Abstract

Aim of this prospective, randomized study is to introduce and compare a new technique of reduction of the anterior dislocation of the shoulder with the “Hippocrates” and “Kocher” methods, as far as its efficacy, safety and intensity of the pain felt by the patient during the reduction, are concerned. This is the first reported prospective, randomized comparative study of three reduction techniques of anterior dislocations of the shoulder.

154 patients suffering from acute anterior shoulder dislocation participated in the study. Patients were randomly assigned to one of the three study groups (New, “Hippocrates” and “Kocher”) and underwent reduction of their dislocation performed by residents orthopaedic surgeons.

The groups were statistically comparable (age, male/ female ratio, mechanism of dislocation, mean time interval between injury and first attempt of reduction).

Reduction was achieved with the “Fares” method in 88.6%, with the “Hippocrates” in 72.5% and with the “Kocher” in 68% of the patients. This difference was statistically significant, favoring the new method (p=0.033). The mean duration of the reduction (p=0.000) and the mean reported by the patients VAS with the new method (p=0.000) were also statistically significantly lower than those of the other methods. No complications were noted in any group.

The new method seems to be more effective, faster and less painful method of reduction of the anterior shoulder dislocation, when compared with the “Hippocrates” and the “Kocher” methods. It is easily performed by only one physician and it is not more morbid that the other two methods.

Aggrecan is a major constituent of joint cartilage. A prominent feature in joint disease is loss of Aggrecan. The aim of this study was to assess the relation between the concentration of Aggrecan in the synovial fluid of knee joint and this of the peripheral blood in patients suffering from end stage knee osteoarthritis

37 postmenopausal women suffering from end-stage idiopathic knee osteoarthritis, scheduled to undergo Total Knee Arthroplasty (TKA), were enrolled in this study. Their mean age was 69.8 years (range: 49–81 years). The serum levels of Aggrecan were evaluated one day pre-operatively whether synovial fluid levels from fluid taken during the operation day.

Patients suffering from any endocrine disorder, rheumatoid or other secondary arthritis or any other disease that could interfere with the cartilage homeostasis were excluded from the study. Concentrations of aggrecan turnover were measured with appropriate assays.

Moderate correlation between serum and synovial fluid concentrations of aggrecan was revealed (r= 0, 337, p=0,197)

Serum levels of aggrecan may be related to the synovial concentration of Aggrecan in patients suffering from end stage knee osteoarthritis. The possible significant relationship between these markers may be of value in assessing cartilage degradation in patients with involvement of a single joint with a blood sample. However this correlation needs to be further investigated

Objective: The clinical significance of biochemical bone markers in the diagnosis and severity of Osteoarthritis remains still unknown. The relationship between biochemical bone turnover markers and commonly recognizable radiographic features of knee and hip osteoarthritis remains unclear.

Purpose: We evaluated the serum levels of Receptor Activator of Nuclear Factor-κB Ligand (RANKL), Bone-specific Alkaline Phosphatase (b-ALP), Osteocalcin and Osteoprotegerin in two groups of patients suffering from osteoarthritis of the Knee or Hip respectively, aiming to correlate these results with the radiographically assessed severity of the disease and the patients’ age. The results between the two groups were also compared.

Patients-Methods: Between March 2007 and February 2009, a total of 175 patients suffering from Knee or Hip Osteoarthritis were enrolled in the study. Following proper radiographic evaluation, the osteoarthritic changes of patients were graded by 3 orthopaedic surgeons according to the system of Kellgren and Lawrence; at the same time the serum levels of biochemical markers were determined.

Results: Osteoprotegerin was found to be positively correlated with age in both the Knee (r=0.376, p=0.000) and Hip (r=0.425, p=0.001) group, whether Osteocalcin was significantly correlated with the age in the group of Knee Osteoarthritis(r=0.218, p=0.02). No other significant correlation was noted between the serum level of markers and age of patients in both groups. There was not significant difference in the mean serum level of biochemical markers among patients belonging to each of the four different levels of severity of hip and knee OA. There was no significant impact of the type of Osteoarthritis, to the serum level of all biochemical markers.

Conclusions: Based on our results, it seems that none of the serum biochemical markers studied can be used (either independently or in combination with the others) as surrogates for radiographic imaging in Hip and Knee osteoarthritis.

Background: The clinical significance of bone turnover markers is well recognized, at least in several diseases affecting the bone metabolism. However, their clinical significance (if any) remains still unknown in patients undergoing Total Joint Arthroplasty (TJA). Changes in the levels of some markers have been reported in the early postoperative period after Total Hip Arthroplasty; however their exact postoperative course has not been clearly documented yet. In order to assess the clinical value of biochemical markers when trying to determine the fixation of orthopaedic implants, it is necessary to clarify their normal postoperative course.

The aim of this study was to extend the evaluation of the course of bone turnover markers over a longer period (12 postoperative months) following a TJA, and to assess the postoperative course for two of them (RANKL and Osteoprotegerin) for the first time.

Methods: The serum levels of RANKL, Osteocalcin, Osteoprotegerin and bALP were determined one day preoperatively and several times during the first postoperative year in patients suffering from idiopathic osteoarthritis that underwent total knee (n=23) and hip arthroplasties (n=24).

Results: There were statistically significant changes in the serum levels of all markers over time (p< 0,001). RANKL values initially increased and then gradually decreased. Following an initial decrease, Osteocalcin values continuously increased until the 2nd postoperative month and then continuously decreased. Osteoprotegerin initially increased, then decreased until the 4th postoperative month and then increased again reaching a peak 8 months postoperatively. Bone-specific ALP decreased until the 7th postoperative day. After that time it continuously increased, reaching a peak at the 8th month, and then it gradually decreased. There were no major differences in the postoperative course of all markers between the hip and knee arthroplasties.

Conclusions: The levels of all bone markers did not uniformly ‘return’ to their preoperative values one year postoperatively. A one-year period is not enough, when assessing an orthopaedic implant’s fixation with the use of bone turnover markers.

Background: Little work has focused on the effect of formal bracing on the health-related quality of life (QOL) of affected adolescents

Aim: The aim of this comparative study was to assess the quality of life of adolescents with Idiopathic Scoliosis in relation with the duration of application of modified Boston brace, as a conservative treatment.

Methods: 91 adolescents, 10 to 18 years old with idiopathic scoliosis who were treated conservatively with modified Boston brace took part in this study. The mean daily time of brace application was over 12 hours. Adolescents with history of acute or chronic illness, surgical treatment, mental retardation, neuromuscular disease or other congenital anomaly were excluded from the research.

The adolescents were divided in two groups. In the first group (n=47) were included adolescents wearing the brace for over two years (mean time of application 3, 3 years) and the second group (n=44) included adolescents, which have been treated with Boston brace for less than two years (mean time of application 1, 2 years).

Every child completed a detailed questionnaire (SRS-22) concerning the evaluation of function, pain, self image, mental health and satisfaction with management. Both groups were comparable according to age and degrees of scoliotic curve.

Results: There was no statistical significant difference concerning the results in every domain of the questionnaire between both groups. However the results concerning mental health show tendency towards significance favoring the second group.

Conclusion: Mental health of adolescents with Idiopathic Scoliosis wearing modified Boston brace needs to be further investigated.

Background: There are several methods to reduce anterior shoulder dislocations but only few studies compare the efficacy, safety and reliability of the different techniques. As a result, deciding which technique to use is seldom based on objective criteria. Aim of this prospective, randomized study is to introduce a new method of reduction of the anterior dislocation of the shoulder (“Fares”) and to compare it with the “Hippocrates” and “Kocher” methods, as far as its efficacy, safety and intensity of the pain felt by the patient during the reduction, are concerned.

Methods: Between September 2006 and June 2008, a total of 154 patients suffering from acute anterior shoulder dislocation (accompanied by a fracture of the greater tuberosity or not) were enrolled in the study. Patients were randomly assigned to one of the three study groups (“Fares”, “Hippocrates” and “Kocher”) and underwent reduction of their dislocation performed by first and second-year residents orthopaedic surgeons. A Visual Analogue Scale (VAS) was used to determine the intensity of the pain felt during reduction.

Results: The groups were statistically comparable (age, male/female ratio, mechanism of dislocation, mean time interval between injury and first attempt of reduction). Reduction was achieved with the “Fares” method in 88.6%, with the “Hippocrates” in 72.5% and with the “Kocher” in 68% of the patients. This difference was statistically significant, favoring the “Fares” method (p=0.033). The mean duration of the reduction (p=0.000) and the mean reported by the patients VAS with the “Fares” method (p=0.000) were also statistically significantly lower than those of the other methods. No complications were noted in any group.

Discussion: The “Fares” method was statistically proven to be a significantly more effective, faster and less painful method of reduction of the anterior shoulder dislocation, when compared with the “Hippocrates” and the “Kocher” methods. It is easily performed by only one physician, it is applicable both to anterior shoulder dislocations and fractures-dislocations and it is not more morbid that the other two methods.

Background: Hip fractures in the elderly have epidemic character. Although hip fractures have been considered as a single, homogeneous condition, there are two major anatomic types of proximal femoral fractures: intertrochanteric and femoral neck.

Aim: The purpose of our study is determining if patients suffering from these two types of hip fracture have different characteristics. Are demographics predictor factors of the type of hip fracture following fall in the elderly?

Patients and Methods: A retrospective study of patients admitted to a tertiary referral hospital for a hip fracture between 2003 and 2007 was conducted A total of 652 patients participated in the study, aged between 64–97 years old. 159 patients were men and 493 women.

Patients were divided into two groups according to the type of hip fracture. Group 1 included 299 patients with subcapital fractures, 61 men and 238 women and the second group 353 patients with intertrochanteric fractures, 98 men and 298 women. Patients’ demographics concerning age, sex, weight, height on admission at the hospital were compared between groups.

Results: The mean age (79± 9,4) of the patients with intertrochanteric fracture was statistically significant greater(Mann-Whitney test, p=0,001) than this of the patients with femoral neck fractures (76± 11,5).The sex ratio between the two groups seem to be significant different (x2 test, p=0,029) However following stratification of the data the effect of sex on the type of fracture disappeared. Mean height (Mann-Whitney test, p=0,765) and weight (Mann-Whitney test, p=0,448) did not differ significantly between the two groups. The mean time of hospitalization for the group of intertrochanteric fractures was significantly greater than this of the subcapital group(Mann-Whitney test. p=0,001).

Conclusions: It appears that intertrochanteric fracture patients have intrinsic factors (older age and consequently poor health) impacting upon their risk of fracture and ability to recover. Differences in patient characteristics and sequelae do exist between femoral neck and intertrochanteric hip fracture patients that impact upon recovery. However somatometric characteristics as height and weight did not differ significantly between the two types of fractures.

Introduction: Aim of this prospective study was the evaluation of the impact of TKA on the serum level of I-PTH, as continuously elevated levels of the latter may potentially play a negative role in an orthopaedic implant’s incorporation process.

Methods: The study-group was formed by 119 post-menopausal women suffering from end-stage idiopathic knee osteoarthritis scheduled to undergo TKA. Another 110 women that underwent elective non-orthopaedic operations were used as a control-group. The serum levels of I-PTH, Ca, P & creatinine were evaluated and the clearance of creatinine was calculated one day preoperatively and on the seventh postoperative day. Patients with abnormal preoperative values, suffering from endocrinopathies, rheumatoid or other secondary arthritis, osteoporosis or diseases interfering with bone homeostasis, as well as patients receiving medication affecting bone metabolism, were excluded. None had suffered any fracture or underwent any orthopaedic operation during the 36 months prior to her enrollment.

Results: The two groups were statistically comparable [age (p=0.72), weight (p=0.43), duration of menopause (p=0.31), serum creatinine level (p=0.49), creatinine clearance (p=0.74), preoperative serum I-PTH value (p=0.67)]. Sixteen patients of the study- (13.4%) and one of the control-group had abnormally elevated post-operative I-PTH values. Further analysis showed a statistically non-significant trend towards decrease in the post-operative I-PTH values of the study-group (p=0.16) compared with the control-group’s results were the I-PTH values remained statistically unchanged (p=0.55). No statistically significant difference was found in the postoperative serum I-PTH values between the two groups (p=0.21). The patients’ weight (p=0.76), age (p=0.77), serum creatinine (p=0.92) and creatinine clearance (p=0.96) did not have a statistically significant impact on the observed alteration of I-PTH values after TKA (study-group).

Discussion/Conclusion: The serum levels of I-PTH slightly decrease following TKA. This may attributed to the necrosis or apoptosis initiated immediately after implantation, leading to increased bone resorption and increased serum calcium concentrations that may well decrease the endogenous PTH production. Another possible explanation is the temporary immobilization of the patients undergoing TKA. A substantial number of our study-group’s women had abnormally elevated post-operative I-PTH values. Regardless of what actually caused it, the negative impact of continuously elevated PTH on bone formation, may interfere with the implant’s incorporation procedure, hence the evaluation of serum I-PTH before and after TKA is strongly recommended.

Background: The relation between Adolescent Idiopathic Scoliosis (AIS) and exercising is rather ambiguous. The latter has often been considered both as a therapeutic means as well as a causative factor of the former. Aim of this cross-sectional case-control study was the assessment of the incidence of AIS among athletes and non-athletes in order to determine whether athletic activities play a potential role (positive or not) in the development of AIS.

Methods: A group of 2387 adolescents (1177 boys and 1210 girls) was evaluated. Their mean age was 13.4 years (range:12–15 years). All patients completed a detailed questionnaire concerning personal, somatometric and secondary sex characteristics, type, duration and character of daily performed physical activities and existing cases of AIS among their relatives. The patients were classified into 2 groups according to their answers; ‘athletes’ and ‘non-athletes’. The 2 groups were statistically comparable as far as age, height, weight, onset of menstruation and prevalent extremity were concerned. All children underwent physical examination by 3 orthopaedic surgeons that were unaware of their level of athletic activities. Children considered, by all examiners, to be suspicious of suffering from scoliosis underwent further radiographic evaluation.

Results: One hundred and seventy seven children (66 boys and 111 girls) were considered as suspicious; in 99 cases (athletes: 48, non-athletes:51) AIS was radiographically confirmed. No statistically significant difference was found between athletes and non-athletes adolescents (p=0.927), athletes and non-athletes boys (p=0.888) and athletes and non-athletes girls (p=0.804), as far as the prevalence of AIS was concerned. There was also no statistically significant difference between male athletes and non-athletes (p=0.899) and female athletes and non-athletes (p=0.311) as far as the mean value of the Cobb angle of the main scoliotic curve was concerned.

Conclusions: This study’s results show that systematic exercising is not positively or negatively associated with a higher or lower incidence of AIS. Furthermore, actively participating in sports activities doesn’t seem to correlate with the degree of the main scoliotic curve either.

Introduction: Parathyroid hormone (PTH) is a major regulator of bone metabolism. Continuously elevated levels of PTH activate osteoclasts, whereas its intermittent administration principally induces osteoblastic activity. There is increasing evidence that intermittent treatment with PTH may enhance the early fixation of orthopaedic implants. Aim of this study was the evaluation of the impact of Total Knee Replacement (TKR) on the serum level of Intact-Parathyroid Hormone (I-PTH), as continuously elevated levels of the latter may potentially play a negative role in the implant’s incorporation process.

Methods: During a period of 29 months, one hundred and nineteen postmenopausal women suffering from end-stage idiopathic knee osteoarthritis, scheduled to undergo TKR, were enrolled in this prospective study. Their mean age was 69.8 (±6.01) years. The serum levels of I-PTH, Calcium, Phosphorus & Creatinine were evaluated and the clearance of creatinine was calculated one day pre-operatively and on the seventh post-operative day. Patients with abnormal preoperative values were excluded from the study. Furthermore, patients suffering from any endocrine disorder, rheumatoid or any other secondary arthritis, osteoporosis or any other disease that could interfere with their bone homeostasis as well as patients receiving medication affecting bone metabolism, were also excluded from the study. None had suffered any fracture or underwent any orthopaedic surgical operation during the 36 months prior to their enrollment.

Results: Sixteen patients (13.4%) had abnormally elevated post-operative I-PTH values. However, statistical analysis revealed a statistically significant trend towards decrease in post-operative I-PTH values (p=0.018). The weight (p=0.763), age (p=0.776), serum creatinine level (p=0.922) and creatinine clearance of the patients (p=0.963) did not have a statistically significant impact on the observed alteration of I-PTH values after TKR.

Discussion and Conclusion: The serum levels of I-PTH seem to decrease following a TKR. This is more or less expected, as immediately after implantation, bone cells adjacent to the implant are likely to be dead due to necrosis or apoptosis. The latter is a strong stimulus for bone resorption that probably leads to increased serum calcium concentrations that may well decrease the endogenous PTH production. Another possible explanation could be the temporary immobilization of the patients undergoing TKR. However, a substantial number of women had abnormally elevated post-operative I-PTH values. Regardless of what actually caused that increase, the negative impact of continuously elevated PTH on bone formation, may interfere with the implant’s incorporation procedure, hence the evaluation of serum I-PTH before and after TKR is strongly recommended.

Background: Caudal extradural steroid injection is an alternative method of treating patients with chronic low back pain and sciatica.

Aim: The purpose of our study is determining the effectiveness of the caudal extradural steroid injection in patients with severe chronic low back pain and sciatica.

Patients – Methods: A total of 158 patients with severe and chronic low back pain and sciatica participated in the study, aged 23–78 years old. 86 patients were men and 72 women.

Patients were divided into two groups according to the injected drug. Group 1 or the injected group (n=91) received a caudal extradural injection (CEI) that consists of 12 to 15 ml of 2% xylocaine together with 1 ml of Betamethasone Dipropionate and Betamethasone phosphate. Group 2 or the placebo group (n=52), received a caudal extradural injection that consists of 6–8 ml of 2% xylocaine mixed with 6–8 ml of water for injection. The mean duration of symptoms was comparable between the two groups.

In order to estimate the degree of recovery from symptoms, all patients answered a specific questionnaire. The Oswestry Disability Index Questionnaire (ODI) was answered by all patients on the first day of clinical examination, and on different follow-up periods after caudal injection.

The straight leg-raising test was evaluated in all patients at the same follow – up periods.

Results: Recovery from symptoms and a decrease in the O.D.I score after the CEI was observed in both groups. However the mean ODI score of the injected group was statistically significant lower than this of control group for a period until one month after the injection (p < 0,001, Wilkoxon Signed Ranks test). Also the mean improvement time of positive SLR test in the injected group was statistically significant lower than this of control group (log rank test, p = 0,019)

Conclusions: The caudal extradural steroid injection is a reasonable non-surgical therapeutic option among patients with severe chronic low back pain and sciatica. It offers pain relief to patients who do not respond to prolonged conservative therapy, or who refuse surgery. It can easily be performed in the outpatient clinic.