Agresivna granulomatoza nakon ugradnje bescementne totalne endoproteze kuka kao rezultat upalne reakcije na čestice metala: prikaz slučaja

Massive osteolysis and granulomatous pseudotumor tissue reactions are longterm complications of total hip replacement. It is a condition of localized bone resorption in contact with prosthetic material. It is speculated to be a consequence of metal hypersensitivity or inflammatory reaction to excessive wear. Ten years after total cementless hip replacement (metal on polyethylene surface), a 70-year-old patient presented with hip pain and pseudotumor with massive osteolysis of proximal femur on x-ray. Intraoperatively, extensive metallosis with significantly worn metal head (316L stainless steel) and only slightly worn polyethylene insert was found. Upon extraction, parts of the affected tissue and bone that were in direct contact with the prosthesis were sent for histopathologic analysis. Microscopic examination showed necrotic soft and bone tissue, mainly bone marrow with numerous histiocytes and multinucleated giant cells containing lots of pigmented particles (presumed to be metal particles as a result of implant surface wear). In this case, the primary cause of osteolysis and granulomatosis was inflammatory reaction to metal debris. Aggressive granulomatosis has been first described in cemented prostheses and afterwards also in cementless ones. Conditions such as primary or metastatic neoplastic processes and infection should be excluded. The presence of foreign molecular particles due to wear of the prosthesis by different mediators has been presumed to cause an inflammatory reaction that leads to bone resorption and loosening of the prosthesis.Masivna osteoliza i pseudotumorska granulomatozna reakcija su dugoročne komplikacije totalne artroplastike kuka. Radi se o stanju lokalizirane koštane resorpcije na mjestu kontakta s protetskim materijalom. Pretpostavlja se da je to posljedica preosjetljivosti na metal ili upalne reakcije na prekomjerno trošenje materijala. Deset godina nakon totalne artroplastike kuka (metalna glava, polietilenski acetabularni umetak) 70-godišnji bolesnik dolazi s bolovima u kuku te masivnom osteolizom proksimalng femura na radiogramu. Intraoperacijski je nađena opsežna metaloza sa značajno istrošenom metalnom glavom (316L nehrđajući čelik) i samo manjim dijelom istrošenim polietilenskim umetkom. Dijelovi zahvaćenog tkiva i kosti koji su bili u izravnom dodiru s protezom su poslani na patohistološku analizu. Mikroskopski pregled je pokazao nekrotično meko i koštano tkivo, koštanu srž s brojnim histiocitima i multinuklearnim gigantskim stanicama koje sadrže puno pigmentnih čestica (pretpostavlja se da su to čestice metala kao rezultat trošenja površine implantata). Uzrok osteolize s granulomatozom u ovom slučaju je bila upalna reakcija na čestice metala nastale trošenjem glave proteze. Agresivna granulomatoza je prvi puta opisana u cementnim protezama, a potom i kod bescementnih proteza. Primarni ili metastatski neoplastični procesi i infekcije prvotno moraju biti isključeni kao uzrok. Pretpostavlja se da prisutnost molekularnih čestica kao posljedica trošenja endoproteze preko različitih posrednika uzrokuju upalnu reakciju koja dovodi do resorpcije kosti i nestabilnosti proteze

Je li kronični sindrom bolne prepone bermudski trokut sportske medicine?

Chronic groin pain is one the most complex conditions encountered in the field of sports medicine. Conservative treatment is long lasting and the result of treatment is often uncertain and symptom recurrences are common, which can be very frustrating for both the patient and the physician. The complex etiology and uncertainties during treatment of chronic groin pain is the reason why some authors call it the Bermuda Triangle of sports medicine. In our prospective, 7-year study, 114 athletes with chronic groin pain resistant to conservative therapy were treated surgically. In 109 athletes with sports hernia, we performed nerve neurolysis along with resection of the genital branch of the genitofemoral nerve and we also reinforced the posterior wall of inguinal canal using a modified Shouldice technique. In 26 athletes that had concomitant adductor tendinosis and in 5 athletes with isolated tendinosis we performed tenotomy. Eighty-one of 83 patients with isolated sports hernia returned to sports within a mean of 4.4 (range, 3-16) weeks. Thirty-one athletes with adductor tenotomy returned to sports activity within a mean of 11.8 (range, 10-15) weeks. If carefully diagnosed using detailed history taking, physical examination and correct imaging techniques, chronic groin pain can be treated very successfully and quickly, so it need not be a Bermuda Triangle of sports medicine.Kronični sindrom bolne prepone je jedno od najsloženijih stanja u sportskoj medicini. Konzervativno liječenje je dugotrajno, ishod liječenja neizvjestan uz brojne recidive, a sve to djeluje frustrirajuće na sportaša i na liječnika koji ga liječi. Zbog brojnih nejasnoća oko etiologije i liječenja kronični sindrom bolne prepone neki nazivaju i bermudskim trokutom sportske medicine. U prospektivoj studiji kroz 7 godina 114 sportaša s kroničnim sindromom bolne prepone otpornim na konzervativnu terapiju liječeno je operativno. Kod 109 sportaša sa sportskom hernijom učinjena je neuroliza ilioingvinalnog živca, resekcija genitalne grane genitofemoralnog živca i pojačanje stražnje stijenke ingvinalnog kanala duplikaturom transverzalne fascije modificiranom tehnikom po Shouldiceu. Kod 26 sportaša koji su uz sportsku herniju imali i tendinozu aduktora te kod 5 sportaša s izoliranom tendinozom aduktora učinjena je tenotomija aduktora. Od 83 sportaša s izoliranom sportskom hernijom 81 se vratio sportu nakon 4,4 tjedna (raspon 3-16 tjedana). Sportaši s tenotomijom aduktora (n=31) vratili su se sportskim aktivnostima nakon 11,8 (raspon 10-15) tjedana. Ako se pažljivo razmotre smetnje sportaša, učini detaljan pregled i utvrdi pravi uzrok bolova, liječenje može biti kratkotrajno i uspješno, a sindrom bolne prepone ne mora predstavljati bermudski trokut sportske medicine

Uloga vanjskog fiksatora u liječenju dislociranih pilon fraktura distalne tibije

Results of treatment in patients with high-energy displaced pilon fractures are presented. During five years, 15 patients with displaced pilon fractures (AO type C2 and C3) were treated. All other types of fracture were excluded from the study. Fractures were identified using standard radiographs and computed topography scanning. The method and timing of the operation were dictated by the status of soft tissues. In all fractures, external fixation was placed immediately and was left until the initial callus bridged the fracture fragments. In case of moderate contusion of soft tissues, limited incision and minimal internal osteosynthesis was done in the same act. In patients with more severe soft tissue damage, limited open reduction and restoration of articular surface was undertaken in second procedure after 7 days on average. All fractures united and the average time of healing was 4 months. Two patients had superficial infections that resulted in prolonged wound healing, and another four patients had pin site infection. There were no cases of deep infection, nonunion or malunion, but we had five cases of secondary osteoarthritis. Results were evaluated by Teeny and Wiss rating system. The results were as follows: 5 excellent results, 10 good and fair results, and no poor results. This study showed that external fixation with open reduction and limited internal osteosynthesis, with or without bone grafting, could be an option in the management of displaced multifragmentary pilon fractures with soft tissue injury. It was followed by significantly less complications with better functional results compared to open reduction and internal plate fixation.Prikazuju se rezultati liječenja bolesnika s dislociranim pilon prijelomima potkoljenice. Tijekom 5 godina liječili smo 15 bolesnika s dislociranim pilon frakturama distalne tibije (AO tip C2 i C3), a svi ostali tipovi prijeloma izuzeti su iz ovog promatranja. Prijelomi su dijagnosticirani standardnom radiografijom i kompjutorskom tomografijom. Vrijeme i metoda operacije ovisili su o stanju mekih česti. Kod svih fraktura odmah je postavljen vanjski fiksator i zadržan je do početnih znakova kalusnog premoštavanja prijeloma. U slučajevima kada su meka tkiva bila umjereno oštećena u istom aktu učinjena je ograničena otvorena repozicija s minimalnom unutarnjom osteosintezom. Kod bolesnika s izrazitim oštećenjima mekih tkiva otvorena repozicija i restauracija zglobne plohe učinjena je u drugom postupku u prosjeku 7 dana od ozljede. Svi promatrani prijelomi su zarasli u prosjeku za 4 mjeseca. Kod dva bolesnika zabilježeno je produženo cijeljenje rane zbog površinske infekcije, a kod 4 bolesnika bila je prisutna infekcija uz pinove fiksatora. Nije bilo slučajeva duboke infekcije, pseudoartroze ili loše sraslog prijeloma, ali je zabilježeno 5 slučajeva sekundarnog osteoartritisa. Rezultate smo analizirali u skladu s Teenyjevim i Wissovim sustavom ocjenjivanja. Ostvarili smo 5 odličnih te 10 dobrih i zadovoljavajućih rezultata, a loših rezultata nismo imali. Ovaj rad pokazuje da primjena vanjskog fiksatora s otvorenom repozicijom i minimalnom osteosintezom, sa spongioplastikom ili bez nje, može biti metoda izbora za dislocirane pilon frakture potkoljenice s ozljedom mekih tkiva. Usporedivo s otvorenom repozicijom i unutarnjom fiksacijom pločama praćena je sa značajno manjim brojem komplikacija i s boljim funkcionalnim rezultatom

Spontaneously Ruptured Gastrointestinal Stromal Tumor (GIST) of the Jejunum Mimicking Acute Appendicitis

Gastrointestinal stromal tumors (GISTs) are characterized with diverse clinical presentations, including acute and chronic gastrointestinal bleeding, abdominal pain, presence of an intra-abdominal mass, anorexia, and intestinal obstruction. A 60-year-old obese woman presented as an acute abdominal emergency with right lower quadrant (RLQ) pain and tenderness, nausea and leukocytosis, all mimicking acute appendicitis. Laparotomy revealed a spontaneously ruptured GIST of the jejunum, which was localized to the RLQ due to postoperative adhesions following previous two cesarean sections and cholecystectomy. Complete surgical resection was performed, followed by an uneventful early postoperative course

Treatment of proximal fifth metatarsal bone fractures in athletes

Cilj: Usporediti rezultate konzervativnog i operativnog liječenja prijeloma proksimalnog dijela pete metatarzalne (V MT) kosti kod sportaša. Ovi prijelomi predstavljaju velik dijagnostički i terapijski izazov. Uobičajeno su podijeljeni u 3 zone: tuberozitas (zona I), metafiza (zona II) i proksimalna dijafiza (zona III). Radi kompromitirane cirkulacije karakterizira ih otežano i dugotrajno cijeljenje koje nerijetko završava razvojem pseudartroze, naročito kod mladih i fizički aktivnih osoba. Ispitanici i metode: U Kliničkoj bolnici Merkur u periodu od 13 godina liječen je 61 sportaš s ukupno 65 prijeloma V MT kosti u zoni II i III. Svi ostali pacijenti isključeni su iz promatranja. Pacijenti su podijeljeni u 2 skupine: Skupina 1 – operativno liječeni i Skupina 2 – konzervativno liječeni prijelomi. U Skupini 1 bilo je 50 (77 %) prijeloma, a u Skupini 2 15 (23 %) prijeloma. Za osteosintezu je u početku studije korišten klasični maleolarni vijak koji je radi komplikacija u kasnijem tijeku studije zamijenjen debljim intramedularnim vijkom. Rezultati liječenja praćeni su radiološkim i kliničkim pregledom, a evaluirani Modified Foot scoreom (MFS). Rezultati: Period praćenja iznosio je u prosjeku 12 mjeseci. U Skupini 1 većina prijeloma je sanirana u periodu od 8 tjedana. Produženo cijeljenje bilo je prisutno kod 7 (14 %) prijeloma. U kasnijem rehabilitacijskom periodu 3 pacijenta (6 %) imala su refrakturu koja je riješena reoperacijom i postavljanjem jačeg vijka. U Skupini nisu zarasla 2 prijeloma, 7 (46 %) prijeloma zaraslo je u periodu od 6 mjeseci, a 5 (33 %) od njih naknadno je operirano. U konačnici su svi operirani prijelomi zarasli. S obzirom na MFS, Skupina 1 u odnosu na Skupinu 2 imala je statistički značajno (p < 0,01) bolji rezultat. Zaključak: Dobra dijagnostika i klasifikacija prijeloma te operativno liječenje prijeloma metafize i proksimalne dijafize garantira brzo cijeljenje i rani povratak punoj sportskoj aktivnosti.Aim: To compare the results of conservative and surgical treatment of fractures of the proximal fifth metatarsal (V MT) bone in the athletes. These fractures represent a great diagnostic and therapeutic challenge. They are traditionaly divided into 3 zones: tuberosity (zone I), metaphysis (zone II), and proximal diaphysis (zone III). Due to the compromised circulation, these fractures are characterized by difficult and prolonged healing that ends with the development of pseudarthrosis, especially in young and physically active individuals. Patients and Methods: During the 13-year period in University Hospital Merkur 61 athletes with a total of 65 fractures of V MT bones in zone II and III were treated. All other patients were excluded from this study. The patients were divided into 2 groups: Group 1 - operatively treated and Group 2 - conservatively treated fractures.There were 50 (77%) fractures in Group 1 and 15 (23%) in Group 2. At the beginning of the study, a maleolar screw was used for osteosynthesis but due to complications it was later replaced by a stronger intramedullary screw. Treatment results were followed by radiological and clinical examination and evaluated by Modified Foot score (MFS). Results: The follow-up period averaged 12 months. In the Group 1 most fractures healed within 8 weeks. Prolonged healing were present in 7 (14%) fractures. In the later rehabilitation period 3 (6%) patients had refracture which was resolved by reopereting and installing a stronger screw.In the Group2, 7 (46%) fractures did not heal over a 6-month period and 5 (33%) of them underwent surgery. Finally, all operated fractures were healed. According to MFS, the Group1 had a significantly better result. Conclusion: Good diagnosis and classification of fractures, as well as surgical treatment of fractures of the metaphysis and proximal diaphysis, guarantee rapid fracture healing and early return to full sport activity

Stable Gastric Pentadecapeptide BPC 157 May Recover Brain–Gut Axis and Gut–Brain Axis Function

Conceptually, a wide beneficial effect, both peripherally and centrally, might have been essential for the harmony of brain–gut and gut–brain axes’ function. Seen from the original viewpoint of the gut peptides’ significance and brain relation, the favorable stable gastric pentadecapeptide BPC 157 evidence in the brain–gut and gut–brain axes’ function might have been presented as a particular interconnected network. These were the behavioral findings (interaction with main systems, anxiolytic, anticonvulsive, antidepressant effect, counteracted catalepsy, and positive and negative schizophrenia symptoms models). Muscle healing and function recovery appeared as the therapeutic effects of BPC 157 on the various muscle disabilities of a multitude of causes, both peripheral and central. Heart failure was counteracted (including arrhythmias and thrombosis), and smooth muscle function recovered. These existed as a multimodal muscle axis impact on muscle function and healing as a function of the brain–gut axis and gut–brain axis as whole. Finally, encephalopathies, acting simultaneously in both the periphery and central nervous system, BPC 157 counteracted stomach and liver lesions and various encephalopathies in NSAIDs and insulin rats. BPC 157 therapy by rapidly activated collateral pathways counteracted the vascular and multiorgan failure concomitant to major vessel occlusion and, similar to noxious procedures, reversed initiated multicausal noxious circuit of the occlusion/occlusion-like syndrome. Severe intracranial (superior sagittal sinus) hypertension, portal and caval hypertensions, and aortal hypotension were attenuated/eliminated. Counteracted were the severe lesions in the brain, lungs, liver, kidney, and gastrointestinal tract. In particular, progressing thrombosis, both peripherally and centrally, and heart arrhythmias and infarction that would consistently occur were fully counteracted and/or almost annihilated. To conclude, we suggest further BPC 157 therapy applications

Cytokines and Chemokines Involved in Osteoarthritis Pathogenesis

Osteoarthritis is a common cause of disability worldwide. Although commonly referred to as a disease of the joint cartilage, osteoarthritis affects all joint tissues equally. The pathogenesis of this degenerative process is not completely understood; however, a low-grade inflammation leading to an imbalance between anabolic and katabolic processes is a well-established factor. The complex network of cytokines regulating these processes and cell communication has a central role in the development and progression of osteoarthritis. Concentrations of both proinflammatory and anti-inflammatory cytokines were found to be altered depending on the osteoarthritis stage and activity. In this review, we analyzed individual cytokines involved in the immune processes with an emphasis on their function in osteoarthritis

Polychromatic Flow Cytometric Analysis of Stromal Vascular Fraction from Lipoaspirate and Microfragmented Counterparts Reveals Sex-Related Immunophenotype Differences

Mesenchymal stem/stromal cells or medicinal signaling cells (MSC)-based therapy holds promise as a beneficial strategy for treating knee OA (osteoarthritis), but there is no standardized protocols nor mechanistic understanding. In order to gain a better insight into the human MSC from adipose tissue applied for autologous OA treatment, we performed extensive comparative immunophenotyping of the stromal vascular fraction from lipoaspirate or microfragmented lipoaspirates by polychromatic flow cytometry and investigated the cellular components considered responsible for cartilage regeneration. We found an enrichment of the regenerative cellular niche of the clinically applied microfragmented stromal vascular fraction. Sex-related differences were observed in the MSC marker expression and the ratio of the progenitor cells from fresh lipoaspirate, which, in female patients, contained a higher expression of CD90 on the three progenitor cell types including pericytes, a higher expression of CD105 and CD146 on CD31highCD34high endothelial progenitors as well as of CD73 on supra-adventitialadipose stromal cells. Some of these MSC-expression differences were present after microfragmentation and indicated a differential phenotype pattern of the applied MSC mixture in female and male patients. Our results provide a better insight into the heterogeneity of the adipose MSC subpopulations serving as OA therapeutics, with an emphasis on interesting differences between women and men

Innate Vascular Failure by Application of Neuroleptics, Amphetamine, and Domperidone Rapidly Induced Severe Occlusion/Occlusion-like Syndromes in Rats and Stable Gastric Pentadecapeptide BPC 157 as Therapy

Even before behavioral disturbances, neuroleptics, amphetamine, and domperidone application rapidly emerged severe occlusion/occlusion-like syndrome, shared innate vascular and multiorgan failure in rats, comparable to occlusion/occlusion-like syndrome described with vessel(s) occlusion or similar noxious procedures application. As therapy, i.e., activation of the collateral pathways, “bypassing key” (activated azygos vein pathway, direct blood flow delivery), the stable gastric pentadecapeptide BPC 157 is a novel solution. Recently, BPC 157 therapy particularly counteracted neuroleptic- or L-NAME-induced catalepsy, lithium intoxication, and schizophrenia positive and negative symptoms (amphetamine/methamphetamine/apomorphine/ketamine). In rats with complete calvariectomy, medication (BPC 157 10 µg/kg, 10 ng/kg ip or ig) was given 5 min after distinctive dopamine agents (mg/kg ip) (haloperidol (5), fluphenazine (5), clozapine (10), risperidone (5), olanzapine (10), quetiapine (10), or aripiprazole (10), domperidone (25), amphetamine (10), and combined amphetamine and haloperidol) and assessed at 15 min thereafter. All neuroleptic-, domperidone-, and amphetamine-induced comparable vascular and multiorgan failure severe syndrome was alleviated with BPC 157 therapy as before major vessel(s) occlusion or other similar noxious procedures. Specifically, all severe lesions in the brain (i.e., immediate swelling, hemorrhage), heart (i.e., congestion, arrhythmias), and lung (i.e., congestion, hemorrhage), as well as congestion in the liver, kidney, and gastrointestinal (stomach) tract, were resolved. Intracranial (superior sagittal sinus), portal, and caval hypertension and aortal hypotension were attenuated or eliminated. BPC 157 therapy almost annihilated arterial and venous thrombosis, peripherally and centrally. Thus, rapidly acting Virchow triad circumstances that occur as dopamine central/peripheral antagonists and agonist essential class-points, fully reversed by BPC 157 therapy, might be overwhelming for both neuroleptics and amphetamine