Nicolas Aigner

Pharmacological management of aseptic osteonecrosis in children

Aseptic osteonecrosis (AON) in children can progress during ossification of cartilage in periods of increased growth or excessive physical stain and may occur in various locations in the skeleton. Disturbance of blood supply to the bone has been suggested as the main pathological mechanism involved in AON, which is characterised by the death of bone marrow and trabecular bone. The extent and development of osteonecrosis and the duration of disease until restorative healing, depend on the formation of new blood vessels, the spreading of vessels in the affected bony areas, the absorption of osteonecrotic tissue and the structure of new bone. Conservative and operative treatment options for AON vary according to the location and development of the disease and the age of the patient. The goal of all treatment options currently used today is to achieve relief of physical load in the affected bone and to promote and regulate blood supply. Treatment should be started early in order to minimise the extent of osteonecrosis and allow restorative healing. As the processes of myelopoiesis, myelophthisis and fracture healing become more clear, interest has focused on advances in the utilisation of bioactive factors to salvage bone in children affected by AON. Such methods include the use of osteoinductive agents, such as cytokines and bone morphogenetic proteins, as well as factors that stimulate angiogenesis and regulate blood supply. Currently, the prostacyclin analogue, iloprost (Ilomedin®, Schering AG), has been successfully used in a pilot study in children suffering from early stages of AON.

Bone marrow edema of the forefoot after chevron osteotomy--a rare cause of metatarsalgia: a case report.

Treatment options of bone marrow edema syndrome, which is associated with vascular disturbances, are protracted nonoperative treatment or core decompression which still demands several weeks until complete recovery. We obtained excellent results by the use of the vasoactive drug iloprost, a stable prostacyclin analogue, leading to a complete relief of symptoms in cases of bone marrow edema which had initially suggested early avascular necrosis of the second metatarsal head. The bone marrow edema of the second metatarsal bone was thought to be due to altered biomechanics following a distal first metatarsal chevron osteotomy. During the five days of iloprost infusion, the patient reported relief of rest pain. After therapy, the pedobarogram was normalized. The AOFAS forefoot score improved from 44 to 85 points after one month, and to 95 points after three months. At that time, the marrow showed normal signals. Without additional intervention the patient was able to resume normal activities.

Radiographic evaluation of the acromion in impingement syndrome: Comparison with arthroscopic findings in 147 shoulders

We analyzed standardized scapulolateral and anteroposterior view radiographs in 147 patients with impingement syndrome to detect a subacromial osteophyte or spur, which should be of value in those patients who require surgical treatment. Standard anteroposterior view radiographs with a fixed tube angulation, 0 and 30 degrees, were compared to anteroposterior view radiographs with individual tube angulation (the radiograph beam was tilted caudally, depending on the slope of the acromion). In all patients, we identified an acromion bony overhang on the anteroposterior view radiographs with individual tube angulation having an average thickness of 5 mm, which correlated well with the intraoperative findings at arthroscopic acromioplasty. In only 35% of the patients did we detect a subacromial osteophyte or spur on radiographs with a fixed tube at 0 degrees angulation and in 92%, we found a false impression of a spur on the 30-degree views because of overexposure. We conclude that, anteroposterior view radiographs with an individual caudally-tilted X-ray beam, depending on the acromion slope, can show the whole spur and/or size of the osteophyte, on the anterior margin of the acromion.