Sokratis Varitimidis

1,25-Dihydroxyvitamin D(3) and extracellular inorganic phosphate activate mitogen-activated protein kinase pathway through fibroblast growth factor 23 contributing to hypertrophy and mineralization in osteoarthritic chondrocytes.

Hypertrophy and impaired mineralization are two processes closely associated with osteoarthritis (OA). 1,25-dihydroxyvitamin D3 (1a,25(OH)2D3) and inorganic phosphate (Pi) are two important factors that are implicated in calcium and phosphate homeostasis of bone metabolism and both can be regulated by the circulating phosphaturic factor fibroblast growth factor 23 (FGF23). The objective of this study was to investigate the role of 1a,25(OH)2D3 and Pi and the molecular mechanism through which they contribute to hypertrophy and mineralization in human osteoarthritic chondrocytes. For this purpose, primary human chondrocytes were obtained from articular cartilage which was collected after total knee replacement surgery in OA patients. FGF23, fibroblast growth factor receptor 1c (FGFR1c), vitamin D3 receptor (VDR), and phosphate inorganic transporter-1 and -2 (PiT-1 and PiT-2) expression levels were evaluated and found to be significantly higher in OA chondrocytes compared with normal. In addition, we observed that the binding of FGF23 to FGFR1c was stronger in OA chondrocytes compared with normal. Chromatin immunoprecipitation (ChIP) assay revealed, for the first time, the presence of two vitamin D response elements (VDREs) in the FGF23 promoter. Treatment of normal chondrocytes with 1a,25(OH)2D3 or Pi resulted in significant up-regulation of VDR, FGF23, PiT-1, PiT-2 mRNA and protein levels, extracellular signal-regulated kinases 1/2 (ERK1/2) phosphorylation and induction of hypertrophy markers collagen type X (COL10A1), osteopontin (OPN), osteocalcin (OC), catabolic markers metalloproteinase-13 (MMP-13) and the apoptotic marker caspase-9. Furthermore, VDR silencing in OA chondrocytes negatively regulated FGF23, COL10A1, OPN, OC, MMP-13 and caspase-9 expressions and ERK1/2 phosphorylation. Finally, combined VDR silencing and PiT-1, PiT-2 inhibition in OA chondrocytes resulted in additive down-regulation of FGF23 expression, ERK1/2 activation and COL10A1, OPN, OC, MMP-13 and caspase-9 expression levels. We propose that 1a,25(OH)2D3 and Pi act synergistically through FGF23 signaling and ERK1/2 phosphorylation contributing to late hypertrophic events and impaired mineralization in osteoarthritic chondrocytes.

Complex regional pain syndrome type I as a consequence of trauma or surgery to upper extremity: management with intravenous regional anaesthesia, using lidocaine and methyloprednisolone

Complex regional pain syndrome type I (CRPS-I) is a known complication after surgery or trauma to the upper extremity and is difficult to treat. A simple and easily tolerated method of treatment that includes intravenous regional anaesthetic block with lidocaine and methyloprednisolone is presented. One hundred and sixty-eight patients with CRPS-I of the upper extremity were treated in a 5-year period. At the end of treatment 88% of the patients reported minimal or no pain. After a mean follow-up of 5 years (range 28 months to 7 years) complete absence of pain was reported by 92% of patients. The symptoms of the acute phase of the syndrome were reversed. Early recognition and prompt initiation of treatment is very important for the course of the disease as symptoms can be reversible when treatment starts early. Permanent results with a functional upper extremity and very satisfactory pain relief can be anticipated.

Pediatric Terrible Triad Elbow Fracture Dislocations: Report of 2 Cases

An elbow dislocation associated with radial head and coronoid process fractures, the terrible triad injury, has an unpredictable outcome in adults and is rare in children. We present 2 such injuries in children, 1 combined with an olecranon fracture, and both with good early clinical outcomes. However, in 1 of the 2 cases, avascular necrosis of the proximal radius was evident on radiographs.

Long Term Outcome of Primary Total Knee Arthroplasty. The Effect of Body Weight and Level of Activity

Total knee arthroplasty has been a successful treatment in the management of advanced knee osteoarthritis for pain relief, quality of life and function improvement for almost the last 40 years. By the year 2030, it is estimated that in the United States, the demand for total knee replacement will show a 673 % increase from the present day, with the number of operations reaching almost 3.48 million annually [1]. Constant improvement of implant materials and surgical techniques has made this operation one of the most successful procedures in medicine with several studies showing prosthesis survival more than 80–90 % at 15–20 years follow-up [2, 3]. Success rate and revision surgery for aseptic loosening is generally dependent on the degree of wear and osteolysis of the implant. Factors that influence the outcome of total knee arthroplasty are implant design and material, surgical technique and patient related conditions (Fig. 7.1). Body weight and level of activity are also patient specific factors that may affect the durability of total knee arthroplasty (TKA) [4].

Complicated septic arthritis after knee arthroscopy in a 75-year-old man with osteoarthritis and a popliteal cyst.

A 75-year-old man presented in shock secondary to septic arthritis of the knee. The patient, with a known history of knee osteoarthritis, was treated elsewhere for mechanical locking symptoms and effusion with arthroscopic debridement, and developed septic arthritis, which disseminated to the leg and foot after a tear in the capsule, and a ruptured pyogenic popliteal cyst. Open debridement of the knee joint, and drainage of the abscesses of the leg and foot, were performed. Antibiotic-loaded cement beads were left in the residual space. Debridement was repeated and cement beads removed after 4 days, and finally the infection was eradicated without any serious consequences for the patient. There is debate over arthroscopic intervention for osteoarthritic knees. The presence of a popliteal cyst, which is a rather common finding in the latter, could be related to a significant number of complications, such as septic arthritis.

Economics of Orthopaedic Infections: A Bottomless Pit

In the current socioeconomic environment, where the hospitals are under pressure to decrease costs, the staggering financial and social burden of the hospital-acquired and the Surgical Site Infections, become an important and largely preventable patient safety problem. Cost is a parameter that needs to be considered when clinical practices are assessed. Understanding the true societal costs of the musculoskeletal infections occurring either during the hospital stay or thereafter, is crucial and further research is required with regard to the comparative effectiveness of specific interventions. Infection prevention, early diagnosis, and immediate intervention for an effective management have become a focus of attention for patients, prayers, and regulatory organizations now demanding accountability and reductions in the rates of periprosthetic infections. It is necessary for all Orthopedic surgeons and health care settings to adhere to evidence-based best practices such as prophylactic antibiotic use, surgical site skin-preparation techniques, and hand hygiene rules and also to constantly adhere to all preoperative, intraoperative, and postoperative interventions that could effectively prevent infection. Rigorous economic evaluation and formal cost-effectiveness analysis comparing various infection control and prevention strategies are required, and this research should be conducted from multiple perspectives. Orthopaedic surgeons, the allied infection specialist physicians and researchers should rather engage with health policy makers, funding agencies and the industry in a co-ordinated effort to urgently address the adverse health and economic burden from the musculoskeletal infections, the problem of the antibiotic resistant bacteria, and the scarcity of new classes of antibacterial drugs on the health-care systems and society. It is essential to have priorities and take appropriate measures to decrease mortality and the consumption of the valuable and limited health care resources, sealing the bottom of this “bottomless pit”.

Reflex sympathetic dystrophy as a consequence of trauma or surgery. Management with intravenous local anaesthetic blockade

Aim: Refex sympathetic dystrophy (RSD) manifests with severe burning pain, vasomotor instability, and osteopenia of the affected part. This study evaluates the results of treatment with intravenous anaesthetic blockade. Method: Twenty-five patients, 8 with post-traumatic and 17 with post-operative RSD were treated in our department. All patients presented with signs of sympathetic system hyperactivity including burning pain, swelling, stiffness and dystrophy of the arm. Pain (rated with the use of a visual analogue scale), ROM and grip strength were documented. The extremity was exsanguinated with an Esmarch bandage and a tourniquet was applied. LidoCaine 0.5% (20ml) and methylprednisolone (120mg) were injected intravenously. Tourniquet was deflated after 20 minutes. The procedure was repeated 2-4 times (weekly intervals) depending on the persistence of symptoms. Results: Follow-up ranged from 10 to 22 months (average 14). A mean of 2.8 blockades/patient were required for the subsidence of RSD signs. 88% of patients had no pain. Grip strength was 92% and ROM was 83% of the opposite side. Conclusions: Intravenous sympathetic blockade with lidocaine and methylprednisolone appears effective in management of RSD. Pain relief and improvement of motion can be expected in most patients.