Pediatric Hemophilic Arthropathy of the Knee: Treatment With Circular External Fixator and Intra-articular Injection of Platelet-Rich Plasma.

There are limited reports about managing knee flexion contracture (KFC) due to hemophilic hemarthrosis with the Ilizarov technique and platelet-rich plasma intraarticular injection administration. This article aims to describe a case of KFC treated with a circular external fixator and intraarticular administration of platelet-rich plasma in a pediatric patient. A 12-year-old male patient suffering from hemophilia A was being monitored by our department due to knee effusions. Extensive knee flexion contracture of the left knee was seen. The Ilizarov technique was chosen for surgical management of the worsening knee flexion contracture. The duration of distraction was six weeks. Due to localized pain and functional impairment, intra-articular administration of platelet-rich plasma (PRP) was applied twice, on the first month after the circular frame removal and at a six-month follow-up, with clinical and functional improvement. Our clinical case report demonstrates that PRP intra-articular injections are likely to provide an improvement in pain and knee joint function, as well as joint hyperemia, even in the case of already established knee flexion contracture, which was managed with a circular distraction device. However, more studies regarding the Ilizarov technique and the PRP intraarticular administration are needed for a protocol to be established for the management of the hemophilic knee joint in the pediatric population.

Surgical Treatment of Congenital Kyphosis in Children: Report of a Rare Complication of Remote Cerebellar Haemorrhage.

Congenital deformities of the spine lead to an imbalance in the longitudinal growth of the spine. These growth abnormalities may lead to three main patterns of deformity: scoliosis (the most common), kyphosis or lordosis (the least common). Despite the recent improvements in imaging and the routine use of neuromonitoring in the surgical treatment of congenital kyphosis, this surgery may be associated with a high rate of complications such as neurologic deficit, pulmonary thromboembolic events, infection, deep vein thrombosis, implant failure, and dural injury. In this paper, we report a rare yet devastating complication to raise awareness about patients who have unexpected neurological deterioration after spinal surgery. Early recognition of remote cerebellar haemorrhage (RCH) symptoms is crucial since rapid diagnosis and management lead to a favourable outcome for this potentially life-threatening complication. To our knowledge, this is the first reported case in children.

Salmonella Septic Hip Arthritis in Immunocompetent Children: Three Case Reports and Literature Review.

Septic arthritis is an orthopaedic emergency, especially considering the pediatric population. Salmonella is a less common aetiologic factor for septic arthritis compared with other Gram-negative bacteria. Its isolation in immunocompetent children and infants is quite rare, with an estimated incidence of 0.1% to 0.2% of septic arthritis cases among children. We report three rare cases of hip septic arthritis with Salmonella as a confirmed pathogen in immunocompetent children, with two of them being infants. The main symptoms that occurred in all three cases were fever, hip pain/no bearing, and diarrhoea, as well as elevated levels of WBC, C-reactive protein and ESR. The duration of their hospitalization was 20, 26 and 52 days. One case was treated only with antibiotics, while the other two with surgical drainage with/without arthrotomy. All cases had a follow-up of at least one year, with only one of the infants having the femoral head in a subluxated position and early signs of osteonecrosis. Fluoroscopy-assisted closed reduction had to be performed and maintained by hip spica. A new femoral epiphysis was formed at the time of the last follow-up 2.5 years later. Our case series highlights the possibility of Salmonella typhi septic hip arthritis in immunocompetent individuals. Therefore, Salmonella species must always be kept in mind during the differential diagnosis of septic arthritis in a clinically relevant setting.

Routine needle biopsy during vertebral augmentation procedures. Is it necessary?

Vertebral augmentation procedures are currently widely performed to treat vertebral compression fractures. The purpose of this study was to determine the frequency of underlying previously unrecognized etiology in a consecutive series of patients undergoing kyphoplasty to treat vertebral compression fractures. A prospective histological evaluation of vertebral body biopsy specimens from presumed osteoporotic vertebral compression fractures were performed in order to identify aforementioned causes. Over a 2-year period, vertebral body biopsies from 154 vertebral levels were performed in 75 patients undergoing kyphoplasty for vertebral compression fractures. All patients received a preoperative workup that included plain radiographs, MRI, whole body bone scan, and laboratory examinations. Bone specimens were obtained from affected vertebral bodies and submitted for histologic evaluation to identify the prevalence of an underlying cause. All specimens demonstrated fragmented bone with variable amounts of unmineralised bone, signs of bone-remodeling and/or fracture-healing. In 11 patients underlying pathology other than osteoporosis was identified (prostate cancer, 1; pancreatic cancer, 1; colon cancer, 1; breast cancer, 2; multiple myeloma, 3; leukemia, 1; and lung cancer, 2). In all but one patient the results of the biopsy confirmed the diagnosis suspected from the preoperative workup. For the last patient, namely the one with pancreatic cancer, the workup did not identify the origin of the primary tumor, although the patient was considered to have a compression fracture secondary to metastatic disease of unknown origin, the vertebral biopsy suggested the presence of adenocarcinoma which eventually was proven to be pancreatic cancer. In augmentation procedures for vertebral compression fractures, bone biopsy should be reserved for the patients where the preoperative evaluation raises the suspicion of a non-osteoporotic etiology.

Proximal tibial stress fractures associated with primary degenerative knee osteoarthritis.

Tibial stress fractures are not rare--they have been extensively studied in young athletes and soldiers and in elderly people with rheumatoid arthritis, osteoporosis, Paget's disease, pyrophosphate arthropathy, and hyperparathyroidism--but they seldom occur in patients with severe primary degenerative knee osteoarthritis. The etiology, diagnosis, and optimal treatment of these fractures remain a challenge. In this article, we review the English-language literature on the symptoms, diagnosis, treatment options, and final outcomes of these fractures, and we report 2 new cases of proximal tibial stress fractures in elderly women with severe primary degenerative knee osteoarthritis.

Anatomic double-bundle versus single-bundle ACL reconstruction: a comparative biomechanical study in rabbits.

Thirty New Zealand white rabbits underwent anterior cruciate ligament (ACL) reconstruction in their right knees; 15 animals underwent a double-bundle anatomic ACL reconstruction using the medial third of the patellar tendon and the semitendinosus tendon. Additionally, 15 animals underwent ACL reconstruction, using a single-bundle semitendinosus tendon autograft. The knees of both groups were evaluated with a device similar to the KT1000 arthrometer onto which a dial indicator was attached (Mitutoyo dial indicator 2050) in 30 degrees and 90 degrees of flexion, preoperatively, after ACL resection and 3 months postoperatively. Statistical analysis of the results revealed that for 90 degrees of knee flexion, the mean estimated anterior shift for the double-bundle technique was 1.92 mm lesser than that of the single-bundle technique (P = 0.006). For 30 degrees of knee flexion, the mean anterior shift was again lesser than that of the single-bundle technique by 0.66 mm, but this difference was not statistically significant. The described double-bundle ACL reconstruction technique resulted in a more stable knee as far as the anterior tibial shift was concerned as compared to a single-bundle ACL reconstruction. This animal model may be potentially useful in the future for the study of other parameters influencing the outcome of the double-bundle ACL reconstruction.

High levels of synovial fluid osteoprotegerin (OPG) and increased serum ratio of receptor activator of nuclear factor-kappa B ligand (RANKL) to OPG correlate with disease severity in patients with primary knee osteoarthritis.

OBJECTIVE: Evaluation of serum and synovial fluid OPG and sRANKL in 37 patients with primary knee osteoarthritis. DESIGN AND METHOD: OPG and sRANKL were measured using ELISA. RESULTS: OPG, sRANKL and sRANKL/OPG were increased in osteoarthritis patients' serum. Synovial OPG was higher than serum OPG, while sRANKL/OPG was higher in the serum; both correlated with disease severity. DISCUSSION: RANKL/OPG pathway is implicated in the pathogenesis of knee osteoarthritis being a suitable target for therapeutic intervention.

Transient osteoporosis of the knee.

A 52-year-old man presented with a 3-week history of right knee pain, significant enough to prevent weight bearing. There was no history of knee injury or disease. On knee examination, an effusion and medial joint line tenderness was noted. Knee range of motion was full, but painful. Radiographs revealed minor osteoarthritic changes. Laboratory values were within normal limits, including those associated with infection. Magnetic resonance imaging showed decreased signal intensity on T1-weighted images within the medial femoral condyle and corresponding increased signal intensity on T2-weighted consistent with bone marrow edema as well as edema to the adjacent soft tissues. Bone scanning showed increased uptake of radioisotope in the medial femoral condyle. The patient was diagnosed with bone marrow edema syndrome, and managed medically with analgesics and continued non weight-bearing status. At the 1-month follow-up, his symptoms had improved significantly. The patient progressively increased weight bearing as tolerated over the subsequent weeks. At 12-week follow-up, symptoms had completely resolved. Magnetic resonance imaging showed no signal abnormalities in the affected knee. Transient osteoporosis is an uncommon and typically self-limiting condition that can be challenging to diagnose and treat. The clinician must be aware of this entity, as well as its typical course, to prevent unnecessary testing and invasive intervention.