Bisphosphonate treatment in children with acute lymphoblastic leukemia and osteonecrosis - radiological and clinical findings in a national cohort

Background: Osteonecrosis (ON) is a recognized complication of childhood ALL, but its optimal management remains unestablished. This study evaluated the effect of bisphosphonate (BP) treatment on the evolution of ON lesions in childhood ALL. Material and Methods: We included a national cohort of ALL patients diagnosed with symptomatic ON before 18 years of age and treated with BPs (N = 10; five males). Patients were followed both clinically and with serial MRIs. ON lesions were graded according to the Niinimaki classification. Results: The 10 patients had a total of 55 ON lesions. The median age was 13.3 years at ALL diagnosis and 14.8 years at ON diagnosis. Four patients had received HSCT before the ON diagnosis. BPs used were pamidronate (N = 7), alendronate (N = 2) and ibandronate (N = 1). The duration of BP treatment varied between 4 months and 4 years. In 4/10 patients, BP treatment was given during the chemotherapy. BPs were well-tolerated, with no severe complications or changes in kidney function. At the end of follow up 13/55 (24%) ON lesions were completely healed both clinically and radiographically; all these lesions were originally graded 3 or less. In contrast, ON lesions originally classified as grade 5 (joint destruction; N = 4) remained at grade 5. All grade 5 hip joint lesions needed surgical treatment. During BP treatment, the pain was relieved in 7/10 patients. At the end of follow-up, none of the patients reported severe or frequent pain. Conclusion: BP treatment was safe and seemed effective in relieving ON-induced pain in childhood ALL. After articular collapse (grade 5) lesions did not improve with BP treatment. Randomized controlled studies are needed to further elucidate the role of BPs in childhood ALL-associated ON.Peer reviewe

PLS3Mutations Cause Severe Age and Sex-Related Spinal Pathology

Objective:Mutations in the X-chromosomalPLS3-gene, encoding Plastin 3, lead to severe early-onset osteoporosis, suggesting a major role for PLS3 in bone metabolism. However, the consequences of abnormal PLS3 function in bone and other tissues remain incompletely characterized. This study evaluated spinal consequences of aberrant PLS3 function in patients withPLS3mutations. Design:A cross-sectional cohort study with spinal magnetic resonance imaging of 15PLS3mutation-positive (age range 9-77 years) and 13 mutation-negative (9-70 years) subjects. Images were reviewed for spinal alignment, vertebral heights and morphology, intervertebral disc changes and possible endplate deterioration. Results:Vertebral changes were significantly more prevalent in the mutation-positive subjects compared with the mutation-negative subjects; they were most abundant in upper thoracic spine, and in all age groups and both sexes, although more prominent in males. Difference in anterior vertebral height reduction was most significant in T5 and T6 (p= 0.046 andp= 0.041, respectively). Mid-vertebral height reduction was most significant in T3 and T5 (p= 0.037 andp= 0.005, respectively), and, for male mutation-positive subjects only, in T4 and T6-10 (p= 0.005-0.030 for each vertebra). Most of the abnormal vertebrae were biconcave in shape but thoracic kyphosis or lumbar lordosis were unchanged. Vertebral endplates were well-preserved in the mutation-positive subjects with even fewer Schmorl nodes than the mutation-negative subjects (10 vs. 16). Conclusions:Compromised PLS3 function introduces severe and progressive changes to spinal structures that are present already in childhood, in both sexes and most abundant in upper thoracic spine. Cartilaginous structures are well-preserved.Peer reviewe

Comparison of ultrasonographic, radiographic and intra-operative findings in severe hip osteoarthritis

Aim of this study was to assess the US findings of patients with late-stage hip OA undergoing total hip arthroplasty (THA), and to associate the US findings with conventional radiography (CR) and intraoperative findings. Moreover, the inter-rater reliability of hip US, and association between the US and Oxford Hip Score (OHS) were evaluated. Sixty-eight hips were included, and intraoperative findings were available on 48 hips. Mean patient age was 67.6 years and 38% were males. OA findings—osteophytes at femoral collum and anterosuperior acetabulum, femoral head deformity and effusion—were assessed on US, CR and THA. The diagnostic performance of US and CR was compared by applying the THA findings as the gold standard. Osteoarthritic US findings were very common, but no association between the US findings and OHS was observed. The pooled inter-rater reliability (n = 65) varied from moderate to excellent (k = 0.538–0.815). When THA findings were used as the gold standard, US detected femoral collum osteophytes with 95% sensitivity, 0% specificity, 81% accuracy, and 85% positive predictive value. Concerning acetabular osteophytes, the respective values were 96%, 0%, 88% and 91%. For the femoral head deformity, they were 92%, 36%, 38% and 83%, and for the effusion 49%, 85%, 58% and 90%, respectively. US provides similar detection of osteophytes as does CR. On femoral head deformity, performance of the US is superior to CR. The inter-rater reliability of the US evaluation varies from moderate to excellent, and no association between US and OHS was observed in this patient cohort.</p

Short-term survival of cementless Oxford unicondylar knee arthroplasty based on the Finnish Arthroplasty Register

Background: Cementless unicondylar knee arthroplasty (UKA) was introduced to secure longterm fixation and reduce the risk of revision. Experience with cementless UKA fixation is limited. Methods: The short-term survival (up to five years) of cementless Oxford UKA was assessed using data from the Finish Arthroplasty Register and was compared with that of cemented Oxford 3 UKA and total knee arthroplasty (TKA). Datawere obtained, from the Finnish Arthroplasty Register, on 1076 cementless Oxford UKAs and 2279 cemented Oxford 3 UKAs performed for primary osteoarthritis in 2005-2015. The Kaplan-Meier method, with revision for any reason as the endpoint, was used to assess the survival of these two UKA groups, and the results were compared with that of 65,563 cemented TKAs treated for primary osteoarthritis over the same period. The risk of revision of both Oxford prostheses was compared using Cox regression model, with adjustment for age and sex, with the cemented TKA group as reference. Results: The three-year survival was 93.7% for the cementless Oxford, 922% for the cemented Oxford 3, and 97.3% for the cemented TKA. The corresponding figures at five years were 92.3%, 88.9%, and 96.6%, respectively. The revision rate for both the cementless Oxford and the cemented Oxford 3 was significantly increased when compared with the cemented TKA (P <0.001). Conclusions: The survival of the cementless Oxford method was higher than that of the cemented Oxford 3 in the short term. The overall survival of Oxford UKA was poor in comparison with contemporary TKAs. (C) 2019 Elsevier B.V. All rights reserved.Peer reviewe

High tibial osteotomy and unicompartmental knee arthroplasty:the treatment of isolated medial osteoarthritis of the knee:a registry-based study in Finland

Abstract High tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are performed for the treatment of isolated medial osteoarthritis (OA) of the knee. In the treatment of knee OA, the incidence of osteotomies has decreased with the popularisation of knee arthroplasties, but it is still indicated in young and active patients. Results of HTO tend to deteriorate over the time and patients may need to undergo subsequent total knee arthroplasty (TKA). TKA after HTO is a demanding procedure, and the influence of previous osteotomy on the results of TKA is not defined. Results of UKAs are controversial. Single centre studies have shown good results, but arthroplasty registers report consistently inferior survivorships compared with TKAs. However, comparison of register survivals may be inadequate because differences in the demographics of the patients have not been taken into account. The aims of the current nationwide register-based study were to assess incidence of osteotomies and survivorship of HTO in the treatment of knee OA, and to compare survivorship of TKAs performed after HTO with primary TKAs between 1987 and 2008 in Finland. In addition, this study reports survivorship of UKAs over a 25 year period and compare it with the survival of cemented TKAs. Based on this study, the overall incidence of osteotomies has decreased, especially in females, in the treatment of knee OA during the last two decades. In the patients less than 50 years of age, the incidence of osteotomies has been stable or slightly increased. Register-based survivorship of HTO was inferior compared with smaller cohort studies and females and patients aged &#62;50 years had the poorest results. The survivorship of TKA after osteotomy was slightly inferior compared with primary operations in general, but any clinical significance was minor. In this study UKA had inferior survivorship compared with TKA, even after adjusting for the age and gender of the patients. The reported survivorship of UKA was similar to those from available unadjusted arthroplasty register data. Surgeons should be made aware of this, but the reasons for incoherence with single-centre studies are not yet established and need further study.Tiivistelmä Sääriluun katkaisu- ja kääntöleikkauksia (osteotomia) ja osatekonivelleikkauksia tehdään polven sisäsyrjän nivelrikon hoitamiseksi. Tekonivelleikkausten yleistyttyä osteotomioiden määrä on vähentynyt polven nivelrikon hoidossa, mutta niitä tehdään edelleen nuorille ja aktiivisille potilaille. Osteotomian jälkeen polveen voidaan joutua asentamaan kokotekonivel. Tämä leikkaus on vaativa, ja edeltävällä osteotomialla voi olla vaikutusta kokotekonivelleikkauksen tuloksiin. Polven sisäsyrjän nivelrikkoa voidaan hoitaa osteotomian ja kokotekonivelleikkauksen lisäksi osatekonivelellä. Polven sisäsyrjän osatekonivelleikkauksen tulokset ovat kuitenkin ristiriitaisia. Yksittäisissä tutkimuksissa on raportoitu hyvistä tuloksista, mutta tekonivelrekisterien raporteissa osatekonivelleikkauksen uusintaleikkausriski on kokotekonivelleikkausta selvästi suurempi. Tämän rekisteritutkimuksen tarkoituksena oli selvittää polven nivelrikon vuoksi tehtyjen osteotomialeikkausten määrän kehitystä ja polven nivelrikon vuoksi tehtyjen säären osteotomialeikkausten tuloksia Suomessa vuosina 1987–2008. Lisäksi tutkimuksessa selvitettiin samalla ajanjaksolla osteotomian jälkeisten kokotekonivelleikkausten uusintaleikkausriskiä verrattuna primaareihin tekonivelleikkauksiin ja polven osatekonivelleikkausten uusintaleikkausriskiä verrattuna polven kokotekonivelleikkauksiin. Tutkimuksessa todettiin seuraavaa: polven nivelrikon vuoksi tehtyjen osteotomialeikkausten määrä on kahden viimeksi kuluneen vuosikymmenen aikana vähentynyt, etenkin naispotilailla. Osteotomialeikkausten määrä on kuitenkin pysynyt samana tai hiukan noussut alle 50-vuotiailla. Tässä rekisteritutkimuksessa säären osteotomian jälkeisen tekonivelleikkauksen uusintaleikkausriski oli suurempi kuin pienemmissä tutkimussarjoissa keskimäärin. Lisäksi tutkimuksessa todettiin, että säären osteotomian jälkeisten kokotekonivelleikkausten uusintaleikkausriski on suurempi kuin primäärien kokotekonivelleikkausten, mutta eron kliininen merkitys on vähäinen. Osatekonivelten osalta todettiin, että iän ja sukupuolen mukaan vakioitujen osatekonivelleikkausten uusintaleikkausriski on suurempi kuin kokotekonivelleikkausten. Tulosten ero yksittäisten tutkimusten ja rekisterien välillä on kuitenkin suuri, mikä vaatii lisätutkimuksia

Poor acetabular component orientation increases revision risk in metal-on-metal hip arthroplasty

Abstract Background: The rate of and the reasons for the failure of metal-on-metal (MoM) bearings have recently been discussed in literature. The aim of this study was to evaluate the influence of acetabular cup inclination and version angles on revision risk in patients with MoM hip arthroplasty. Methods: We retrospectively reviewed 825 patients (976 hips) who underwent a MoM hip arthroplasty between 2000 and 2013. There were 474 men and 351 women, with a mean age of 58 (19–86) years. Acceptable cup orientation was considered to be inside the Lewinnek′s safe zone. Results: The mean acetabular inclination angle was 48.9° (standard deviation, 8.1°; range, 16°–76°) and version angle 20.6° (standard deviation, 9.9°; range, −25 to 46°). The cup was found to be outside the Lewinnek′s safe zone in 571 hips (58.5%). Acetabular cup revision surgery was performed in 157 hips (16.1%). The cup angles were outside Lewinnek′s safe zone in 69.2% of the revised hips. The mean interobserver reliability and intraobserver repeatability of the measurements of cup inclination and version angles were excellent (intraclass correlation coefficients &gt; 0.90). The odds ratio for revision in hips outside vs inside the Lewinnek′s safe zone was 1.82 (95% confidence interval, 1.26–2.62; P = 0.0014). Conclusions: Our findings provide compelling evidence that a cup position outside the Lewinnek′s safe zone is associated with increased revision risk in patients with MoM arthroplasty

Comparison of ultrasonographic, radiographic and intra-operative findings in severe hip osteoarthritis

Abstract Aim of this study was to assess the US findings of patients with late-stage hip OA undergoing total hip arthroplasty (THA), and to associate the US findings with conventional radiography (CR) and intraoperative findings. Moreover, the inter-rater reliability of hip US, and association between the US and Oxford Hip Score (OHS) were evaluated. Sixty-eight hips were included, and intraoperative findings were available on 48 hips. Mean patient age was 67.6 years and 38% were males. OA findings—osteophytes at femoral collum and anterosuperior acetabulum, femoral head deformity and effusion—were assessed on US, CR and THA. The diagnostic performance of US and CR was compared by applying the THA findings as the gold standard. Osteoarthritic US findings were very common, but no association between the US findings and OHS was observed. The pooled inter-rater reliability (n = 65) varied from moderate to excellent (k = 0.538–0.815). When THA findings were used as the gold standard, US detected femoral collum osteophytes with 95% sensitivity, 0% specificity, 81% accuracy, and 85% positive predictive value. Concerning acetabular osteophytes, the respective values were 96%, 0%, 88% and 91%. For the femoral head deformity, they were 92%, 36%, 38% and 83%, and for the effusion 49%, 85%, 58% and 90%, respectively. US provides similar detection of osteophytes as does CR. On femoral head deformity, performance of the US is superior to CR. The inter-rater reliability of the US evaluation varies from moderate to excellent, and no association between US and OHS was observed in this patient cohort