adiponectin, leptin, sOB-R and free leptin in plasma and SF did not differ significantly across categories of OA severity. However, the ratio of SF to plasma leptin was significantly lower in the advanced OA stage compared with early stages of the disease (P = 0.02). After adjustment for sex and BMI, plasma leptin positively correlated with categories of OA severity (r = 0.23, P = 0.02), whereas SF/plasma leptin negatively correlated with OA stage (r = -0.27, P = 0.01). Cluster analysis showed that all men were included in one cluster and distributed in different stages of OA, whereas women formed three clusters with similar BMI, but those who were older and had the highest plasma leptin levels suffered from advanced OA. CONCLUSION: Plasma leptin positively correlated with the severity of knee OA. The ratio of SF to plasma leptin might be a marker related to the severity of knee OA. Further studies should investigate whether similar associations exist in other joints affected by OA.

Serum TGF-beta2 and TGF-beta3 are increased and positively correlated to pain, functionality, and radiographic staging in osteoarthritis.

The goal of this study was to verify or reject the hypothesis that systematic differences exist in various profibrotic or antifibrotic factors between osteoarthritic patients and controls, as well as between different stages of osteoarthritis. The study group comprised 63 patients with knee osteoarthritis and 18 controls. Transforming growth factor-beta (TGF-beta)1, -2, -3; tissue inhibitor of metalloproteinase (TIMP)-1 protein levels; and gelatinolytic activity of matrix metalloproteinase (MMP)-1, -2, -3, -9 activities were measured by enzyme-linked immunosorbent assay and gelatin zymography, respectively. Visual analog scale scores, Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, Lequesne clinical osteoarthritis scales, and Kellgren-Lawrence radiographic grading were recorded for each patient.Transforming growth factor-beta2 and -3 (in contrast to TGF-beta1 and TIMP-1) serum protein levels were significantly higher in osteoarthritic patients compared to controls (210%+/-14% [P<.001] and 232%+/-7% [P<10(-7)], respectively). Additionally, TGF-beta2 and -3 were strongly positively correlated to Kellgren-Lawrence radiographic grading of the disease (P<10(-5) and P<10(-7), respectively). Moreover, TGF-beta2 correlated positively with the WOMAC scale (P=.007). However, TIMP-1 decreased as osteoarthritis progressed clinically, but remained irrelevant to radiographic staging. Furthermore, activities of MMP-2 and -9, but not MMP-1+/-3, were lower in patients with osteoarthritis.

Systematic effects of surgical treatment of hip fractures: gliding screw-plating vs intramedullary nailing.

AIM: Numerous studies have been published regarding the comparison between intramedullary nail and the dynamic hip screw and plate for the fixation of intertrochanteric fractures in elderly patients. In this paper we present a comparative study of these two methods regarding their systemic effects on this group of patients. MATERIALS-METHODS: This is a randomized trial of 120 consecutive patients with an intertrochanteric fracture treated with either extramedullary fixation (dynamic hip screw and plate; DHS, Synthes-Stratec, Oberdorf, Switzerland) or intramedullary nail (Gamma nail, Stryker Howmedica, Freiburg, Germany and Endovis BA, Citieffe, Bologna, Italy). The parameters that we assessed pre-operatively, in addition to their demographics, included their mental state (MMSE), their nutritional and immune state and their pulmonary function. Intra-operatively we calculated the amount of radiation exposure, the amount of blood loss and the length of operative time for each procedure. Postoperatively we repeated the calculation of the mental and pulmonary state and the blood loss, during days 1, 3, and 10 and related them to the ease of the patient's mobilization. RESULTS: Decreased bleeding and post-operative pain, reduced post-operative morbidity and faster recovery of function were better but not significant in the group of intramedullary fixation (all p>0.05). However, in the same group there were slightly more patients in whom the MMSE was falling, together with their pulmonary function, suggesting that this method probably predisposes to higher chances of pulmonary dysfunction and the possibility of pulmonary embolism. CONCLUSION: We found no significant differences between the two methods of stabilization of these fractures regarding their systemic effects perioperatively. The classic dynamic hip screw can preserve its position as a safe and effective solution for these already vulnerable patients having sustained a trochanteric fracture against the novel intramedullary techniques.

Peroneal nerve damage by bicortical tibial screw in ACL reconstruction.

Arthroscopically assisted anterior cruciate ligament reconstruction is regarded as a minimally invasive surgery with low morbidity but complications still occur. Reports of neurovascular injuries related to graft harvesting, tunnel placement, or graft fixation are limited. A rare case of peroneal nerve injury related to hardware used for graft fixation in the tibial in a 28-year-old female patient who underwent an anterior cruciate ligament reconstruction surgery using a patellar tendon graft (bone-tendon-bone graft) is presented. Post-operatively, the patient presented with clinical signs of peroneal nerve damage and a reduced range of motion of the knee. Plain radiographs of the knee showed the bicortical screw which used for tibial fixation of the graft, penetrating the fibula and projecting beyond the lateral cortex of the fibular neck. The patient was treated with removal of the hardware and the graft. Intensive physiotherapy resulted in gradual improvement and at 6 months after the second operation the patient regained full range of motion of the knee and almost full muscle strength performing her daily activities without any difficulty and she is at the moment unwilling to undergo further procedure.

Talar body fracture combined with bimalleolar fracture.

The incidence of talar fractures is relatively low affecting usually young patients, while recent epidemiological studies have shown that talar body fractures represent a significant proportion of the total number of talar fractures. Talar body fractures are usually high-energy injuries and often a combined talar neck and body fracture is noted. An association between talar body fractures and ankle fractures has also been recorded involving the medial or lateral malleolus. The only report of a talar fracture combined with a bimalleolar ankle fracture that was found in the literature is referred to a talar neck fracture. In this report, a combination of a talar body fracture and bimalleolar ankle fracture in a polytraumatised young patient is presented. This combined injury pattern seems to be very rare, since a similar case was not found in the literature. An open reduction and internal fixation of the talar body fracture as well as the bimalleolar fracture, followed by a prolonged non-weight bearing, led to a fracture healing with no evidence of osteonecrosis. Minimal osteoarthritic changes of the tibiotalar joint were noted at 3 years follow-up with satisfactory functional results.

Anastomosis between the median and ulnar nerve in the forearm. An anatomic study and literature review.

Anastomosis between the median and ulnar nerve in the forearm has been shown to be of clinical significance. We aimed to determine the presence of median to ulnar nerve communications in the forearm of the Greek population by anatomical studies. At the same time we defined the types and patterns of the anastomoses found and compared them to those reported in similar studies that were retrieved after a wide review of the literature. One hundred and sixty three forearms from 100 cadavers (53 males, 47 females, 25-91 years old) were carefully dissected to observe median and ulnar nerve communication. The anastomosis was found in 10 cadavers; it was bilateral in 4 and unilateral in 6, on the right side in four and on the left side in two. It occurred in 7 of the 53 male cadavers (14%) and in 3 of the 47 females (6.5%). Overall, the anastomosis was found in 14 of the 163 forearms (8.6%). No case of ulnar to median nerve anastomosis in the forearm was found in anatomical examination.