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JRPMS 2018

Mini Review Article JRPMS, Vol 2, No 1, March 2018, p.2-6
Hypophosphatasia in adults
Antonia A. Kountouri, Anna Papadopoulou
Keywords: ALPL gene, PEA, PLP, Alkaline phosphatase, Asfotase alfa
Hypophosphatasia (HPP) is a sporadic inheritable disease. Patients suffer from defective bone and teeth mineralization, due to low levels of alkaline phosphatase (ALP). It is caused by mutations in the ALPL gene which encodes the tissue-nonspecific isoenzyme (TNAP or TRANSALP) of alkaline phosphatase. Hypophosphatasia is classified into six forms: lethal perinatal, benign prenatal, infantile, childhood, adult and odontohypophosphatasia. The adult form is the rarest and the mildest of all types characterized by low levels of alkaline phosphatase, increased levels of pyridoxal-5'-phosphate (PLP) in serum and increased levels of phosphoethanolamine (PEA) in urine. ALPL mutations associated with adult hypophosphatasia are either autosomal recessive or autosomal dominant. Patients' phenotype depends on the site of the enzyme these mutations affect. Although, there is not a treatment for this disease actually, enzyme replacement treatment (ERT) with asfotase alfa promises a lot to patients.
Case Report Article JRPMS, Vol 2, No 1, March 2018, p.7-11
Misdiagnosis of alkaptonuria in an elderly patient
Georgia C. Tseliou, Mayra P. Giannelou, Evangelos A. Boulios, Anastasia K. Klangou, George N. Katsoulis, George D. Bailas, Athanasios I. Georgountzos
Keywords: Alkaptonuria, Ochronosis, Homogentisic acid (HGA), Low back pain, Degenarative arthropathy
Alkaptonuria is a rare hereditary metabolic disorder, resulting from deficiency of enzyme homogentisate 1,2-dioxygenase (HGD). Its features include spine and peripheral joint arthritis, as well as bluish discoloration of cartilage tissues. We report a case of an 81 year old male with a 5 year history of low back pain and progressively increasing stiffness of the spine, incorrectly diagnosed as ankylosing spondylitis and treated with non steroid anti-inflammatory drugs (NSAIDs) and sulfasalazine. Diagnosis of alkaptonuria was based on the characteristic ochronotic pigmentation of ears and eyes cartilage and typical radiographic findings of the spine-narrowed intervertebral spaces and intervertebral disc calcification, combined with the presence of homogentisic acid in the patient’s urine. Complete history,physical and radiological examinations revealed severe degenerative arthropathy of knee, hip and shoulder joints, which had led to bilateral total hip and knee arthroplasty in the last 7 years. Due to the patient’s cardiovascular comorbidity and advanced age, surgical treatment of ochronotic spine arthropathy was not considered. Management of the patient was based on analgesic treatment and vitamin C. Although alkaptonuria is a rare disease it should be considered in patients, even the elderly ones, who present with low back pain and severe degenerative arthropathy.
Review Article JRPMS, Vol 2, No 1, March 2018, p.12-17
The role of CT and MRI in imaging of Paget bone disease
Spyridon G. Adamopoulos, Glykeria M. Petrocheilou
Keywords: Paget, Bone, Computed tomography, Magnetic resonance imaging
Paget disease (PD) is a common bone disease characterized by abnormal bone turnover that follows a disorderly osteoclastic overactivity. In typical PD, imaging assessment is accomplished with conventional radiography and bone scintigraphy. CT and MRI may have complementary roles in the imaging workflow of PD preventing inappropriate investigation and helping the management planning at an early stage. Apart from discovering incidental findings, CT and MRI contribute substantially to the diagnosis of less typical cases, the delineation of PD pathology in complex anatomic areas, the differential diagnosis from sinister causes and the accurate assessment of specific complications.
Case Report Article JRPMS, Vol 2, No 1, March 2018, p.18-21
Bilateral transient osteoporosis of the knees during pregnancy. A case report and review of the literature
Nikolaos Milonas, Panagiotis Touzopoulos, Christos P. Zafeiris, Nikolaos Papantoniou, Eufrosini Koutsoubeli, Athanasios Chatzigiannakis
Keywords: Transient osteoporosis, Knee, Pregnancy
Transient osteoporosis is a rare self-limited condition that affects mostly middle-aged men or women in the third trimester of pregnancy. The most commonly affected joint is the hip, while bilateral involvement of the knees is extremely rare. Complete resolution of symptoms and MRI findings occurs over 8 to 10 months after clinical onset. We present a case of a 40-year-old woman diagnosed with bilateral transient osteoporosis of the knees, in the early postpartum period treated for 6 months with calcitonin, analgesics and physiotherapy.
Review Article JRPMS, Vol 2, No 1, March 2018, p.22-30
The multiple roles of steroids and anabolic steroids and its relations to cardiovasular and musculoskeletal pathology: a brief review
Margarita Theodorakidou, Olti-Alexandra Nikola, George I. Lambrou
Keywords: Corticosteroids, Anabolic steroids, Cardiovascular, Musculoskeletal
Steroids are defined as compounds included in the family of terpenoid lipids. Specifically, anabolic steroids are synthetic steroids of the androgen steroids. Since the beginning of the 20th century, anabolic steroids have proven influence on physical strength, endurance and muscle tissue synthesis. They have been used both for military purposes as well as for athletic achievements. Their use has been expended thereafter up to the point that side-effects began to become apparent. To date, it is well documented that anabolic steroids have adverse side effects on the primary and secondary sex characteristics. Steroids attribute male characteristics to females, and, at the same time, sterility and erection dysfunctions to males. Several studies have shown that the use of anabolic steroids is connected to dysfunctions of the cardiovascular system. No direct adverse effects have been reported on the function of cardiovascular system during the use of anabolic steroids, however, it has been shown that there is an indirect connection between anabolic steroids and cardiovascular disease. Steroids elevate levels of cholesterol and triglycerides which both are related to high risk of cardiovascular disease. The present work reviews the hitherto known connections between steroids in general, both synthetic and naturally occurring to the risk or not of cardiovascular disease.
Οriginal Article JRPMS, Vol 2, No 2, June 2018, p.39-45
Femoral stem sagittal balance - Do we need a new entry point?
Meletis Rozis, Mathaios Bakalakos, Vasilios D Polyzois, John Vlamis, Spyros Pneumaticos
Keywords: Femoral stem, Entry point, THA, Sagittal balance
Objectives: Femoral stem positioning is of great importance in hip arthroplasty. Straight stem sagittal balance gains recently more attention in the literature. Methods: We performed a both clinical and cadaveric study in order to identify a possible ideal stem entry point at the level of the proximal femur, that ensures an optimal sagittal stem centering. We compared the sagittal tilt of 52 patients with femoral stem implantation in post-operative x-rays, dividing them in two groups depending on posterior neck cortex perforation. Subsequently, femoral neck osteotomy was performed in 40 cadaveric femurs. After placing an average straight stem, measurements of stem axis and femoral neck were made, in order to identify a possible area that could be used as a landmark, through which an optimal sagittal centering could be achieved. Results: Based on our results, stem sagittal tilt differed significantly when posterior neck was spared. In cadaveric evaluation, when posterior neck cortex was not perforated, the tip of stem was in contact with the posterior diaphysis cortex, thus malpositioned in the sagittal plane. We additionally found a statistically significant difference between neck centre and a) stem posterior boarder and b) neck posterior cortex distance. Conclusions: We conclude that placing the femoral stem just posteriorly to the posterior neck cortex, seems to be a good technique in order to achieve optimal sagittal balance of the femoral component.
Mini Review JRPMS, Vol 2, No 2, June 2018, p.46-52
Prevention of orthopaedic infection in spine surgery
Effrosyni Koutsoumpeli, Nikolaos Koutsoumpelis
Keywords: Prevention, Spine surgery, Surgical site infection
Surgical site infection (SSI) in spine surgery is a complication that increases not only the time of patient-recovery and the mortality but also the duration of hospitalization and subsequently the total hospital costs. The objective of this review is to identify the preventable risk factors, to reduce SSI in spine surgery. There are several factors that are associated with an increased risk of postoperative SSI. Some of them are associated with the health status of patient (ASA score >2, diabetes, obesity, smoking, urinary tract infection or incontinence, hypertension), while others with the surgical procedure (hand and instrument antisepsis, revision surgery, invasiveness, CSF leak, dural tear, blood loss, transfusion) and the compliance of the patient. Preoperative patient optimization and perioperative strategies can minimize the risk of SSI. Understanding the pathogenesis is essential to develop prevention strategies and improve surgical outcomes.
Review Article JRPMS, Vol 2, No 2, June 2018, p.53-57
Clinical consequences of pseudotumors in hip arthroplasty
Georgios I. Karagiannis
Keywords: Total hip arthroplasty, Metal-on-metal, Pseudotumor, Hip revision, Metal ions
The occurrence of pseudotumors currently constitutes an important topic of interest among orthopaedic surgeons who prefer metal on metal arthroplasty and especially hip resurfacing arthroplasty. Adverse reactions to metal ions are associated with the formation of such lesions and the orientation of implants has also been implicated in their pathogenesis. The diagnosis of pseudotumors is as difficult as complex. There is a variety of symptoms and patients with mild or tolerable pain may not seek medical attention. Revision surgeries may be the only solution in some cases. The goal of this article is to review the clinical presentation, prognosis of pseudotumors and associated complications, based on evidence published in the literature.
Οriginal Article JRPMS, Vol 2, No 2, June 2018, p.58-61
Incidence and anatomic location of fractures resulting from static line parachuting in the Greek Army Forces: A retrospective study
Filippos Zigras, Spilios Dellis
Keywords: Parachute, Paratrooper, Parachuting fracture, Ankle brace
Objectives: The incidence and patterns of parachuting fractures were investigated in Greek Armed Forces and compared to those of other studies in an attempt to assess the safety of parachuting. Methods: Data of 26.429 military static line parachute (SLP) jumps on 4019 paratroopers were collected by the official archive of the Greek parachuting military school during a 2 year period. Results: The total number of fractures was 55 in 26.429 SLP jumps. The overall rate was 2,1 fractures per 1000 descents. The fracture rate for the recruits, within the 18-30 year old group (5,3 fractures per 1000 jumps) was significantly higher (P<0,0005) than for the officers, the 30-60 year old group (1,1 fractures per 1000 jumps). Ankle fractures were the most common, accounted for 47,3% of the cases. Fracture - dislocation of the shoulder might be the new “paratroopers’s fracture”, which was encountered in 14,5% of the cases. Conclusion: We conclude that our data compares favorably with other studies except for higher rate of ankle fracture. It is recommended that a parachute ankle brace (PAB) should be worn by all paratroopers, especially those with lack of experience.
Case Report JRPMS, Vol 2, No 2, June 2018, p.62-66
Bilateral iliac stress fracture in a young male Military cadet: report of an unusual case
Christos Apergis, Georgios Bekas, Christos Zafeiris, Terpsithea Koureta, Konstantinos Raptis
Keywords: Bilateral fractures, Iliac fractures, Stress fractures, Fractures in military population
Stress fractures are common in highly active people, such as athletes or the military population and occur more frequently in the tibia and especially the tarsal and metatarsal bones. Concomitant bilateral presentation is rare and especially bilateral iliac bone stress fracture has never been reported in the current English literature. We present a case of a young Air Force cadet with acute onset of bilateral hip pain, while participating in the routine military training program. Clinical examination, radiologic evaluation and MRI established the diagnosis of bilateral iliac bone stress fracture. The patient followed conservative treatment with partial weight bearing using crutches and the symptoms disappeared after a 3 month period.
Case Report JRPMS, Vol 2, No 2, June 2018, p.67-71
Acute compartment syndrome of the foot after an ankle sprain: a case report
Christos Christoforidis, Panagiotis Lepetsos, Stamatios Papadakis, Anastasios Gketsos, Theodoros Balfousias, George Macheras
Keywords: Acute compartment syndrome, Ankle sprain,Fasciotomy, Muscle necrosis, Intracompartmental pressure
The aim of this study is to report the case of a patient with an acute foot compartment syndrome after an ankle sprain, discussing the diagnostic challenges and rarity of such an uncommon complication of a very common and low-trauma event. A 19-year old young man presented at the emergency department for a twisting injury of his left ankle. Physical and radiological evaluation revealed a 2nd degree lateral ankle sprain and the patient was treated conservatively. Two days later, the patient returned to the emergency department, late at night, with worsening and excruciating pain of his left foot and inability to walk. Physical evaluation showed severe swelling of the left foot and decreased range of active and passive motion. X-rays and CT scan were negative for fractures. An emergency fasciotomy of the lateral and medial compartment of the foot was performed and necrotic muscle parts were removed. Postoperatively, patient’s symptoms were controlled and a week later he was discharged from the hospital. Twelve months later, the patient is pain-free with full range of motion of his left ankle and foot.