Denosumab ed osteoporosi grave: studio osservazionale su efficacia, tollerabilità e compliance del paziente

Il Denosumab è un anticorpo monoclonale umano diretto contro il RANK ligando, il principale mediatore del riassorbimento osseo. Si tratta di uno studio osservazionale su 278 pazienti in trattamento con Denosumab. Al termine del periodo di osservazione sono stati valutati parametri inerenti l'efficacia, la compliance e la tollerabilità del trattamento

CONFRONTO TRA RICOSTRUZIONE BIOLOGICA E SINTETICA DEL LEGAMENTO CROCIATO ANTERIORE DEL GINOCCHIO UTILIZZANDO LA MEDESIMA TECNICA CHIRURGICA ARTROSCOPICA AD UN FOLLOW-UP MEDIO DI 8 ANNI

Introduzione: Lo scopo di questo studio retrospettivo è stato quello di confrontare l’outcome clinico, funzionale e radiografico di pazienti sottoposti a ricostruzione del legamento crociato anteriore con un graft autologo (tendini dei muscoli gracile e semitendinoso) o sintetico di seconda generazione (LARS®), in pazienti con lesione sintomatica del LCA. Materiali e Metodi: Sono stati rivalutati 50 pazienti(25 GR-ST vs 25 LARS) trattati presso la nostra clinica. I pazienti sono stati valutati da un punto di vista clinico, funzionale oggettivo e soggettivo (tramite le schede di valutazione Lysholm Score, la International Knee Documentation Committee e la Tegner Activity) e strumentale (tramite radiografie del ginocchio in ortostatismo analizzando la degenerazione dello spazio articolare, classificazione di Alhback). La tecnica chirurgica eseguita in tutti i pazienti è quella artroscopica trans-tibiale con half-tunnel femorale. Risultati: Ad un follow-up medio di 8 anni le manovre specifiche di valutazione del LCA, eseguite dallo stesso operatore, evidenziano un Lachman test debolmente positivo (+ - -) solamente nel 24% dei casi nei pazienti con LARS®, nessun paziente marcatamente positivo (+ + -) o totalmente positivo (+ + +); tra i pazienti operati con gracile-semitendinoso il 56% dei casi presentano una lieve, marcata o totale positività. Più marcata la discrepanza con la manovra del Cassetto Anteriore: pazienti con LARS® presentano lieve positività (+ - -) nel 16% dei casi rispetto ai pazienti con gracile-semitendinoso (48%). La maggior instabilità articolare si riflette anche nelle maggiori alterazioni radiografiche riscontrate nei pazienti in cui il LCA è stato ricostruito con tendini gracile-semitendinoso (pazienti senza alterazioni 64% vs 84% del LARS; pazienti in stadio 1-2 di Alhback 32% vs il 16% del LARS). Questi dati ci mostrano come una maggior instabilità porti come conseguenza un più alto grado di degenerazione articolare. I punteggi ottenuti dal test di valutazione soggettivo IKDC sono sovrapponibili, il 64% dei pazienti con LARS ed il 60% dei pazienti con gracile-semitendinoso hanno ottenuto un punteggio ottimo (80-100). Conclusioni: Il nostro studio a medio-lungo termine evidenzia una maggior stabilità articolare nella ricostruzione del LCA con LARS rispetto al gracile-semitendinoso alla valutazione clinica e radiografica mentre non mostra significative differenze tra i due gruppi dal punto di vista funzionale

Comparison of 50 vertebral compression fractures treated with surgical (kyphoplasty) or non surgical approach

The presence of a vertebral fracture increases the risk of a new fracture within a year by at least five times and the risk further increases in case of recurrent fractures (domino effect). The pain and fracture kyphosis can compromise respiratory function. Many patients sustain serious cardiovascular, musculoskeletal, metabolic, and immune complications related to immobility and bedrest. This study is a clinical and radiological assessment of a consecutive cohort of 50 patients with vertebral fractures. We made comparison of 25 vertebral compression fractures treated with surgical (kyphoplasty) or non surgical approach. Systematic reviews of this procedure have shown significantly improved back pain and quality of life compared to conservative therapy. When performed by a well-trained practitioner in appropriately selected patients, kyphoplasty is a safe and effective treatment for fresh vertebral compression fracture

Clinical and surgical approach of severe bone fragility fracture: clinical case of 4 fragility fracture in patient with heavy osteoporosis

An accurate diagnosis of osteoporosis and a proper treatment are today recognized to be the most important facts for prevention and for a correct arrangement and treatment of fragility fractures. In the text the Authors describe a case of severe osteoporosis aggravated by 2 femur fractures and 2 periprosthetic fractures occurred in 2 months. In such cases the orthopaedic surgeon needs to formulate first a clinical osteoporotic pattern, than its treatment together with a surgery suitable choice, that has to take into consideration of the bone structural characteristics. In the case described one can note that fractures healing occurred thanks to both an improvement in surgical techniques and antiosteoporotic pharmacological support; in the specific case the Authors used strontium ranelate for its osteoinductive capacity. In our opinion is crucial that the treatment used by orthopaedic surgeons is not related only to the “by-hand” treatment but take into consideration both the underlying disease and the possibility of positively affect bone healing with specific drug therap

Bilateral transient osteoporosis of the hip with unilateral fracture in a 40 years old pregnant woman

Purpose: Some physiological events in women’s life such as pregnancy and lactation can be associated to a condition known as Transient Osteoporosis of the Hip (TOH); if not promptly diagnosed it can lead to significant consequences such as femoral neck fracture. In this paper we describe a case of bilateral TOH, focusing on the importance of early treatment and how it influenced the outcome. Methods: A 40 years old post-delivery woman came to our attention for hip pain and a left femoral neck fracture was diagnosed. Magnetic resonance (MRI) showed bilateral edema of the femoral head. She underwent total hip replacement on the left side; toe-touch weight bearing and pharmacological therapy were prescribed for the right hip. Results: MRI at nine months showed complete regression of the femoral head and neck edema; the patient was clinically asymptomatic. Conclusion: If not promptly diagnosed and treated, TOH can potentially evolve in fracture. Many therapeutic strategies have been suggested since now; we believe that avoiding weight bearing on the involved hip as early as possible is the key to recovery

Femoral fractures in the extremely elderly

At the Trauma Unit of Pisa we performed an observational study reviewing nineties that about 200 patients were treated and underwent surgery for femoral neck fracture from 1998 to 2005. The clinical and radiographic results obtained were discrete, with a mortality of 42.5%, the survivors are still having a good quality of life

Allungamento tibiale con esito osteomielite trattata con innesto di perone vascolarizzato: case report

Introduzione: Negli ultimi decenni il progresso nei dispositivi medici nell’allungamento degli arti, nei casi di nanismo e nelle deformazioni derivanti da difetti congeniti, traumi, tumori e infezioni ha avuto una progressiva evoluzione. Attualmente le metodiche di allungamento disponibili vanno dall’utilizzo di fissatori esterni circolari o assiali all’impiego di chiodi endomidollari telescopici. A seconda del segmento osseo interessato è necessario scegliere il dispositivo più adatto: per questo riportiamo un caso particolare di allungamento tibiale in esiti di osteomielite, trattata con bonifica con innesto di perone vascolarizzato, eseguito mediante fissatore esterno e il relativo risultato clinico e radiografico a 10 mesi di follow-up. Materiali e Metodi: Una ragazza caucasica di 22 anni è giunta alla nostra osservazione con anamnesi remota di grave osteomielite tibiale destra all’età di 5 anni, per cui era stata sottoposta a molteplici interventi in altre sedi fino alla risoluzione della problematica infettiva con consolidazione ossea ottenuta grazie a un innesto di perone vascolarizzato; residuava una dismetria tibiale in minus a destra di 5 cm, per cui è stata sottoposta ad intervento di allungamento tibiale mediante l’utilizzo di un fissatore esterno LRS (Limb Reconstruction System) Orthofix. Risultati: La lunghezza prefissata è stata raggiunta, l’allungamento manuale progressivo giornaliero è stato affidato alla paziente, sono stati eseguiti controlli clinico-radiografici periodici, lamobilizzazione articolare è stata concessa da subito mentre il carico parziale progressivo è stato concesso a partire dai 4 mesi. A circa 9 mesi è stato rimosso il dispositivo previa valutazione dinamica amplioscopica della resistenza del callo osseo. Discussione: L’allungamento del segmento osseo, eseguito su un pregresso intervento di innesto di perone vascolarizzato, poteva porre alcune problematiche sia sulla sede di osteotomia, sia sul sistema da utilizzare. L’allungamento prefissato è stato comunque raggiunto senza complicanze, la paziente è soddisfatta dei risultati clinici, al momento non riferisce dolore e presenta lo stesso range articolare pre-operatorio sia di ginocchio che di caviglia. Conclusioni: A livello tibiale il sistema di allungamento con fissazione esterna rappresenta una valida metodica, che garantisce un adeguato controllo clinico della procedura e una buona compliance da parte del paziente, anche in casi “difficili” come quello descritto

Indices of risk assessment of fracture of the proximal humerus

Osteoporotic fractures are now a social problem for incidence and costs. Fractures of the proximal humerus events are frequent and constantly increasing. It is estimated that they are 20% of all osteoporotic fractures. Bone densitometry in most cases underestimates the real humeral bone density. There is little information about osteoporotic changes in the proximal humerus and their association with the cortical thickness of the humeral shaft. The ratio between the thickness of the cortical and the total diameter of the humeral diaphysis is the cortical index. Fracture risk limit value is 0.231. Convinced of the need to quantify in a reproducible way the real local humerus bone density, we performed a comparative evaluation of bone density of the humerus and femur in patients admitted to our clinic for fractures of the humerus and femur. We evaluated 28 women treated surgically for a fragility fracture of the proximal humerus or femur neck in 2010. All cortical index obtained were lower than the limit for fracture risk set at 0.231, so the IC was more predictive of neck medial fractures of the femur than had DEXA and the U.S. The information about the cortical index may provide a simple way of determining the bone quality of the proximal humerus and of facilitating decision-making in the surgical treatment of patients with fractures of the humerus. So we want to emphasize the importance of therapy for osteoporosis even in patients with fractures of the proximal humerus, which often have not critical densitometric values of femur or column, but they are at risk of new fractures

Humeral bone fragility in patients with shoulder prosthesis: a case of humeral periprosthetic refracture

In recent decades there has been an increase in upper limb prosthetic surgery, primarily for the shoulder, for osteoarthritis disease and for traumatic pathology. It is occurring in parallel an increase in periprosthetic fractures of the humerus, although with less impact than other anatomical districts such as the hip. We report a case of humeral periprosthetic refracture in a 66-years-old female patient. The humerus bone quality is worse than in other districts in patient of the same age. The fragility humerus fracture are increasing, affecting relatively younger individuals than those with femoral neck fractures and represent an independent risk factor for the occurrence of subsequent fractures. Actually humeral BMD is underestimated by traditional densitometric evaluation technique

LARS versus hamstring tendon autograft in anterior cruciate ligament reconstruction: a single-centre, single surgeon retrospective study with 8 years of follow-up

PURPOSE: The choice of graft type in the anterior cruciate ligament (ACL) reconstruction remains a subject of controversy. The aim of this study was to assess the outcomes in ACL reconstructions performed using a four-strand hamstring tendon graft (4SHG) or a LARS ligament comparing the effectiveness of the two grafts at a medium follow-up of 8 years. METHODS: This retrospective, single-centre, single surgeon study evaluated the clinical, functional and radiographic outcomes in 50 patients who underwent ACL reconstruction (25 4SHG and 25 LARS). Patients who underwent surgery after more than 6 months from injury and showed radiographically visible degenerative changes at time of surgery were excluded from the study. RESULTS: None of the patients underwent re-surgery in the same knee. The range of motion of the operated knee, compared to the contralateral, was good for both groups. The anterior drawer test resulted negative in 21 patients (84%) in the LARS group and eight patients (32%) in the 4SHG group (P = 0.039). The Lachman test was negative in 19 patients (76%) in the LARS group and in 11 patients (44%) in the 4SHG group (P = 0.045). Although other results of ACL reconstruction measured by Lysholm scores, IKDC evaluation, Tegner scores and radiographic images showed using a LARS graft tended to be superior to using a 4SHG, there were no statistically significant differences calculated. CONCLUSION: Our results suggest that 4 years after ACL reconstruction using a LARS ligament or 4SHG dramatically improves the function outcome, while the patients in the LARS group displayed a higher knee stability than those in the 4SHG group.Purpose: The choice of graft type in the anterior cruciate ligament (ACL) reconstruction remains a subject of controversy. The aim of this study was to assess the outcomes in ACL reconstructions performed using a four-strand hamstring tendon graft (4SHG) or a LARS ligament comparing the effectiveness of the two grafts at a medium follow-up of 8 years. Methods: This retrospective, single-centre, single surgeon study evaluated the clinical, functional and radiographic outcomes in 50 patients who underwent ACL reconstruction (25 4SHG and 25 LARS). Patients who underwent surgery after more than 6 months from injury and showed radiographically visible degenerative changes at time of surgery were excluded from the study. Results: None of the patients underwent re-surgery in the same knee. The range of motion of the operated knee, compared to the contralateral, was good for both groups. The anterior drawer test resulted negative in 21 patients (84%) in the LARS group and eight patients (32%) in the 4SHG group (P = 0.039). The Lachman test was negative in 19 patients (76%) in the LARS group and in 11 patients (44%) in the 4SHG group (P = 0.045). Although other results of ACL reconstruction measured by Lysholm scores, IKDC evaluation, Tegner scores and radiographic images showed using a LARS graft tended to be superior to using a 4SHG, there were no statistically significant differences calculated. Conclusion: Our results suggest that 4 years after ACL reconstruction using a LARS ligament or 4SHG dramatically improves the function outcome, while the patients in the LARS group displayed a higher knee stability than those in the 4SHG group