Study Design: Repeated Measures.

Objectives: To determine the short term impact of cold water immersion on sensory and vascular functions in patients with Distal Radius Fracture (DRF) and compare responses in the injured and uninjured hands.

Background: Cold exposure is used to assess neurovascular function. Cold is also used as therapeutic agent to reduce pain and swelling. There is a scarcity of trials that have looked at the impact of cold exposure in patients with DRF.

Methods: Twenty patients with DRF, aged 18 to 65 yrs. were recruited after cast removal. All patients underwent Immersion in Cold water Evaluation (ICE) which consisted of 5 min of hand immersion in water at 12°C. Skin Blood Flow (SBF) in hands, Skin Temperature (S Temp.) in index and little fingers and sensory Perception Thresholds (sPT) at 2000Hz (for Aβ fiber) and 5 Hz (for C fiber) were obtained from ring finger, before ICE, immediately after (0 min, 1 min) and 10 min later. Differences were analyzed using repeated measures.

Results: In the DRF hand, SBF increased immediately (Mean Difference = -42.2 A.U), at 1 min (-35 A.U) and 10 min after ICE (-1 A.U). Skin Temp. In index and little fingers decreased immediately after ICE (9.9°C and 9.1° C) and did not return to baseline by 10 min (4°C and 4.1°C). ICE had no effect on sPT at 5 Hz (p>0.05). There was no difference between the DRF and uninjured hand on all measures(p>0.05) except for the sPT at 2000Hz, which remained high on the DRF side for up to 10 min (-1.8 m. A).

Conclusion: Normal cold responses consistent with ‘hunting reaction’ were observed after ICE in both hands. Aβ fibers on DRF side became less sensitive after ICE. These findings suggest that a brief immersion in cold water does not produce any adverse events associated with cold exposure.

To ensure the possible accelerated osteogenesis of long bone fractures in patients with concomitant spinal cord injury and to investigate the mechanism causing it with the understanding of a possible neuro-hormonal cause, a hormonal bioassay of the blood of 21 of these patients was measured in the prospective controlled study and compared to 20 patients with only spinal cord injuries, 30 patients with only long bone fractures, and 30 healthy volunteers.

The study results showed that Long bone fractures in patients with associated acute traumatic spinal cord injury of quadriplegia or paraplegia heal more expectedly, faster and with exuberant florid union callus (P>0.001) and showed statistically significant higher levels of parathyroid hormone and growth hormone (p<0.005) and normal corticosteroids levels. Patients with long bone fractures only showed consistent and statistically significant higher level of noradrenaline and adrenaline hormones compared to patients with spinal cord injury alone or associated with long bone fractures (p<0.001). Leptin hormone shows statistically significant consistent decrease in patients with spinal cord injury and concomitant long bone fractures compared to healthy subjects (p<0.001). We believe, according to the results of this study that bone healing is accelerated in long bone fractures in patients with associated spine fractures and spinal cord injuries. We also can conclude that bone healing has a central neuronal control and a combined neuro- hormonal mechanism with a relative inhibition of the sympathetic nervous system is a possible cause of accelerated healing of long bone fractures in patients with associated spinal cord injury.

Background: Preoperative arthroscopic examinations were carried out in patients with varus deformity among those with osteoarthritis of the ankle caused by malalignment, and to assess the severity of the disease on the basis of the arthroscopic findings, and the associations of these findings with X-ray findings and the indications for supramalleolar osteotomy were evaluated.

Methods: A total of 57 joints in 56 patients were investigated, and the mean follow-up period was 4 years. The proportion of the surface area of the ankle that had become hardened into an eburnation was classified according to a five-grade scale on the basis of preoperative arthroscopy: Grade 1 indicated fibrillation of the articular cartilage alone with no evident eburnation; Grade 2, eburnation was limited to the medial malleolar articular surface; Grade 3, eburnation extended across the medial shoulder of the talus, but covered <25% of the talocrural joint; Grade 4, eburnation covered ≥25% but <50% of the talocrural joint; and Grade 5, eburnation covered ≥50% of the talocrural joint. The surgical procedure used was lateral closing wedge osteotomy, and assessments were carried out using Takakura, et al.’s clinical score and Tanaka, et al.’s radiographic grading system.

Results: Initially, 3 joints were Grade 1, 19 were Grade 2, 15 were Grade 3, 16 were Grade 4, and 4 were Grade 5. Postoperatively, 30 joints were Grade 1, 14 were Grade 2, 7 were Grade 3, 4 were Grade 4, and 2 were Grade 5. Clinical scores showed an improvement from 63.9±11.2 points preoperatively to 81.9±13.2 points postoperatively.

Conclusion: Patients who were classed as Grade 3 or below by preoperative arthroscopy showed improved clinical outcomes and radiographic grades. To assess the proportion of cartilage, that may be affect postoperative outcomes, preoperative arthroscopy should be done prior to the supramalleolar osteotomy.

Symptomatic OA is generally defined by the presence of pain, aching, or stiffness in a joint with radiographic OA. The age-standardized prevalence of symptomatic hand and knee OA is 6.8% and 4.9%, respectively, in Framingham subjects age ≥26 years. However, prevalence of symptomatic knee OA was 16.7% among subjects age ≥45 in the Johnston County Osteoarthritis Project, much higher than that reported in the Framingham Study. About 9% of subjects in the Johnston County study had symptomatic hip OA

Osteoarthritis, a chronically painful debilitating joint disease affecting many aging adults, is not always amenable to, or improved by current pharmacologic and surgical approaches. In light of the contribution of peri articular structures to the osteoarthritic pain cycle, this exploratory overview and opinion piece was designed to examine if there is sufficient evidence in favor of treating muscle both as the sole means of reducing osteoarthritic pain or as a supplementary strategy for minimizing joint pain and further joint damage. To this end, research that focused on the sources of osteoarthritis pain, especially those detailing some aspect of neuromuscular derived pain was assessed. As well, research examining the outcome of treating muscle as regards osteoarthritis pain was explored. The results show that muscle can be deemed to play a key role in the osteoarthritis pain cycle. Moreover, treatments directed towards improving muscle function in some way tend to yield pain relief, when used alone, or in combination with other approaches, regardless of joint or method examined. It is concluded more work to better understand the muscle pain linkages in osteoarthritis will produce both a better understanding of the pathology associated with this disease, as well as its amelioration.

T he Complex Regional Pain Syndrome type 1 (CRPS1) is a reflex sympathetic dystrophy syndrome, that occurs after an illness or injury that didn’t directly damage the nerves in your affected limb

Sarcomas are extremely heterogenous and exceedingly rare group of malignancies. Broadly, the term ‘sarcoma’ encompasses both Soft Tissue Sarcoma (STS) including GIST (Gastro Intestinal Stromal Tumors) and bone sarcomas, though there might be some overlap between the two entities. For the years together, the standard treatment for advanced/ metastatic STS was ifosfamide and / or doxorubicin based chemotherapy. Treatment for STS in yesteryears depended largely upon general sensitivity for chemotherapy and not for individual histological subtypes or translocation studies. However, in last few years, with the advent of new agents like imatinib, trabectidin, pazopanib and eribulin, a lot of things have changed. The success in bone sarcomas during this timeframe has not been as tangible as STS but newer therapies like denosumab and Rexin G have some potential activity in selected subsets. In this review, we will try to highlight the latest advances in both advanced/ metastatic STS and bone sarcomas.

Objective: This study aims to investigate the effect of ibandronate, which is a biphosphonate and acts by inhibiting osteoclasts in osteoporosis treatment, on fracture healing in rat tibia model.

Material and Method: 60 Wistar-Albino type male rats were divided into two groups as study (ibandronate) and control. Under general anesthesia standard closed fractures were created on right tibias of all rats using blunt ended needle holder by three point principle and then closed reduction and fixing with intramedullary nail (0.5 mm) were provided. The day of fractures were created, one oral dose of 250 μg ibandronate (Bonviva® tablet 150 mg, Roche, Istanbul, Turkey ) was given to each group A, B, C and D. 1 month after 250 μg oral dose administration to groups E and F the day the fractures were created, the second dose of 250 μg ibandronate was administered. The rats were killed at 2nd week in groups A and B, at 4th week in groups C and D, and at 6th week in groups E and F. Oral administrations were performed by the same person with 15 gauge plastic feeding through nasogastric gavage. Fracture healing was evaluated as biomechanically, radiologically and histologically.

Results: No positive or negative radiological, biochemical and histological effect of ibandronate was detected, starting from the first day and reaching to 6 weeks, in healing process of closed tibia fractures created and fixed with IM nails in rats.

In the year 1879 [1], Paul Segond mentioned about the Anterolateral Ligament (ALL) for the f irst time in orthopedic literature.

Lateral Epicondylitis, or more commonly called “tennis elbow,” is a musculoskeletal condition characterized by pain upon extension and contraction of the fingers, wrist, and elbow. Such elbow pain can oftentimes be debilitating, as patients find themselves unable to work, enjoy their hobbies, or perform simple household tasks

The World Health Organization (WHO) defines osteoporosis as a disease characterized by low bone mass and deterioration of the micro architecture of bone tissue, which causes an increased brittleness of the same, with a consequent increase in fracture risk. Osteoporosis affects more than 200 million individuals in the world, potentially 5 million people in Italy, of which 80% post-menopausal women.

In the daily practice of Orthopedics and Traumatology departments is very frequent hospitalization for fracture of the femoral neck in elderly patients. In our study we observed 162 patients hospitalized with hip fracture diagnosis at two Italian hospitals. In most cases there were fragility fractures with previous diagnosis of osteoporosis, but patients had never received an anti osteoporotic therapy. The prescription of a medical therapy in patients with osteoporosis is an essential prevention of secondary fractures.

Introduction: Venous Thromboembolism (VTE) is a leading cause of mortality among hospitalized patients [1]. In the United States, Pulmonary Embolus (PE) causes almost 300,000 deaths per year [2]. 12% of annual deaths are due to VTE [3]. Major orthopaedic surgery (e.g., hip or knee replacement) is associated with a high risk for postoperative VTE [1,4,5]. In hip fracture surgery without thromboprophylaxis, the incidence of VTE reported is 35% with venography, and symptomatic VTE is about 3% [6].

Because the clinical diagnosis of VTE is unreliable and its first manifestation may be a life-threatening PE, it is recommended that patients undergoing hip or knee replacement receive routine thromboprophylaxis with anticoagulant therapy after surgery unless they have contraindications to anticoagulant therapy [1,4,7,8].

This study quantifies the efficacy and safety of enoxaparin (LMWH) versus dabigatran (Indirect Anti-X) in patients with hip fractures.

Material and Methods: This prospective randomized study compared daily doses of LMWH 40 mg subcutaneously with Indirect Anti-X 220 mg orally in consecutive patients with hip fractures. Patients were evaluated with Doppler scans for deep DVT on postoperative days 5 and 30 and with a clinical evaluation on postoperative days 30, 45, 90, and 120.

Results: 330 study patients. LMWH Group: 165 patients (males 38%). Average age 72.4 years (range 32 to 84 years). Day 5 postoperative Doppler scan detected 1 asymptomatic distal DVT. Another patient later (in the period between day 5 to 30 day control) presented with signs of a PE and had a Doppler scan positive for proximal DVT. The V/Q scan was positive and the patient was treated per standard guidelines. Day 30 Doppler scan detected 11 DVTs (3 proximal and 8 distal). 4 of these were symptomatic (1 proximal and 3 distal). All were evaluated in the emergency department. After diagnosis, 2 were readmitted for studies and treatment, and 2 were discharged home. All 4 of these patients were started on LMWH as suggested by local guidelines. The overall incidence of PE in this group was 0.6%. Doppler scan detected DVTs in 6.6% (symptomatic 2.4%) of the LMWH group. 2 patients returned for the evaluation of bleeding, 2 for superficial wound infections and 3 for thigh hematomas.

Anti-X Group: 165 patients (males 43.3%) enrolled. Average age 69.3 years (range 18 to 73 years). Day 5 postoperative Doppler scan detected no DVTs. The postoperative day 30 Doppler scan detected 5 DVTs (1 proximal and 4 distal). An additional patient was diagnosed with a PE (V/Q scan positive, Doppler scan negative). 2 symptomatic patients (one with distal DVT who developed symptoms during in-hospital rehabilitation and one with a proximal DVT) were readmitted and treated per standard guidelines. The incidence of PE in this group was 0.68%, with Doppler scan-detected DVTs 3% (1.2% symptomatic). 1 patient had an hematoma involving 2/3 of the thigh, 1 had a wound infection, and 2 had a rash.

There were no significant differences between the two thromboprophylactic treatments, and the Fishers exact test was not significant for any individual complication or total number of complications. No patient died during the study period.

Conclusion: Both LMWH and Anti-X appear to be equally effective prophylactic medications for the prevention of deep venous thrombosis after proximal femur fracture surgery. The cost benefits of using Anti-X may be considerable.

Chondromyxoid fibroma is a rare benign primary bone tumor composed of immature myxoid mesenchymal and cartilaginous tissue. It has a predilection for the metaphyseal area of long tubular bones of lower extremities in young patients. Its occurrence in calcaneus is very rare and few cases of calcaneal involvement have been reported in literature. This mass can mimic other benign and malignant bone tumors owing to its variable histologic features. A case report is demonstrated, discussing the problems of misdiagnosis. A brief review of the literature is presented.

Fracture of femoral neck is a serious complication of transient hip osteoporosis during pregnancy. A case of atraumatic bilateral femoral neck fracture was reported. The diagnosis was made two months after delivery. The patient refused surgery. Spontaneous healing was noted firstly on the right hip and secondly on the left.

This perspective appraises the pathology, etiology, clinical presentation and therapy of osteoporosis, in particular for men, and focuses on implications for oral healthcare

A significant increase in physical activity or a recent change in the routine activity level may result with stress fractures, which are seen more frequently in soldiers and athletes due to repetitive activities such as running and marching. Clinical assessment and x-rays are not always enough to diagnose stress fracture, thus further radiological assessment is often needed Here we aimed to present a case of an atypical stress fractures in a soldier seen after a prolonged repetitive activity.

The compression of the nerve is a known pathology since the late fifties, described for the first time par Thompson & Kopell. Many etiologies have been described, including traumatic aetiology further to a fracture of the scapula by bullet wound, which is never reported in the literature and falls within the framework of a syndrome of trapping. The identification of the NSS lesion requires not only careful clinical examination of the shoulder, but also a detailed neurophysiological evaluation, possibly using imagery.

Diagnosis and treatment of this compression should be as early as possible, before the installation of irreversible amyotrophy. The surgery of different causes of compression has improved the functional prognosis of the injured shoulder.

Purpose: To determine the clinical and radiological variables that are associated with the undertaking of the Latarjet procedure, rather than a Bankart procedure, for anteroinferior shoulder instability.

Methods: Clinical and radiological (CT scan) data was evaluated retrospectively, on a cohort of 66 patients who had undergone surgery for recurrent anteroinferior, glenohumeral instability.

Odds ratios (95%confidence intervals) were calculated for each variable to determine its association with performance of the Latarjet procedure as opposed to an arthroscopic soft-tissue reconstruction.

Results: Linear glenoid bone loss and ipsilateral, previous stabilization surgery were the two variables demonstrated to be associated with a significantly higher likelihood of the patient undergoing a Latarjet procedure.

Age at surgery, treating surgeon, and sports involvement were not associated with an increased likelihood of the patient undergoing a Latarjet procedure.

Conclusion: None of the clinical parameters analyzed demonstrated an association with an increased likelihood of undergoing a Latarjet procedure for anteroinferior shoulder instability.

Consistent with the published literature, we identified 19% linear glenoid bone loss as our cut-off for undertaking a Latarjet procedure for anteroinferior shoulder instability.

Level of evidence: IV

We present the case of a 26-year-old patient who came to the emergency department for aggression with a puncture injury (ice picking) at the T12 thoracic vertebra.

Introduction: Popliteal artery injuries are frequently encountered in case of fractures, dislocations or after penetrating trauma. Lower limb blunt traumas are associated to popliteal artery injuries in 28 to 46% of cases.

Objective: Our objective was to report this particularity.

Clinical examination: The evaluation of the tibial plateau fracture was performed with the Schatzker classification. The nervous injury was classified according to the Seddon classification. We did not find a classification for post-traumatic acute arterial injury

Results: There was a motor deficit of the common fibular nerve without sensitive deficit. The radiological examination showed a complex bicondylar fracture Schatzker 5.

An open reduction and internal fixation with a buttress plate was planned and performed 4 days following the trauma.

The postoperative follow-up was marked by the appearance of a distal necrosis of the 1st and 4th toes with coldness of the forefoot one week after the operation; the pedal and retro-tibial pulses were diminished. Doppler ultrasound and Angio-scan revealed a narrow stenosis of imprecise etiology due to artefacts related to the osteosynthesis material, however, there was a substitute blood network. The patient received curative-dose anticoagulants combined with Sintron and Aspegic.

Discussion: Penetrating trauma is the main cause of vascular lesions in the extremities. They are followed by closed trauma including traffic accidents, falls and crushing. In addition, closed trauma can lead to slow progression of arterial insufficiency.

Inadequate initial examination and delayed vascular repair lead to amputation in 60-80% of cases. It is therefore of paramount importance to evaluate the vascular state not only at the initial examination but above all repeatedly in the following hours and days. In our patient, edema was one of the factors which made difficult the proper monitoring of the distal pulse. Therefore, it seems appropriate to include in the monitoring of knee trauma, whether or not there is a fracture of the tibial plateau, more tests such as Doppler ultrasound, angiography, Angio-scan and MRI.

Conclusion: The dogma which recommended the realization of MRI or even Angio-scan of the knee only after dislocations should be extended to the fractures of the tibial plateau especially in a context of high velocity and this at the beginning and at the end of the management.

This report is of a 20-year-old woman with an osteochondroma of the proximal fibula with scalloping of tibia who presented with chronic pain and swelling in the right popliteal fossa that had been present from 3 years. Magnetic resonance imaging findings can’t enable accurate diagnosis because of the similarities between osteochondroma and low-grade chondrosarcoma. Thus, biopsy of this tumor was necessary. Extemporaneous Histopathological examination confirmed the benign nature of osteochondroma, thus, we performed debulking of the tumour with complete excision.

Objectives: The aim of this multicentre study was to determine the effect of oral alendronate over 2 years on Bone Mineral Density (BMD) and bone turnover in patients with Ankylosing Spondylitis (AS).

Methods: 180 patients were randomised to receive alendronate 70 mg weekly or placebo. Change in BMD over 2 years was assessed by Dual X-Ray Absorptiometry (DXA) scan, bone turnover by serum markers (Procollagen Type 1 Amino-Terminal Propeptide (P1NP) and Carboxy-Terminal Collagen Crosslinks (CTX)) and vertebral fracture by bone morphometry.

Results: At 2 years, patients in the alendronate group showed a significant mean increase in BMD of 5.6% at the lumbar spine compared to a mean increase of 1.4% in the placebo group. At all regions of the hip, BMD increased significantly in the alendronate group. There was a non significant decrease at all hip site in the placebo group. Serum markers showed a significant (p<0.001) reduction in bone turnover in the treated group but not in the placebo. No incident morphometric vertebral fracture rates were observed in either group.

Conclusions: Oral alendronate is effective at reducing bone turnover and increasing BMD in patients with established AS. Although not demonstrable in this short study, an effect on fracture risk is likely to be seen in a higher risk group treated over a longer period.

Introduction: Isolated fractures of the sacrum are rare and in principle related to a direct posterior shock. The occurrence of a pseudarthrosis of a sacrum associated with neurological disorders is an exceptional eventuality.

Case: Female subject 38, victim of a traffic accident occurring 3 months previously, consulted for a neglected trauma of the left hemi pelvis with relative functional impotence of the lower left limb. Clinical examination resulted in a painful lameness with a makeshift cane, pain in inguinal palpation and mobilization of the left hip. The gluteus medius muscle was rated at 0. There were no sphincteric disorders.

Observations: The standard X-ray showed a fracture of the left ischiopubic branch. At CT, there was also a vertical fracture of the left hemi-sacrum passing through the sacral holes and a fracture of the anterior column of the homolateral acetabulum.

The electromyogram showed a left L5 and S1 radiculopathy, a truncular involvement of the SPI (myelinic type) and of the left SPE (axonal type).

At 6 months of follow-up and after a medico-physical treatment (analgesic of pallium-II, vitamino-therapy B and functional rehabilitation); the patient fully recovered with pain only squatting and a gluteus medius to 5.

Results and Conclusion: In traumatology of the pelvis, the standard images are often ill-readable, hence the interest of CT. In the absence of displacement and / or root compression, functional treatment is mandatory. The occurrence of a pseudarthrosis associated or not with irreducibility or a persistence of the neurological syndrome indicates a surgical approach.

Introduction: Since 1990, several investigators have reported an increase in the incidence of spinal cord injuries, with penetrating trauma being the leading cause of spinal cord injury in some urban trauma centers [1]. We report a case with an inlet at L4-L5 and a final migration at S1.

Observation: Trader of 28 years, received January 21, 2016 for low back pain and desire to remove a projectile at the level of the spine. The loco-regional examination found a scar of the orifice in projection of the fourth and fifth lumbar vertebra. The radiological assessment carried out showed: on radiography the projectile at the sacral level; And to the computed tomography, an oval hyper dense formation of size 31x15x10 mm extended from the first sacral vertebra to the second sacral vertebra in relation to the evoked ball with a solution of continuity of the right blade facing it.

At the exploration, one noticed the ball buried in the sacral channel pushing back the nerve elements in posterior and with a prominence of a radicular section to the right, and a fracture of the blade to the right.

Discussion: Spinal lesions by firearm are increasingly common. Kuijen et al. [2] were able to identify four cases of bullets left in place with delayed neurological symptoms. However, these bullets remained localized in epidural as in our patient. The only discrepancy is that the symptomatology was early in our clinical case with a motor unilateral motor deficit secondary to an axonal lesion. The decision to leave or remove a fragment lodged in the spinal canal depends on several factors. Given its composition in copper and lead, the risk of further development of neurological complications was evident. He also had other neurological complications, not related to the toxicity of the different components of the projectile, but to its presence in the sacral canal. And this is all the more increased by the narrowness of this channel and by the rather large number of mesh roots found there.

Conclusion: In addition, imaging plays an important role in the initial management of patients with hemo dynamically stable bales regardless of the location of the projectile. CT is very useful to objectify the trajectory of the ball and to make a precise lesional balance thus making it possible to provide valuable information for the management of this condition.

Surgical Site Infections (SSI) is a dreaded complication of orthopedic surgery. The authors report a prospective study to this effect in the orthopedic traumatology department of the Aristide Ledantec hospital over one year from July 2011 to August 2012. The study concerned all the patients operated in emergency during this period and who had developed an infection during their hospitalization period. Among the 266 osteosyntheses performed, we observed 24 early surgical site infections, including 20 which were shallow and 4 deep, were observed. The overall incidence was 9%. There were 17 cases of clean surgeries and 7 cases of contaminated surgery. There were 13 men and 11 women. The time of infection onset after osteosynthesis was 8, 84 days on average. Globally 16 cases of monobacterial infection, 2 cases of polybacterial infection and 6 negative cultures were reported. Klebsiella peumoniae and Escherichia Coli were the most frequently encountered germs. Debridement of the operative wound was performed in 8 cases or 33% associated with antibiotherapy adapted to the antibiogram. Mainly Imipènme was used as antibiotic.

We report a case of primary ulnar intraneural ossification at the elbow. It is the case of a 54-year-old unemployed woman who presented bone metaplasia with thickening and calcification of the ulnar nerve resulting in the disappearance of the fascicles. Only a similar case is found in the literature review.

Introduction: Pandiaphysitis is a particular form of chronic osteomyelitis by the extent of infection on the diaphysis but also the risk of complications. It is disabling, tenacious, potentially life-threatening and is common in our developing countries where it is a public health problem.

Objective: To describe the anatomo-clinical and therapeutic aspects of pandiaphytes in the orthopedic and trauma department of a low-income country.

Material and method: This is a retrospective study from January 2009 to December 2016. We included patients treated in the department and whose file was complete.

Results: We collected 29 cases of pandiaphysitis. The average age was 23.69 years old. There was a clear predominance of the male sex with a ratio of 3.83. The only land found was sickle cell disease (4 cases). Bloodborne infections were predominant. The consultation period ranged from 1 to 33 years. The preferred seat was the lower limb with 65.52% of cases. On radiography, the sequestering form was the most represented. The stapyloccocus aureus germ was the most represented organ (75% of patients). Antibiotic medical treatment was systematic (patients being received at the pushing stage). Surgical treatment was done in 25 patients. After evaluation, we had 44.83% favorable evolution. Complications and sequelae have been observed: recurrence, unequal limb length, deformities and one case of death.

Conclusion: Pandiaphysitis is a serious pathology, causing multiple sequelae that negatively impact the quality of life of patients. Acute outbreaks can cause fatal sepsis.

Introduction: Graves’ disease (GD) is one of the organ-specific autoimmune thyroid diseases, while SLE is an autoantibody mediated systemic autoimmune disease. A literature review lends itself to the known association of hypothyroidism, autoimmune thyroiditis, thyroid cancer but rarely hyperthyroidism to systemic lupus erythematosus in age and sex matched controls. About one third of the patients with autoimmune thyroid diseases are Anti-Nuclear Antibody (ANA) positive. About one tenth of patients with autoimmune thyroid diseases, who are ANA positive, may also be positive for other lupus antibodies such as Anti-Double Stranded DNA (Anti-dsDNA), Anti-Ro, and Anticardiolipin (aCL). The association of Anti Smith Antibody positive SLE and Graves’ disease is extremely rare in adults and none reported in the pediatric population.

Case presentation: An 11-year-old Caucasian female from mid-Missouri was diagnosed with Graves’ disease and was started on Methimazole. On day 30th of therapy, she presented with small joint arthritis and eventually was diagnosed as systemic lupus erythematosus by the Rheumatologist. This is the first case report of overlap syndrome of juvenile Graves’ disease and anti-Smith antibody positive juvenile SLE in the pediatric population.

Discussion and Conclusions: The coexistence of GD with the SLE could be explained as a part of the lupus syndrome, an overlap disease, or drug induced lupus due to methimazole therapy in a Graves’ disease patient. It is utmost importance to identify the correct diagnosis to estimate the current treatment and long-term outcome of the patient. It appears from the published literature that the coexistence of thyroid abnormalities and lupus does not affect mutual disease activity, though the type of association affects the patient outcome (REF).

Introduction: Management of pain in patients with knee osteoarthritis remains a challenge due to patients’ age, comorbidities, necessity of medicines such as Nonsteroidal Anti-Inflammatory Agents (NSAIDS) should be taken for a long period, and this raises the requirements for well-tolerated medicinal product such as amtolmetin guacil whose gastro sparing action is mediated though increasing of Nitric Oxide-synthesis.

Patients and methodology: Fifty patients aged 50-69 years with knee osteoarthritis of stage II- III by Kellgren& Lawrence scale, were enrolled in the study. Patients were divided into 2 groups. Group I (30 patients) was assigned for amtolmetin guacil (AMG) tablets, 600 mg twice daily (Niselat, produced by Dr Reddys Laboratories Ltd) and group II (20 patients) was assigned for diclofenac sodium (DS) tablets, 50 mg twice daily. Duration of treatment was 1 month. Patients were assessed by WOMAC questionnaire, Lequesne Index, functional movement assessment. All adverse events reported were documented during the study period.

Results: The efficacy of treatments, as assessed by pain intensity (WOMAC) showed that AMG was associated with a significant reduction in pain intensity as compared to diclofenac by 30 days, 55% and 30% respectively. The improvement in functional abilities was significantly better with AMG as compared with DS by day 20 (35% and 24% respectively), and day 30, (50% and 30% respectively). AMG was well tolerated and was not associated with gastrointestinal adverse effects and hepatic function. In patient who completed 30 days of treatment, AMG was more frequently accessed as having “improvement” or “substantial improvement” as compared to DS.

Conclusions: Amtolmetin guacil is an effective treatment for knee osteoarthritis and provides better reduction in pain and improvement in functional abilities of patients. The better safety profile of AMG makes it a choice of treatment for the older patients and patients with high risk of gastrointestinal complications.Good patient tolerance to the treatment and high level of patient assessment of treatment efficacy should positively impact compliance and treatment efficacy.

We report the case of a 27 year old male who presented with persistent and unresolved shoulder pain status post shoulder arthroscopy for a SLAP lesion. A thorough history, examination, and laboratory analysis yielded the diagnosis of Rocky Mountain Spotted Fever (RMSF), a rare cause of monoarticular joint pain. After appropriate treatment with oral doxycycline the patient’s symptoms resolved. This case stresses the importance of remaining cognizant for non orthopaedic causes of joint pain during orthopaedic clinical evaluation. This case represents a rare manifestation of RMSF as inflammatory arthritis of the shoulder.

Purpose: Calcium phosphate ceramics have been widely used as biomaterials for regeneration of bone tissue because of their ability to induce osteoblastic differentiation in progenitor cells. Calcium Phosphate Cements (CPCs) are prepared from different calcium phosphate powder precursors by mixing them together with aqueous phase followed by setting and hardening into monolithic solid. This article provides an overview on the chemistry, kinetics of setting and handling properties such as setting time, cohesion and injectability of CPCs for bone substitution, with an emphasis on their mechanical and biological properties. The processing parameters that can be adjusted to control the setting process, injectibility and cohesive strength are discussed. CPCs are currently used for repair of non-load bearing bone defects due to its brittle nature and low flexural strength. Processing strategies to improve mechanical strength, fracture toughness and reliability of CPCs are also highlighted here. Further, a systematic discussion on the effects of physical (e.g. surface roughness) and chemical properties (e.g. solubility, crystallinity) of CPCs on protein adsorption, cell adhesion and osteoblastic differentiation in vitro is presented. Moreover, the physical and chemical properties of CPCs that govern its efficacy as carrier and candidate biomaterials for controlled release of variety of drugs and bioactive molecules are elaborated. Future research directions to improve the performance of CPCs are highlighted and briefly discussed.

Results: There are mainly two types of CPCs such as apatitic and brushitic that differ in their setting and hardening kinetics and in general brushitic CPC exhibits faster setting kinetic and lower mechanical strength. Setting kinetics, injectability and cohesive strength of both types of CPCs can be regulated by varying powder particle size, polymeric additives and viscosity of mixing liquid. The shortcomings in mechanical properties of such type of cements can be addressed by using bimodal size distribution of precursor particles, incorporating dual setting character in the cement or by preparing biodegradable or bioinert fiber reinforced cement composite. Calcium phosphate cement appears to possess excellent biological properties. CPC properties such as surface charge, crystallinity, slower and controlled degradation, micro and macro tomography positively influence several chronological events such as protein adsorption and cell adhesion that ultimately governs osteoblastic differentiation of progenitor cells. Because of its macro and micro porous structure, CPC serves as an excellent candidate to incorporate drugs and other bioactive molecules, to retain it in a specific target site, and to deliver it progressively with time in the surrounding tissues, by virtue of its biodegradability. Due to its poor mechanical properties, CPCs’ clinical applications are currently limited to craniofacial reconstruction. Further research is necessary to exploit its excellent biological properties with concomitant strengthening of mechanical reliability for its widespread clinical applications.

Conclusions: CPCs possesses a huge prospect to serve as next generation bone substitute material and further research is necessary to ameliorate its performance under clinical situations.

Aim of the Study: To find association between clinical features of systemic sclerosis and esophageal dysmotility disorder based on high resolution manometry (HRM) findings according to the 3rd version of Chicago classification.

Methods: In a cross-sectional study in Firozgar hospital we recruited 150 consecutive SSc patients. All patients fulfilled the 2013 ACR/EULAR classification for SSc criteria. We used water-perfused esophageal high resolution manometry (HRM) having 26-channel silicone-customized catheter.

Results: From all 150 SSc patients who were included in the study, forty-nine (46%) had dcSSc subset of disease with mean age (SD) 47.0 (12.1) years. According to the 3rd version of the Chicago classification, 135 (90%) patients had ineffective peristalsis [weak peristalsis in 24 (16.0%) and failed peristalsis in 111 (74.0%) of patients]. Hypotensive Esophagogastric junction pressure (hEGJP) presented in 47 (31.3%) patients. Two (1.3%) patients had achalasia in HRM. Age, gender, and duration of disease were not different in the above two groups of patients. In multivariate model FVC%, [OR (CI95%): 1.055(1.025-1.086), p<0.001] showed significant association with failed peristalsis.Comparison between average rank of FVC% in peristalsis status groups showed significant difference between average rank of FVC% in patients with failed peristalsis and weak peristalsis p=0.001, and average rank of FVC% in those with failed peristalsis and normal peristalsis p=0.020.

Conclusions: Our findings showed that esophageal dysmotility is a frequent finding in systemic sclerosis patients. The results demonstrated that FVC%, tendon friction rub kept significant concordance with failed peristalsis. Moreover, we noticed a concordance between HRM results and severity of FVC.

The subacromial impingement syndrome is a collective cause of shoulder pain it takes place due to the soft tissue reside in the subacromial space. This occurs by mechanical compression of the soft issues predominantly on the supraspinatus, long head of biceps tendon, subacromial bursae and superior portion of the articular capsule between the greater tuberosity and the under surface of the anteroinferior edge of the acromion. The root cause of this condition has been contested over the last couple of decades nowadays, many studies agree that this condition is multifactorial and management includes physiotherapy, injections, and surgery in some selected patients. This article aims to provide an overview of the clinical features and pathogenesis of subacromial impingement syndrome also discuss the widely accepted non-invasive physiotherapy interventions approach for recovering the subacromial impingement syndrome effectively and efficiently based on other studies.

Bone health is one of the important parts of healthy-life and longevity. In the current scenario, due to indiscriminate uses of pesticides in agriculture, there is a high abundance of toxins and contaminants in the environment and food chain. For this consequence, the present study has investigated the effect of the Biofield Energy Healing (The Trivedi Effect®) Based test formulation on bone health parameters using the human bone osteosarcoma cells - MG-63(ATCC® CRL-1427™). A proprietary formulation was designed that consisted of eight ingredients viz. zinc chloride, ferrous sulfate, sodium selenate, nanocurcumin, copper chloride, magnesium gluconate, vitamin C (ascorbic acid), and vitamin D3 (cholecalciferol). The test formulation was divided into two parts. One part was denoted as the untreated test formulation without any Biofield Energy Treatment, while the other part was defined as the Biofield Energy Treated sample, which received the Biofield Energy Healing Treatment by renowned Biofield Energy Healer, Mahendra Kumar Trivedi. The cell viability assay data of the test formulation showed more than 70% cell viability at the concentration ranges from 0.001 to 10 µg/mL, which indicated its safe and non-cytotoxic nature. Alkaline phosphatase enzyme (ALP) was significantly increased by 80.16%, 292.91%, 200.36%, 22.24%, and 690.35% in the Biofield Energy Treated test formulation group (G4) at 0.0008, 0.001, 0.0033, 0.052, and 10.41 µg/mL, respectively as compared to the untreated test formulation group (G3). As a result of that phosphorus absorption and deposition in bone cells can be increased which can help to make stronger bone. The data demonstrated that the Biofield Treatment has the strong potential for the treatment of patients with arthritis, osteoporosis, and other bone disorders. Thus, Consciousness Energy Healing can be useful as a bone cells growth promoter for different bone-related disorders like low bone density, osteogenesis imperfecta, osteoporosis, etc.

Introduction: The purpose of our study was to describe the epidemiological and therapeutic aspects of the proximal humerus fractures and to evaluate their functional results.

Materials and methods: This was a retrospective study about all patients operated for proximal humerus fracture at the South-Essonne Dourdan-Étampes Hospital Center between January 2016 and December 2017.

Results: 58 patients were operated. Women represented 65.5% with a female / male sex ratio of 1.9. The mean age was 67.3 years (17-95 years). Fracture following a fall in 86% and 60% concern the left side. according to the Neer classification, 65.5% were 2-parts fractures, 22.4% 3-parts fractures and 12% 4 or over 4 parts. In 19% were operated after orthopedic treatment failure. The telegraph nail represents 62% of used materials. 12% of the patients had benefited a total shoulder arthroplasty. At the last follow-up of 14 months (8-22 months) consolidation was achieved in 98% of osteosynthesis. The abduction average was 145 ° (45 ° - 180 °). Mean Constant score was 79 (64 - 95). 1 case of humeral head necrosis was noted and 5 cases of shoulder stiffness in abduction.

Discussion: We believe, as many authors, that many factors seem to influence functional evolution. The type of fracture influences the therapeutic choice and is the main predictor of functional outcome, failure, complications and re-intervention.

Conclusion: There is certainly no consensus in the management of the proximal humerus fracture, but many choices are currently available for surgeons. “Every age group is served”

Osteoblastoma-like osteosarcoma (OBLOS), is a rare malignant lesion with risks of both local recurrence and distant metastasis. It is considered a rare variant of osteosarcoma. The distinction between (OBLOS), and aggressive osteoblastoma is still debatable and challenging. Based on the initial clinical, radiological, and histological findings, a definitive diagnosis might only sometimes be achievable. On the other hand, the significance of a proper diagnosis must be accomplished because the approach to treatment varies greatly depending on the type of lesion. Sufficient tissue sampling is essential to provide the proper diagnosis. In clinicopathological and radiological discordance cases, a high index of suspicion and significant experience are requirements for an appropriate diagnosis. The OBLOS is categorized as a conventional (high-grade) osteosarcoma in the World Health Organization (WHO) classification system. However, several cases that have been published have been identified as low-grade malignant tumors. There are no precise morphological criteria to discriminate between low- and high-grade lesions. We describe a case of osteoblastoma-like osteosarcoma in an 11-year-old boy involving the right proximal humerus. We provide a brief review of the pertinent literature including diagnosis, differential diagnosis, debatable grading of this type of tumors, management, and prognosis.

The present systematic review determined the effects of physical activity/exercise added to Denosumab, Romosozumab, Abaloparatide or Teriparatide-therapy on bone strength and fall incidence in middle-aged and older people with osteopenia/osteoporosis. A systematic literature search of five electronic databases and two registers (up to 30/05/2023) without language restrictions included studies with (a) postmenopausal women and men ≥45 years, with low bone mass that compared study arms with (b) combined interventions of physical activity/exercise and Denosumab or Romosozumab or Abaloparatide or Teriparatide versus (c) isolated pharmaceutical therapy on (d) Bone Mineral Density (BMD) and prospective fall and/or fracture events (e) applying a randomized controlled study design. Finally only one study that compared the effect of Teriparatide and whole-body vibration versus isolated Teriparatide therapy on bone strength parameters was eligible. This trial reported a significant effect of combined vs. isolated therapy for lumbar spine BMD however not for total hip-, radius- and tibia-BMD, bone microarchitecture or bone turnover biomarkers. Thus, reviewing the literature there is rather limited data on additive effects of exercise on novel pharmaceutic therapy for osteoporosis. Nethertheless, considering age, bone status and physical function of most people under corresponding therapies might already justify the recommendation of exercise programs dedicated to reduce number and impact of falls and fall impact that complement the effects of pharmacological therapy on bone strength. Due to the enormous socioeconomic importance of osteoporosis-induced low trauma fractures more studies should focus on the dissection of the impact of individualized exercise programs when combined with medical treatment.