Vassilios Nikolaou

Transient Osteoporosis of the Knee

A 52-year-old man presented with a 3-week history of right knee pain, significant enough to prevent weight bearing. There was no history of knee injury or disease. On knee examination, an effusion and medial joint line tenderness was noted. Knee range of motion was full, but painful. Radiographs revealed minor osteoarthritic changes. Laboratory values were within normal limits, including those associated with infection. Magnetic resonance imaging showed decreased signal intensity on T1-weighted images within the medial femoral condyle and corresponding increased signal intensity on T2-weighted consistent with bone marrow edema as well as edema to the adjacent soft tissues. Bone scanning showed increased uptake of radioisotope in the medial femoral condyle. The patient was diagnosed with bone marrow edema syndrome, and managed medically with analgesics and continued non weight-bearing status. At the 1-month follow-up, his symptoms had improved significantly. The patient progressively increased weight bearing as tolerated over the subsequent weeks. At 12-week follow-up, symptoms had completely resolved. Magnetic resonance imaging showed no signal abnormalities in the affected knee. Transient osteoporosis is an uncommon and typically self-limiting condition that can be challenging to diagnose and treat. The clinician must be aware of this entity, as well as its typical course, to prevent unnecessary testing and invasive intervention.

Total Knee Replacement and Chemical Thromboprophylaxis: Current Evidence

Thromboembolic disease remains one of the most devastating and potentially lethal complications after elective total knee replacement (TKR) surgery. Studies have shown that 40-85% of patients undergoing TKR will develop venographically confirmed deep vein thrombosis (DVT) if they are not given any type of post-operative thromboprophylaxis and approximately 0.1 to 1.7% will suffer fatal pulmonary embolism (PE). Consequently, there is a general consensus that patients undergoing elective TKR require adequate antithrombotic prophylaxis. The following article reviews current evidence regarding chemical thromboprophylaxis after total knee replacement. Clinical guidelines as described by the American Academy of Orthopaedic Surgeons (AAOS), the American College of Chest Physicians (ACCP) and the UKs National Institute for Health and Clinical Excellence (NICE) are summarized along with the differences between the recommendations. The results of the new oral anticoagulants are reviewed as well as the most recent developments in the search for the most effective venous thromboembolism (VTE) prophylaxis after TKR surgery.

Intra-articular Morphine Enhances Analgesic Efficacy of Ropivacaine for Knee Arthroscopy in Ambulatory Patients

The aim of this double-blind, randomized control trial was to compare the effectiveness of intra-articular ropivacaine alone or with morphine or ketoprofen for controlling pain after arthroscopic knee surgery. One hundred fifty-six patients scheduled for elective knee arthroscopy were recruited. All patients received general anesthesia and were randomly assigned to 4 groups to receive intra-articular ropivacaine 40 mg (group R), ropivacaine 24 mg plus morphine 8 mg (group R+M), ropivacaine 36 mg plus ketoprofen 100 mg (group R+K), or normal saline (group N/S). Pain, sedation, orientation, nausea, vomiting, and urine retention were recorded at 0, 1, 2, 4, 8, 12, and 24 hours postoperatively. Pain was evaluated by a 10-cm visual analog scale (VAS). When the pain was >2, a suppository of 400 mg paracetamol plus 10 mg codeine plus 50 mg caffeine was given. Results showed that at 4 hours postoperatively, pain differed significantly among the 4 groups (P<.001), with less pain recorded in the R+M group. Similarly, the number of suppositories administered postoperatively to the R+M group was significantly less (P<.001) vs the other groups. Patients who received ropivacaine and morphine or normal saline had a higher incidence of nausea and vomiting vs the other groups (P=.001 and P=.036, respectively). The combination of intra-articular ropivacaine and morphine is associated with less pain after knee arthroscopy during early recovery but with a higher incidence of nausea and vomiting. However, the addition of ketoprofen to ropivacaine provides relatively satisfactory pain relief, but with fewer side effects compared to morphine.

Experimental Osteomyelitis Caused by Methicillin-Resistant Staphylococcus aureus Treated with a Polylactide Carrier Releasing Linezolid

BACKGROUND The effectiveness of a new delivery system consisting of polymerized dilactide (PLA) with incorporated linezolid was investigated in a rabbit model as a means of treating methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis. METHODS The PLA-linezolid system was prepared after thorough stirring of PLA with linezolid at a 10:1 ratio. Experimental osteomyelitis was established in 40 rabbits by a modification of the Norden model with MRSA as the test isolate. After a hole had been drilled in the upper right femur, the isolate was inoculated using a thin needle working as a foreign body. At three weeks, the needle was removed and cultured, and the PLA-linezolid system was implanted in half the animals (group B); the remaining half was the control group (group A). Animals were sacrificed at regular intervals; tissue around the site of implantation was examined for pathologic changes and cultured quantitatively. RESULTS The prepared system eluted linezolid in vitro at concentrations much greater than the minimum inhibitory concentration (MIC) of the test pathogen for 11 days. At three weeks after inoculation of the test isolate, all animals had osteomyelitis. By the sixth week, bacterial growth from cancellous bone of group B was significantly lower than that in group A. However, this effect was not maintained until the end of the study (weeks 8 and 10), when the differences in bacterial growth in the two groups were not significant. CONCLUSION Polymerized dilactide mixed with 10% linezolid achieved partial arrest of the offending pathogen in an experimental model of osteomyelitis caused by MRSA.

Unilateral Adrenal Hemorrhage After Total Knee Arthroplasty

Adrenal hemorrhage (AH) is a rare but serious condition that is often diagnosed at autopsy. Unilateral adrenal hemorrhage (UAH) in adults is extremely rare and is often due to trauma or anticoagulation or is associated with systemic illness. The case of a 73-year-old man who was diagnosed with UAH several days after an elective total knee replacement is presented. The patient had an uncomplicated procedure and he was treated postoperatively with a prophylactic dose of subcutaneous low-molecular- weight heparin and compression sleeves. On postoperative day 8, he reported sustained epigastric and midback pain at the lower thoracic level. He had a temperature of 38.5°C. On clinical examination, the patient expressed only mild tenderness at the lumbar area. Abdominal ultrasound and computed tomography (CT) scan were inconclusive. On postoperative day 13, the patient experienced no pain but remained febrile. An abdominal CT scan revealed a high-density mass on the left adrenal gland suggestive of hemorrhage. The subcutaneous heparin as well as the antimicrobial therapy was discontinued and a serum cortisol examination was done. Serum levels were within normal values in the evening and the morning. On postoperative day 16, all laboratory values returned to normal and the patient was discharged in excellent condition. Patients who have abdominal pain, hypotension, or both soon after initiation of anticoagulation or patients who experience abdominal pain, fever, nausea, or confusion postoperatively should be screened for AH.

Use of femoral shaft fracture classification for predicting the risk of associated injuries.

Objectives: To investigate the hypothesis that specific fracture patterns in patients with femoral shaft fractures can predict the likelihood of associated injuries. Design: Retrospective cohort study. Setting: Level I trauma center. Patients/Participants: Consecutive patients treated because of a traumatic diaphyseal femoral fracture. Main Outcome Measurement: We studied the association between the Orthopaedic Trauma Association (OTA) fracture classification (derived from initial radiographs) and concomitant injuries of the head, spine, chest, abdomen, and pelvis with a severity of two or more points according to the Abbreviated Injury Scale by logistic regression analysis. Results: One hundred forty-three of 203 patients (80 men, 63 women; mean age 54 ± 26 years) met the inclusion criteria. All patients had unilateral diaphyseal fractures, 64 OTA 32.A (45%), 46 OTA 32.B (32%), and 33 OTA 32.C (23%). In addition, 134 associated injuries were identified in 52 patients. Increasing fracture severity, as expressed by the OTA classification (ie, A, B, C), was significantly associated with a higher likelihood of thoracic (odds ratio [OR], 5.89; 95% confidence interval [CI], 2.59-13.40), pelvic (OR, 4.55; 95% CI, 2.01-10.28), upper (OR, 2.38; 95% CI, 1.27-4.48), and lower extremity injuries (OR, 3.12; 95% CI, 1.78-5.46). Fracture severity explained between 70% and 86% of the probability of having accompanying injuries. Conclusion: Radiographic grading of the severity of a femoral shaft fracture may signal the presence of accompanying injuries and should contribute to the clinical decision-making process in severe trauma.

Calcaneonavicular coalition@@@Synostose calcanéo-scaphoïdienne: A case report and a literature review article

Tarsal coalition is a congenital condition, involving abnormal fusion between tarsal bones, often resulting in decreased mobility, pain, and deformity leading to a rigid planovalgus foot . The most common sites of tarsal coalition reported in the literature are the calcaneonavicular and the talocalcaneal areas. Clinical examination and three radiographic views of the foot, anteroposterior, 45° internal oblique and lateral, are often sufficient for the diagnosis of most calcaneonavicular coalitions. Nevertheless, fibrous and many cases of cartilaginous coalitions cannot be identified with standard radiographic examination and further investigation with CT and MRI is needed. Conservative treatment is the initial choice. Unfortunately, calcaneonavicular coalitions usually respond poorly to conservative treatment. Surgery with excision of the bar that bridges the two bones gives good results in 70 to almost 80% of the patients. Very rarely calcaneonavicular coalition gives symptoms during the third/fourth decade of the life. In these cases it is possible that concomitant degenerative changes have been developed. Many authors believe that triple arthrodesis is the initial treatment of choice for these patients as in the case presented.RésuméLa synostose du tarse est un état congénital, impliquant la fusion anormale entre les os du tarse souvent ayant pour résultat une diminution de la mobilité, des douleurs et un défaut de la forme du pied, le tout menant à un pied rigide de planovalgus. Les emplacements les plus communs de la synostose tarsienne, rapportés dans la littérature, sont les secteurs calcanéo-naviculaire (calcanéo-scaphoïdienne) et talo-calcanéen (astragalo-calcanéenne). L’examen clinique et trois incidences radiographiques du pied, antéro-postérieure, d’oblique à 45° latéral et interne, sont le plus souvent suffisants pour le diagnostic de la plupart des synostoses calcanéo-naviculaires. Néanmoins, beaucoup de cas de synostoses fibreuses ou cartilagineuses ne peuvent pas être identifiées avec l’examen radiographique standard et davantage de recherche avec le scanner et l’IRM est nécessaire. Le traitement conservateur est le traitement initial de choix. Malheureusement, les synostoses calcanéo-naviculaires répondent habituellement mal au traitement conservateur. La chirurgie avec l’excision de la barre qui jette un pont entre les deux os donne de bons résultats dans 70 à presque 80% des patients. Très rarement la synostose calcanéo-naviculaire donne des symptômes pendant la 3ème ou 4ème décennie de la vie. Dans ces cas il est très possible que des changements dégénératifs concomitants aient été développés. Beaucoup d’auteurs croient que la triple arthrodèse est le traitement initial de choix pour ces patients, comme dans le cas présenté.