Zakareya Gamie

The effect of β-blockers on bone metabolism as potential drugs under investigation for osteoporosis and fracture healing

Background: β-Adrenergic receptor antagonists (β-blockers) have a well-recognised antihypertensive action that is mediated through a reduction in cardiac output and in the release of renin from the kidneys and inhibition of the action of endogenous catecholamines on β-adrenergic receptors. This class of drugs has been shown to reduce the incidence of cardiovascular disease. Recent evidence suggests that β-blockers may also have an effect on bone structure, metabolism and fracture healing. Objective: This paper reviews in vitro and in vivo data that suggest β-blockers have primarily an anabolic effect on bone metabolism. Results: The sympathetic nervous system has a catabolic effect on bone, and in vitro studies have shown that adrenergic agonists stimulate bone resorption. The β-blocker propranolol has been shown to increase bone formation in ovariectomised female rats. Also, recent observational clinical studies provide evidence to show that β-blockers are associated with reduction in fracture risk in both men and women. Conclusion: Although there are some controversial studies, most research concludes that β-blockers show promise in the treatment of osteoporosis and fracture healing.

Percutaneous screw fixation for sacral insufficiency fractures: A REVIEW OF THREE CASES

Sacral insufficiency fractures are traditionally treated with bed rest and analgesia. The importance of early rehabilitation is generally appreciated; but pain frequently delays this, resulting in prolonged hospital stay and the risk of complications related to immobility. We describe three women with sacral insufficiency fractures who were treated with percutaneous sacroiliac screws and followed up for a mean of 18 months (12 to 24). They had immediate pain relief, uncomplicated rehabilitation and uneventful healing.

Early Postoperative Bleeding in Polytrauma Patients Treated with Fondaparinux: Literature Review and Institutional Experience

Surgery for pelvic or acetabular fractures carries a high risk of deep-vein thrombosis (DVT). Reports indicate that fondaparinux is a more effective thromboprophylactic agent than low molecular weight heparin (LMWH) after major orthopaedic surgery. The safety and efficacy of fondaparinux was evaluated in a new protocol used for DVT prophylaxis. One hundred and twenty seven patients with pelvic or acetabular fractures received either fondaparinux or enoxaparin and were analysed in a historical non-concurrent study. Specific review points included clinical deep-vein thrombosis (DVT) or pulmonary embolism (PE) and evidence of adverse effects such as bleeding or allergic reactions. Two patients that received enoxaparin were found to have a DVT and one patient had a PE. There was no documented DVT or PE in patients that received fondaparinux. The mean number of units of blood transfused postoperatively was higher in the enoxaparin group; however, multivariate regression modelling demonstrated no significant difference between the groups. The most current large randomised controlled studies investigating the administration of fondaparinux following joint arthroplasty or hip fracture surgery, have demonstrated a slight increase or a similar number of bleeding events in patients treated with fondaparinux when compared to those treated with enoxaparin. The current report supports that fondaparinux, in patients with pelvic and acetabular fractures, can be equally effective as enoxaparin and not associated with adverse bleeding events.

Nailed cementoplasty: a salvage technique for rorabeck type II periprosthetic fractures in octogenarians.

Periprosthetic femoral fractures around a total knee arthroplasty present a surgical challenge in octogenarians with advanced osteoporosis. We describe a salvage technique combining retrograde intramedullary nailing augmented with polymethylmethacrylate cement in 5 patients followed up for a median time of 12 months. The nail/cement construct bridges the femoral canal tightly and simulates a stemmed cemented revision component. All patients had an uncomplicated recovery and returned to their preinjury functional status within 4 months. This procedure does not disrupt the soft tissue envelope around the fracture site, is easy to perform and permits immediate full range of movement. When standard retrograde nailing or plating alone is inadequate in maintaining severely osteoporotic fracture reduction, nailed cementoplasty is proposed as a salvage procedure in octogenarians unfit for lengthy interventions.

Revision of a nonunited subtrochanteric femoral fracture around a failed intramedullary nail with the use of RIA products, BMP-7 and hydroxyapatite: a case report

IntroductionFemoral subtrochanteric fractures are commonly treated using intramedullary devices. Failure of the implant and subsequent nonunion is still an issue, however, and limited evidence exists regarding the most appropriate treatment.Case presentationWe report the case of an 80-year-old Caucasian woman with a subtrochanteric fracture originally treated using a trochanteric gamma nail which failed, resulting in a nonunion and fracture of its proximal end. The nonunion was revised with the removal of the broken trochanteric gamma nail, application of a condylar blade plate, ipsilateral Reamer/Irrigator/Aspirator autografting, recombinant human bone morphogenetic protein-7 and injectable hydroxyapatite cement. The fracture united fully at ten months following revision surgery, with no signs of femoral head avascular necrosis at 18-month follow-up.ConclusionThe essential requirements for success when revising a nonunited fracture are to provide anatomical reduction, mechanical stability, bone defect augmentation and biological stimulation to achieve healing. Current advances in molecular biology, such as recombinant human bone morphogenetic protein-7, and biotechnology such as the Reamer/Irrigator/Aspirator system and hydroxyapatite injectable cement can improve patient outcomes over the use of our traditional revision techniques.

Posterior reversible encephalopathy syndrome in a child with cyclical vomiting and hypertension: a case report

IntroductionPosterior reversible encephalopathy syndrome is characterized by headache, nausea and vomiting, seizures and visual disturbances. It has certain characteristic radiological features, which allow diagnosis in the appropriate clinical setting and enable appropriate clinical therapy to be instituted.Case presentationA 10-year-old Caucasian girl who was hospitalized due to recurrent vomiting was diagnosed as having posterior reversible encephalopathy syndrome after an initial diagnosis of cyclical vomiting and hypertension was made.ConclusionPosterior reversible encephalopathy syndrome is a rare disorder in children. Early recognition of characteristic radiological features is key to the diagnosis as clinical symptoms may be non-specific or mimic other neurological illnesses. To the best of our knowledge this is the first case to report an association between posterior reversible encephalopathy syndrome, cyclical vomiting and hypertension. Furthermore, in this case, the resolution of the abnormalities found on magnetic resonance imaging over time did not appear to equate with clinical recovery.

The Clinical Management of the Patient with Encephalitis

Determining the patency of the airway is crucial for the survival of the patient. In the general assessment of airway patency a clinician must observe the face and the neck. Abnormalities in the jaw mouth and neck must be noted as these could lead to airway compromise and future complications. Speaking to the patient for example by asking their name and observing their response, such as able to communicate in full sentences is a good indicator of unobstructed airways. Changes in vocalisation can be due to Asthma, COPD, emboli, oedema or even pneumonia. If any of these conditions are suspected a definitive diagnosis must be obtained as any of these could lead to further deterioration of the patient.

Lower respiratory tract infection and rapid expansion of an abdominal aortic aneurysm: a case report

IntroductionThe rate of abdominal aortic aneurysm expansion is related to multiple factors. There is some evidence that inflammation can accelerate aneurysm expansion. However, the association between pulmonary sepsis and rapid abdominal aortic aneurysm expansion is rarely reported.Case presentationHere we present a case of a rapidly expanding abdominal aortic aneurysm in a 68-year-old Caucasian man with a concomitant lower respiratory tract infection and systemic sepsis requiring intensive monitoring and urgent endovascular intervention. Our patient had an uncomplicated post-operative recovery and a follow-up computed tomography scan at one month demonstrated no evidence of an endoleak.ConclusionThis case highlights the potential association between pulmonary sepsis and rapid abdominal aortic aneurysm expansion. In such cases, a policy of frequent monitoring should be adopted to identify those patients requiring definitive management.