Bone Complications Research Articles

Conventional Microscopic Stapedotomy: An Obsolete Technique or Still the Gold Standard for the Management of Otosclerosis?

Background and objectivesClinical otosclerosis is a relatively common entity, accounting for 0.5%-2% of the general population. Otosclerosis is characterized by an abnormal bone formation in the temporal bone that eventually causes conductive hearing loss. Bilateral involvement is fairly common. Treatment can be either conservative with medications and a hearing aid, or surgical. Stapedotomy is considered, nowadays, the most effective surgical technique for the management of otosclerosis. The purpose of the present study is to present our long-term results with stapedectomy, the audiological outcome, as well as the complications encountered.Subjects and methodsThis is a retrospective single-centre study. All patients diagnosed with otosclerosis and treated operatively with a stapedotomy from January 2010 to December 2019 were included in the study. Demographic data, air and bone conduction thresholds, complications and length of the prosthesis were recorded. ResultsThe study included a total of 72 patients. The audiological results showed a statistically significant improvement in the air conduction thresholds in all the affected frequencies (p<0.001). Post-operative complications included deterioration or severe hearing loss up to 100 dB (n=1, 1.39%), loss or distortion of taste (n=4, 5.6%) and tinnitus (n=2, 2.8%).ConclusionsOur results demonstrate that stapedotomy is an effective technique for the management of otosclerosis. Stapedotomy, when performed by an experienced surgeon, provides excellent outcomes, with limited complications.

Minimally invasive direct lateral approach debridement, interbody bone grafting, and interbody fusion combined with posterior percutaneous pedicle screw fixation for lumbar spinal tuberculosis

To investigate the clinical efficacy and superiority of direct lateral interbody fusion combined with posterior percutaneous screw fixation in the treatment of lumbar tuberculosis. From June 2013 to August 2016, the clinical data of 83 patients with lumbar tuberculosis were retrospectively analyzed, including 55 males and 28 females, aged from 27 to 72 (49.5±13.5) years. These 83 patients were divided into two groups according to different operation methods, 35 cases in group A were treated with direct lateral interbody fusion combined with posterior percutaneous screw fixation;48 cases in group B were treated with anterior traditional extraperitoneal debridement combined with posterior internal fixation. After operation, regular quadruple antituberculosis drugs were continued for 18 months. The operation time, intraoperative blood loss, hospital stay, bone graft fusion time and complications were compared between the two groups. Visual analogue score (VAS) of lumbar pain, Oswestry Disability Index (ODI), sagittal Cobb angle, erythrocyte sedimentation rate (ESR) and C-reactive protein(CRP) values before and after operation were analyzed. The operation was successfully completed in both groups, and the operation mode was not changed during operation. The operation time, intraoperative blood loss and hospital stay were (149.4±13.3) min, (354.3±69.0) ml, (9.4±1.6) d in group A and(116.8±10.0) min, (721.9±172.3) ml, (11.8±1.7) d in group B, respectively, with significant difference between the two groups (P<0.05). The follow up time was (24.2±5.1) months in group A and (24.0±5.0) months in group B, there was no significant difference between two groups (P>0.05). At the follow-up of 4 months after operation, one patient in group A was found to have enlarged psoas major abscess on the contralateral side, and was cured after secondary operation. No sinus formation, cerebrospinal fluid leakage, internal fixation loosening, fracture or distal junction kyphosis were found during follow-up. The fusion time was (5.1±1.6) months in group A and (5.1± 1.7) months in group B, there was no significant difference between two groups (P>0.05). The VAS, ODI score, sagittal Cobb angle, ESR and CRP value of the lesion segment at the last follow-up of the two groups were significantly improved (P<0.05), but there was no significant difference between two groups (P>0.05). The two kinds of operation can obtain satisfactory clinical effect. Direct lateral interbody fusion combined with posterior percutaneous screw fixation can reduce intraoperative blood loss and hospital stay, which is conducive to early rehabilitation of patients.

The influence of insertion torque values on the failure and complication rates of dental implants: A systematic review and meta-analysis.

The influence of using different insertion torque values on clinical and radiographic outcomes of implant therapy is unclear in the current literature. The aim of this systematic review and meta-analysis was to evaluate the implant outcomes and complications rates using high insertion torque values compared with those using regular insertion torque value levels. Randomized controlled trials (RCTs), nonrandomized controlled clinical trials (NRCCTs), prospective and retrospective cohorts were searched for in electronic databases and complemented by hand searching relevant dental journals. The risk of bias was assessed using the Cochrane Collaboration's Risk of Bias tool for randomized and nonrandomized studies. Data were analyzed using a statistical software. A total of 718 studies were identified, of which, nine studies were included with 1229 dental implants in 684 participants. The meta-analysis of RCTs showed that the overall implant failure rate was not notably in favor of any insertion torque value and the difference between the two groups was not statistically significant (risk ratio 0.85; 95% confidence interval 0.07-10.52; P=0.90). None of the RCTs was registered. The secondary analyses of non-RCTs did not either show any statistically significant difference. Overall meta-analysis did not show any significant differences in peri-implant marginal bone loss or biological/technical complications between high (≥50 Ncm) and regular insertion torque (<50 Ncm). There is insufficient evidence to support the use of high or regular insertion torque even with immediate implant restoration/loading. The short-term implant failure rates, changes in marginal bone level and complication rates were comparable when high or regular insertion torques were used for implant placement. The wide confidence interval indicated that results cannot be interpreted with clinically meaningful benefit for using either high or regular insertion torque.

Does the management of osteofibrous dysplasia of the tibia and fibula in children should be tailored to the extent and location of the lesion? A case control study investigating different surgical options

BackgroundOsteofibrous dysplasia (OFD) is a rare non neoplastic, self-limited intracortical fibro-osseous lesion that most commonly affects the diaphysis of the tibia and fibula of children, the best treatment is still debated. Therefore we performed a retrospective study in children mostly under 10 years old with OFD aiming to determine whether early surgery is necessary and which is the best treatment. HypothesisSymptomatic OFD lesions should be treated proactively, and appropriate treatment can achieve favorable outcome. MethodsWe retrospectively reviewed 23 patients with OFD of the tibia (n=22) and fibula. Management varied according to the severity of symptoms (deformity, pain or pathological fracture) and the extent of the lesion. Cases were divided into four groups (Gr.): Gr. 1: observation (n=4); Gr. 2: curettage and allograft (n=6); Gr. 3: curettage, allograft and elastic stable intramedullary nailing (ESIN) fixation (n=9); Gr. 4: extra-periosteal resection and bone transport (n=5). One patient received two different treatments successively (23 patients and 24 cases). All patients had regular clinical and radiographic follow-up to assess bone consolidation and complications. ResultsIn Gr. 1, four asymptomatic patients underwent observation after open biopsy. Gr. 4 had the lowest local recurrence rate: 0 cases (0%) vs. 4 (66.7%; Gr. 2) vs. 1 (11.1%; Gr. 3) (p=0.002), incidence of deformity: 0 case (0%) vs. 0 (0%; Gr. 2) vs. 3 (50%; Gr. 3) (p=0.023), and pathological fracture: 0 case (0%) vs. 0 (0%; Gr. 2) vs. 1 (16.7%; Gr. 3) (p=0.006), although the consolidation time was longer: 6.8 vs. 2 (Gr. 2) vs. 2.7 months (Gr. 3) (p=0.017) and the rate of complication was higher than those of Gr. 2 and Gr. 3 (p<0.05). Gr. 3 had a lower local recurrence rate: 1 case (11.1%) vs. 4 cases (66.7%) (p=0.002), incidence of deformity: 0 case (0%) vs. 3 cases (50%) (p=0.023), and pathological fracture: 0 case vs. 1 case (16.7%) (p=0.006) than Gr. 2. DiscussionOpen biopsy is an important step in the management of patients with imaging suggestive of OFD in order to rule out Adamantinoma and other bone tumors or infection. Observation should be reserved for asymptomatic patients, while surgical treatment is indicated in patients with persistent pain, pathological fracture or significant deformity of the tibia. ESIN is a valid option to preserve the anatomical axis of the tibia in symptomatic patients with lesions of limited size; large circumferential lesions or recurrence can be managed by extra-periosteal resection and bone transport, although the complication rate can be relatively high. Level of evidenceIII; case control study.

Humerus Lengthening: A Comparison of the Internal Lengthening Nail to External Fixation.

Introduction: Magnetic internal lengthening nails (MILNs) have been used for humeral lengthening to avoid complications associated with external fixation. Purpose/Questions: We compared the 1-year Disabilities of the Arm, Shoulder and Hand (DASH) score, adjacent joint range of motion (ROM), bone healing index (BHI), length achieved, distraction rate, and complications when lengthening the humerus using MILN vs using external fixation. Methods: We conducted a retrospective cohort study of 18 patients (22 humeri) from January 2001 to March 2020 divided into 2 groups, the MILN group (7 patients, 7 humeri) and the mono-lateral fixator group (11 patients, 15 humeri). Results: The MILN group showed larger improvement of DASH scores (average 26.8 and 8 for MILN and fixator groups, respectively), less loss of elbow ROM (average 5° and 7° for MILN and fixator groups, respectively), and shorter time to full recovery of elbow ROM (average 39 days and 122 days for MILN and fixator groups, respectively). In the MILN group, there was slower distraction rate (average 0.66 mm/day and 0.86 mm/day for MILN and fixator groups, respectively), less lengthening achieved (average 5.2 cm and 7 cm for MILN and fixator group, respectively), and a lower lengthening percentage (average 19% and 41% for MILN and fixator group, respectively). Bone healing index (BHI) of 0.94 and 0.99 months/cm for the MILN and the fixator groups were similar. Conclusion: Humeral lengthening using the MILN allowed for early full recovery of joint ROM with comparable functional and radiographic outcomes compared with using external fixators.

Childhood\u2010onset systemic lupus erythematosus with trisomy X and the increased risk for bone complications: a case report

BackgroundSystemic lupus erythematosus is a multi-organ inflammatory autoimmune disease; immune complexes are part of the pathogenesis, but not entirely responsible. Trisomy X is the most common female chromosomal abnormality and the role of an additional X chromosome in the development of systemic lupus erythematosus is well recognized. However, the potential complications and optimal management of childhood lupus with trisomy X remain unclear. Herein, we describe a case of childhood-onset systemic lupus erythematosus associated with severe bone complications presumably secondary to trisomy X.Case presentationA 16-year-old Japanese girl was diagnosed with childhood-onset systemic lupus erythematosus and trisomy X. A chromosomal abnormality (47, XXX) was incidentally identified on bone marrow examination initially done to determine the cause of pancytopenia. She had a persistent headache, fever for six days, diffuse hair loss, mucosal ulcers, butterfly eruptions, and palmar erythema. Furthermore, thrombocytopenia, anemia, and erythrocyte fragmentation were detected, suggesting secondary thrombotic microangiopathy. She was initially treated with intravenous methylprednisolone pulse therapy and prescribed monthly cyclophosphamide for severe disease activity, prednisolone, mycophenolate mofetil, and hydroxychloroquine as remission maintenance drugs. She developed generalized extremity pain that had been worsening throughout the disease. Extremity magnetic resonance imaging performed 12 months after the treatment onset revealed multifocal avascular necrosis, and dual-energy X-ray absorptiometry revealed further decreased bone mineral density. High plasma levels of factor VIII were detected by additional tests for coagulation functions, and we suspected the possibility that factor VIII might cause avascular necrosis due to thrombosis. Currently, she is being treated with prednisolone and MMF for SLE. However, her extremity pain has not been managed effectively even under the administration of non-steroidal anti-inflammatory drugs and pregabalin.ConclusionsAn additional X chromosome has been reported to be associated with factor VIII and osteoporosis. Additionally, elevated plasma levels of FVIII is the risk factors for thrombosis, which leads to the risk of avascular necrosis. Patients with systemic lupus erythematosus complicated by trisomy X might be at a higher risk of avascular necrosis and osteoporosis that can also manifest in childhood systemic lupus erythematosus.

Quality of life and pain in patients with metastatic bone disease from solid tumors treated with bone-targeted agents\u2013 a real-world cross-sectional study from Switzerland (SAKK 95/16)

BackgroundBone-targeted agents (BTAs) are widely used in the management of patients with bone metastases from solid tumors. Knowledge of the impact of their routine care use on patient-reported pain and bone pain-related quality of life (QoL) is limited.MethodsThis real world, cross-sectional study enrolled patients over a 3-month period through oncologists across Switzerland. Patients were ≥ 18 years, had solid tumors and at least one bone metastasis, and received routine care for bone metastases. Physicians provided data on BTA-related practices, risk of bone complications and BTA regimen. Patients completed questionnaires about pain (BPI-SF), general and bone pain-related QoL (FACT-G, FACT-BP) and treatment satisfaction (FACIT-TS-G).ResultsEighteen sites recruited 417 patients. Based on the FACT-BP, 42% of the patients indicated not having bone pain. According to the BPI-SF, 28% reported no, 43% mild, 14% moderate, and 15% severe pain, respectively. Patients not treated with a BTA had better overall QoL (FACT-G: p = 0.031) and bone pain-related QoL (FACT-BP, p = 0.007) than those treated with a BTA. All pain and other QoL scales did not differ between groups. Patients perceived at ‘low risk of bone complications’ by their physician not receiving a BTA reported less pain and better QoL than those considered at ‘low risk’ but receiving BTA treatment or those considered at ‘high risk’ regardless of BTA treatment. Overall satisfaction with the treatment was good; almost 50% of patients reporting that they were completely satisfied.ConclusionsOverall, pain and QoL did not differ according to BTA treatment or physicians’ risk perception. Patient with low risks not receiving BTA treatment reported least pain and highest QoL scores. These results may suggest that treating physicians assess bone complication risk appropriately and treat patients accordingly, but they need to be confirmed by objective determination of longitudinal skeletal complication risk.

Impact of Early Conventional Treatment on Adult Bone and Joints in a Murine Model of X-Linked Hypophosphatemia

X-linked hypophosphatemia (XLH) is the most common form of genetic rickets. Mainly diagnosed during childhood because of growth retardation and deformities of the lower limbs, the disease affects adults with early enthesopathies and joint structural damage that significantly alter patient quality of life. The conventional treatment, based on phosphorus supplementation and active vitamin D analogs, is commonly administered from early childhood to the end of growth; unfortunately, it does not allow complete recovery from skeletal damage. Despite adequate treatment during childhood, bone and joint complications occur in adults and become a dominant feature in the natural history of the disease. Our previous data showed that the Hyp mouse is a relevant model of XLH for studying early enthesophytes and joint structural damage. Here, we studied the effect of conventional treatment on the development of bone and joint alterations in this mouse model during growth and young adulthood. Mice were supplemented with oral phosphorus and calcitriol injections, following two timelines: (i) from weaning to 3 months of age and (ii) from 2 to 3 months to evaluate the effects of treatment on the development of early enthesophytes and joint alterations, and on changes in bone and joint deformities already present, respectively. We showed that early conventional treatment improved bone microarchitecture, and partially prevented bone and joint complications, but with no noticeable improvement in enthesophytes. In contrast, later administration had limited efficacy in ameliorating bone and joint alterations. Despite the improvement in bone microarchitecture, the conventional treatment, early or late, had no effect on osteoid accumulation. Our data underline the usefulness of the Hyp murine model for preclinical studies on skeletal and extraskeletal lesions. Although the early conventional treatment is important for the improvement of bone microarchitecture, the persistence of osteomalacia implies seeking new therapeutic strategies, in particular anti-FGF23 approach, in order to optimize the treatment of XLH.

PARATHYROID STATUS AND ITS ASSOCIATION WITH HAEMOGLOBINOPATHIES AMONG TYPE 2 DIABETES MELLITUS IN SOUTHERN NIGERIA

Background: Endocrine action is integrative and an endocrine dysfunction of one gland is known to affect other endocrine glands. Parathyroid glands are associated with the beta cell function. Thus, insulin resistance observed in type 2 diabetes mellitus (T2DM) may be associated with alterations of parathyroid hormones and their metabolic pathways. These have been reported to have a genetic root, postulated to be aberrant haemoglobin gene resulting in haemoglobin variants. This has not been fully explored in sub-Saharan Africa, which has significant population of haemoglobin variants. Aim: The aim of this study was to evaluate the status of parathyroid dysfunction and its association with haemoglobinopathies among Sub-Saharan Africans with type 2 diabetes mellitus. Method: A total of 204 individuals aged 25 – 80 years which comprised 100 T2DM and 104 Controls without T2DM were enrolled from a tertiary hospital, in Ibadan, Nigeria and environs.10mL intravenous blood was obtained from each participant. Parathyroid Hormone (PTH) was measured using enzyme linked immunosorbent assay (ELISA). Calcium, Phosphate, Albumin and Fasting Plasma Glucose (FPG) were analysed spectrophotometrically. Haemoglobin A2 (HbA2), Haemoglobin A (HbA), Haemoglobin C (HbC) and Haemoglobin S (HbS) and Glycated haemoglobin (HbA1c) were determined by High Performance Liquid Chromatography (HPLC) method using Variant Haemoglobin Testing System (Bio-Rad Variant II). Data analysed using appropriate statistical analysis were significant at p&lt;0.05. Results: Normal parathyroid function, hyperparathyroidism and hypoparathyroidism were present in 93% vs 96%, 3% vs 0.96% and 4% vs 6.73% in T2DM and controls respectively. T2DM and controls with AA and Non AA had 62% vs 31% normoparathyroidism, 3% vs 0% hyperparathyroidism and 2% vs 2% hypoparathyroidism respectively. The association between parathyroid gland disorder in T2DM and controls with the various haemoglobin variants was not significant (p&gt;0.05) but the difference between parathyroid function in the control group with and without Beta Thalassaemia Trait was significant (p&lt;0.05). Conclusion: Hypoparathyroidism and hyperparathyroidism were revealed in Type 2 Diabetes Mellitus and control individuals with haemoglobin genotype AA (HbAA). Hypoparathyroidism was also found among controls with Beta Thalassaemia Trait. Timely identification of these disorders may be helpful in appropriate therapeutic regimen to facilitate bone growth, prevent fractures and complications of parathyroid gland in these individuals. KEYWORDS: Haemoglobin Variants, Parathyroid Dysfunction, Type 2 Diabetes Mellitus (T2DM).

Monocentric experience of primary hyperparathyroidism surgery in Algeria

IntroductionPrimary hyperparathyroidism (PHPT) remains a relatively underdiagnosed disease in developing countries. The aim of this study was to assess the demographic, pathological, biochemical, and surgical characteristics of patients with primary hyperparathyroidism in a university hospital department of otolaryngology in eastern Algeria. Materials and methodWe performed a retrospective analysis of the records of 62 patients operated in our department for primary hyperparathyroidism between January 2002 and December 2013. ResultsThe mean age was 47.7 ± 15 years with a female preponderance (88.7%). The mode of discovery was during a biological assessment for bone syndrome in 42% of cases. The mean calcemia was 2.92 ± 0.6 mmol/L, and the intact serum parathyroid hormone was 867.78 ± 954.50 pmol/L. A total of 54.8% of patients had bilateral neck exploration, and 45.2% had minimally invasive open parathyroidectomy. Postoperative complications were dominated by severe hypocalcemia and hungry bone syndrome. ConclusionThe diagnosis of primary hyperparathyroidism in our country is late, and management is often performed after the appearance of bone and renal complications.

Mechanisms of Bone Impairment in Sickle Bone Disease.

Sickle bone disease (SBD) is a chronic and invalidating complication of Sickle cell disease (SCD), a multisystem autosomal recessive genetic disorder affecting millions of people worldwide. Mechanisms involved in SBD are not completely known, especially in pediatric age. Among the hypothesized pathogenetic mechanisms underlying SBD are bone marrow compensatory hyperplasia and bone ischemic damage, both secondary to vaso-occlusive crisis (VOC), which leads to cell sickling, thus worsening local hypoxia with a negative impact on osteoblast recruitment. Furthermore, the hypoxia is a strong activator of erythropoietin, which in turn stimulates osteoclast precursors and induces bone loss. Hemolysis and iron overload due to a chronic transfusion regimen could also contribute to the onset of bone complications. Vitamin D deficiency, which is frequently seen in SCD subjects, may worsen SBD by increasing the resorptive state that is responsible for low bone mineral density, acute/chronic bone pain, and high fracture risk. An imbalance between osteoblasts and osteoclasts, with a relative decrease of osteoblast recruitment and activity, is a further possible mechanism responsible for the impairment of bone health in SCD. Moreover, delayed pubertal growth spurt and low peak bone mass may explain the high incidence of fracture in SCD adolescents. The aim of this review was to focus on the pathogenesis of SBD, updating the studies on biochemical, instrumental, and biological markers of bone metabolism. We also evaluated the growth development and endocrine complications in subjects affected with SCD.

PREVALENCE OF VITAMIN D DEFICIENCY INPRE-DIALYTIC CHRONIC KIDNEY DISEASE PATIENTS ATTENDING A TERTIARY CENTRE IN NORTH-EAST INDIA

Introduction: Vitamin D deficiency has not only been associated with bone and muscular complications but also with cancer, cardiovascular diseases, infection, maternal and neonatal complications. There are many causes of vitamin D deficiency including socio-demographic factors, the timing of sun exposure, along with drugs, skin, liver, and kidney diseases. India is closer to the equator so is considered to have a lower risk of Vitamin D deficiency but it is not so, with many studies implicating deficiency even in the general population. There are no studies done on the north-eastern Indian population document on vitamin D levels in Chronic Kidney Disease (CKD) patients. Aim: To study the prevalence of Vitamin D deficiency in the pre-dialytic chronic kidney disease. Material and Methods:Observational study was done. 120 CKD patients were included in the study and staging was done according to the MDRD formula. Total 25-OH Vitamin D was measured by the Enzyme Immuno Assay method. Results: 43.33% of the patients in the group were found to have vitamin D deficiency and 26.66% of patients had vitamin D insufficiency. There was a significant association between vitamin D deficiency and stages 4 and 5 CKD. There was not any significant correlation between vitamin D levels with age, sex, body mass index, serum calcium, or albumin. Conclusion:High levels of vitamin D deficiency were seen in the CKD patients of the northeast Indian population. There were statistically significant changes in vitamin D levels and stages 4 and 5 of CKD.

The concept of a cementless isoelastic monoblock cup made of highly cross-linked polyethylene infused with vitamin E: radiological analyses of migration and wear using EBRA and clinical outcomes at mid-term follow-up

BackgroundThe newest generation of cementless titanium-coated, isoelastic monoblock cup with vitamin E-blended highly cross-linked polyethylene (HXLPE) was introduced to the market in 2009. The aim of the present study was to obtain mid-term follow-up data including migration and wear analyses.MethodsThis prospective study investigated 101 primary total hip arthroplasty (THA) cases in 96 patients treated at a single institution. Patients were allowed full weight-bearing on the first day postoperatively. Harris hip score (HHS) and pain and satisfication on a visual analogue scale (VAS) were assessed at a mean follow-up of 79.0 months. Migration and wear were assessed using Einzel-Bild-Roentgen-Analyse (EBRA) software. Radiological acetabular bone alterations and complications were documented.ResultsAt mid-term follow-up (mean 79.0 months, range: 51.8–101.7), 81 cases with complete clinical and radiological data were analyzed. Utilisable EBRA measurements were obtained for 42 hips. The mean HHS was 91.1 (range 38.0–100.0), VAS satisfaction was 9.6 (range 6.0–10.0), VAS rest pain was 0.2 (range 0.0–4.0), and VAS load pain was 0.6 (range 0.0–9.0). Mean migration was 0.86 mm (range: 0.0–2.56) at 24 months and 1.34 mm (range: 0.09–3.14) at 5 years, and the mean annual migration rate was 0.22 (range: − 0.24–1.34). The mean total wear was 0.4 mm (range: 0.03–1.0), corresponding to a mean annual wear rate of 0.06 mm per year (range: 0.0–0.17). Radiographic analysis did not reveal any cases of osteolysis, and no revision surgeries had to be performed.ConclusionsAfter using vitamin-E blended HXLPE in cementless isoelastic monoblock cups, there were no obvious signs of osteolysis or aseptic loosening occurred. No patients required revision surgery after mid-term follow-up. Cup migration and wear values were well below the benchmarks considered predictive for potential future failure.Trial registrationThe trial registration number on ClinicalTrials.gov: NCT04322916 (retrospectively registered at 26.03.2020).

Bone metastasis: mechanisms, therapies, and biomarkers.

Skeletal metastases are frequent complications of many cancers, causing bone complications (fractures, bone pain, disability) that negatively affect the patient's quality of life. Here, we first discuss the burden of skeletal complications in cancer bone metastasis. We then describe the pathophysiology of bone metastasis. Bone metastasis is a multistage process: long before the development of clinically detectable metastases, circulating tumor cells settle and enter a dormant state in normal vascular and endosteal niches present in the bone marrow, which provide immediate attachment and shelter, and only become active years later as they proliferate and alter the functions of bone-resorbing (osteoclasts) and bone-forming (osteoblasts) cells, promoting skeletal destruction. The molecular mechanisms involved in mediating each of these steps are described, and we also explain how tumor cells interact with a myriad of interconnected cell populations in the bone marrow, including a rich vascular network, immune cells, adipocytes, and nerves. We discuss metabolic programs that tumor cells could engage with to specifically grow in bone. We also describe the progress and future directions of existing bone-targeted agents and report emerging therapies that have arisen from recent advances in our understanding of the pathophysiology of bone metastases. Finally, we discuss the value of bone turnover biomarkers in detection and monitoring of progression and therapeutic effects in patients with bone metastasis.

Is Decreased Local Bone Quality an Independent Risk Factor for Complications Following Fracture Fixation of Facial Bones.

Although osteoporosis is associated with increased risks of complications of fracture fixation in the orthopedic literature, the association between local bone quality (LBQ) and complications of facial fracture fixation is unknown. The authors aim to identify that if decreased LBQ is an independent risk factor for complications following facial fracture fixation? The authors conducted a prospective cohort study on patients over age of 50 years who underwent open reduction and rigid internal fixation for facial fractures. The primary predictor was LBQ (low or normal), decided by a combination of 3 panoramic indices. Other predictors included age, gender, body mass index (BMI), comorbidities, trauma-related characteristics, etc. The outcome variable was the presence of hardware-related, fracture-healing, wound, or neurosensory complications during 2-year follow-up. Univariate and multivariate regressions were performed to identify any significant association between predictor and outcome variables. The sample was composed of 69 patients (27 females) with an average age of 58.6 ± 8.6 years and BMI of 25 ± 3.8. Low-LBQ patients were significantly older, more females, had lower BMI, mainly injured from falls, had more complications compared to their normal-LBQ counterparts. However, multivariable logistic regressions demonstrated that only age (adjusted OR: 1.12, P = 0.031, 95% CI: 1.01, 1.23) and diabetes (adjusted OR: 12.63, P = 0.029, 95% CI: 1.3, 122.53) were significantly associated with overall complications after confounding adjustment. The results of the present study indicate that reduced LBQ is not an independent risk factor for complications following facial fracture fixation. The increased risk of complications in low-LBQ patients is more likely to be attributed to other age-related comorbidities such as diabetes. Therefore, the authors recommend detailed workup and good control of comorbidities in elderly trauma patient.

Hiperparatiroidismo primario: conceptos para el cirujano general

Durante las últimas décadas, la incidencia del hiperparatiroidismo primario ha venido en aumento, muy probablemente relacionado con la mayor accesibilidad a los estudios diagnósticos; sin embargo, la forma más común de presentación clínica del hiperparatiroidismo primario es asintomática, en más del 80% de los pacientes. En la actualidad, es menos frecuente el diagnóstico por las complicaciones renales (urolitiasis) u óseas (osteítis fibrosa quística) asociadas. Un tumor benigno de la glándula paratiroides (adenoma único), es la principal causa de esta enfermedad. Por tanto, su tratamiento usualmente es quirúrgico. A pesar de ello, no es frecuente el manejo de esta patología por el cirujano general. En este artículo se revisan conceptos claves para el diagnóstico y manejo de esta enfermedad para el médico residente y especialista en Cirugía general.

Advanced cervical cancer in young women: imaging study of late and very late radiation-related side effects after successful treatment by combined radiotherapy

Radical combined radiotherapy (RT) is a standard treatment for advanced cervical cancer. The aim of our study was to identify morphological late (≥6 months) and very late (≥5 years) radiation-related comorbidities on computed tomography (CT), positron emission tomography/computerized tomography (PET/CT) or magnetic resonance imaging (MRI) scans in young females who survived ≥5 years since RT and were considered as successfully treated. Secondly, we studied a rate of clinically silent radiation-related toxicities apparent on imaging scans that might influenced on future well-being of survived females. Thirdly, we analyzed reasons why patients underwent imaging scans. We included 41 subjects aged under 50 years (mean 41.8±7.2 years, median 41 years), who survived ≥5 years since RT, with at least one available imaging scan ≥3 years since RT. The mean time between RT and the last available scan was 12.3±7.9 years (median 9 years); the mean time of clinical follow-up was 15.4±7.1 years (median 14 years). Fourteen (34.1%) females underwent the first imaging scan in emergency situation and 27 (65.9%) patients due to variable chronic complaints. Grade III-V radiation-related comorbidities occurred in 19 (46.3%) females including one case of death due to radiation-induced osteosarcoma. In 14 of 19 patients, comorbidities were multiple. Four (9.8%) females suffered from life-threatening complications (grade IV): one from an uretero-arterial fistula with massive hematuria and 3 from bowel perforations. Eleven (26.8%) subjects suffered from bowel strictures with ileus development, they underwent mean 1.7±0.8 surgery (median 1.5). The mean time since RT to the first surgery for intestinal complications was 5.4±6.0 years (median 3 years), to the second 12.0±9.6 years (median 11.5 years) and to the third surgery 9.0±4.2 years (median 9 years). Late fistulas formations (vesico-recto-vaginal) were seen in 6 (14.6%) patients. Bone complications were diagnosed in 9 (22.0%) of treated females, one case of osteosarcoma included, 4 of 9 bone complications were clinically silent. In 5 (12.2%) subjects, toxicities grade III-IV first time manifested >5 years since RT, majority of them were multiple. The bowel perforation and fistulas formations were the earliest manifested grade III-IV toxicities, with median time 3 years since RT, the bone complications were the latest manifested with median time 16 years since RT. Our study is not able to bring information about the incidence of late and very late radiation related comorbidities, according to International Federation of Gynecology and Obstetrics (FIGO) recommendations patients are clinically followed only for 5 years and imaging cross-sectional scans are not recommended. However, our study shows that if females successfully treated for advanced cervical cancer report abdominal/pelvic clinical problems, it is highly probable their imaging scans will reveal late radiation related side-effects that may affect the rest of their life. It puts forward question whether females after radical RT should been regularly followed by cross-sectional imaging methods.

Femoral head avascular necrosis in a child with transfusion-dependent beta-thalassemia: a case report

Background: Avascular necrosis of the head of the femur (AVNF) is commonly reported in certain types of hemoglobinopathies, such as sickle cell disease. However, very few cases of AVNF have been reported with transfusion-dependent beta-thalassemia (TDT). Case Presentation: This paper reports a case of a 13-year-old boy known case of TDT who was on regular blood transfusion and iron chelation therapy and who presented with left hip pain associated with movement limitation for 1 month. Musculoskeletal examination revealed tenderness along the joint line of the left hip and decreased range of motion in this hip. Plain X-ray revealed atrophy of the left femoral head. The diagnosis was confirmed with magnetic resonance imaging, which showed left femoral head necrosis. The patient was treated initially with bed rest and analgesia and later by surgery. Conclusion: Many bone complications are associated with TDT such as bone deformity and osteoporosis, but AVNF is a very rare complication and has multifactorial etiology. Physicians are encouraged to consider the possible presentation of AVNF in TDT patients, mainly if they present with hip pain.

High ankle-brachial index predicts cardiovascular events and mortality in hemodialysis patients with severe secondary hyperparathyroidism.

Introduction:Vascular calcification related to severe secondary hyperparathyroidism (SHPT) is an important cause of cardiovascular and bone complications, leading to high morbidity and mortality in patients with chronic kidney disease (CKD) undergoing hemodialysis (HD). The present study aimed to analyze whether ankle-brachial index (ABI), a non-invasive diagnostic tool, is able to predict cardiovascular outcomes in this population.Methods:We selected 88 adult patients on HD for at least 6 months, with serum iPTH>1,000pg/mL. We collected clinical data, biochemical and hormonal parameters, and ABI (sonar-Doppler). Calcification was assessed by lateral radiography of the abdomen and by simple vascular calcification score (SVCS). This cohort was monitored prospectively between 2012 and 2019 for cardiovascular outcomes (death, myocardial infarction (MI), stroke, and calciphylaxis) to estimate the accuracy of ABI in this setting.Results:The baseline values were: iPTH: 1770±689pg/mL, P: 5.8±1.2 mg/dL, corrected Ca: 9.7±0.8mg/dL, 25(OH)vit D: 25.1±10.9ng/mL. Sixty-five percent of patients had ABI>1.3 (ranging from 0.6 to 3.2); 66% had SVCS≥3, and 45% aortic calcification (Kauppila≥8). The prospective evaluation (51.6±24.0 months), provided the following cardiovascular outcomes: 11% of deaths, 17% of nonfatal MI, one stroke, and 3% of calciphylaxis. After adjustments, patients with ABI≥1.6 had 8.9-fold higher risk of cardiovascular events (p=0.035), and ABI≥1.8 had 12.2-fold higher risk of cardiovascular mortality (p=0.019).Conclusion:The presence of vascular calcifications and arterial stiffness was highly prevalent in our population. We suggest that ABI, a simple and cost-effective diagnostic tool, could be used at an outpatient basis to predict cardiovascular events in patients with severe SHPT undergoing HD.

Functional Outcome of Distraction Osteogenesis Using Linear Rail System (LRS) in Adults with Isolated Femoral Bone Gap

Background: The management of bone gap in the femoral shaft has remained difficult and challenging to the orthopaedic and trauma Surgeons. Distraction osteogenesis using the linear rail system (LRS) may be a useful tool in bridging such defects in our environment. Objective: To study the radiologic bone union, functional outcome and complications of distraction osteogenesis in the management of femoral bone gap using linear rail system (LRS). Methodology: A hospital based prospective interventional study conducted at National Orthopaedic Hospital, Dala and Albarka clinic, Dandishe, Kano, between March 2013 and March 2018. Sixty-eight cases were recruited. Every patient had LRS applied after adequate debridement when needed. Primary or interval corticotomy was done depending on the extent of soft tissue dissection in relation to the corticotomy site. Follow up was done until the regenerate had corticalized and LRS removed. Complications were noted and recorded. Radiologic union and functional outcome were assessed using the RUST and ASAMI outcome scores respectively. Data was analyzed using SPSS version 20. Results: Sixty-eight cases were recruited with M: F ratio of 16: 1. The mean age was 36.7 +/- 10.5years. The age range between 36-45years was more commonly treated representing 34(50.0%). Primary corticotomy was done in 52 (76.5%) while interval corticotomy was done in 16 (23.5%). The mean regenerate length achieved was 9.6 +/- 2.7cm. The mean duration of treatment was 20.3 +/- 6 months. Radiologic union was achieved in 66 (97.1%) patients. Sixty-four (94.1%) had excellent or good ASAMI functional outcome scores. Sixty-six (97.1%) were either very satisfied or satisfied with their treatment while 2 (2.9%) were indifferent. The common complications were intermittent pin tract infections recorded in 28 (41.2%), knee stiffness in 18 (26.5), proximal or distal varus deformity in 10 (14.7%) and non-union in 2 (2.9%) of cases. Conclusion: Distraction osteogenesis using LRS can achieve bone union and excellent outcome in the management of bone gap in the femur. However, intermittent pin tract infection, knee stiffness and varus deformities post significant challenges.