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JRPMS 2020

Review Article JRPMS, Vol 4, No 1, March 2020, p.1-7
The role of vitamin D in dental implants osseointegration
Anna-Maria Vesala, Ismene Dontas
Keywords: Dental implants, Implant failure, Osseointegration, Vitamin D, Vitamin D deficiency
Dental implants currently constitute a well-established solution for both functional and aesthetic restoration of complete and partial edentulism. Osseontegration, however, is a complex and multifactorial phenomenon bearing concerns as to its strong association to implant, prosthetics and surgical protocols, as well to patients themselves. This literature review aims to research into potential correlations linking the osseointegration process in dental implants to low levels of vitamin D in dental patients. A number of scientific articles were retrieved from PubMed and MEDLINE databases, using the following key words: “vitamin D deficiency”; “osseointegration”; and “vitamin D AND dental implants”. Αll retrieved studies were limited to those involving human and animal experimental models, and only articles written in English. Nine animal studies investigated the osseointegration process in dental implants that may be attributed to the effects of vitamin D; and five studies used human subjects. However, none of the said studies demonstrated statistically significant differences. A number of patients, especially those with severe deficiency, reported beneficial outcomes following vitamin D systemic administration prior the surgery. In such patients, is important to maintain vitamin D levels, as it ensures bone reconstruction around the implant.
Οriginal Article JRPMS, Vol 4, No 1, March 2020, p.8-14
Coadministration of zoledronic acid and teriparatide in postmenopausal osteoporosis
Christiana Zidrou, Anastasios Beletsiotis
Keywords: Bisphosphonates, Bone mineral density, Osteoporosis, Teriparatide, Zoledronic acid
Objectives: The purpose of this study is to evaluate the effects of combination therapy with an intravenous infusion of zoledronic acid 5 mg and daily subcutaneous teriparatide 20 μg versus either agent alone on bone mineral density (BMD) and bone turnover markers. Methods: From January 2015 to December 2018, 206 postmenopausal women with osteoporosis (aged 55-89 years) were randomized to receive a single infusion of zoledronic acid 5 mg plus daily subcutaneous teriparatide 20 μg (n = 68), zoledronic acid alone (n=69), or teriparatide alone (n=69). The primary endpoint was percentage increase in lumbar spine and total hip BMD (assessed by DXA) at 52 weeks versus baseline. Results: At week 52, lumbar spine BMD had increased 7.5%, 7.0%, and 4.4% in the combination, teriparatide, and zoledronic acid groups, respectively while total hip -BMD increments were 2,3%, 1,1% and 2,2% in respective subgroups. Levels for bone turnover markers (PINP and b-CTX) were significantly lower with combination therapy versus teriparatide alone. Conclusions: The authors concluded that while teriparatide increases spine BMD more than zoledronic acid and zoledronic acid increases hip BMD more than teriparatide, combination therapy provides the largest, most rapid increments when both spine and hip sites are considered.
Review Article JRPMS, Vol 4, No 1, March 2020, p.15-19
Resistance mechanisms in the radiation therapy of osteosarcoma: a brief review
Georgia Koutsomplia, George I. Lambrou
Keywords: Osteosarcoma, Radiological features, Resistance mechanisms, Genomics
Osteosarcoma is the most common primary malignancy of bone, typically presenting in the first or second decade of life. Osteosarcoma is a very aggressive type of tumor, which has devastating effects on the patient. Especially, pediatric patients suffering from osteosarcoma, are very vulnerable to its side-effects. Most patients suffering from osteosarcoma have a very poor prognosis and thus the understanding of its mechanisms, both oncogenetic as well ontogenetic are of crucial importance. The stagnancy of clinical outcomes may is explained by heterogeneity and complexity as well as genetic background. Not many studies have dealt with the molecular mechanisms of resistance to radiation therapy in osteosarcoma, yet the main genes proposed for their participation include p53, p21, NF-κB, RAS, Rb and GRIM-19. In addition, recent studies have highlighted the role of epigenetic mechanisms in osteosarcoma resistance to therapy and in particular the role of miRNAs. Due to the devastating effect of the disease to the suffering patients, more studies are required in order to unravel the radiation-induced cell death resistance.
Mini Review JRPMS, Vol 4, No 1, March 2020, p.20-23
Stem cells in fracture healing
Efstathios G. Athanasakis
Keywords: Stem cells, Fracture healing, Nonunion
Bone fractures are the most common injuries seen in emergency departments worldwide. Fracture healing is a complex physiological process. Existing research has proved that Mesenchymal stem cells (MSCs) assist and augment fracture healing. This review is examining the importance of MSCs in bone healing. A literature search was performed using PubMed, and relevant articles were retrieved.
Review Article JRPMS, Vol 4, No 1, March 2020, p.24-29
Osteoporosis in frail patients
Georgia Manoli, Ioannis K. Triantafyllopoulos
Keywords: Frailty, Osteoporosis, Anorexia Nervosa, Cancer, Oldest Old
Frailty, a condition that many people share nowadays, is connected to both the modern way of life and also age, physical and mental condition of a person. Sometimes, it is characterized by rapid weight alterations, slow walking speed and extreme tiredness, symptoms which vary according to the patient. It is a condition that can be altered or in other cases treated and thus it is can be a challenge for both the doctor and patient. Osteoporosis in such patients can be a riddle - sometimes it is not discovered or it is not treated properly leading to more problems. Sarcopenic patients, namely those with severe anorexic disorders, people with transplants and malignant tumors can be harmed even more because their conditions allow osteoporosis not only to grow but also become harder to be traced by the doctors. Bone loss appreciation is an urgent process because it can prove to be supportive to the patients and doctors and by all means improves the problems that may occur to people suffering from frailty.

Special Issue: Current issues in ACL reconstruction

Guest Editor: Christos K. Yiannakopoulos

Ass. Professor National & Kapodistrian University of Athens. School of Physical Education & Sport Science. Sports Medicine & Excercise Biology Section

Original Article JRPMS, Vol 4, No 2, June 2020, p.30-34
Dressing change frequency following anterior cruciate ligament reconstruction: a pilot study
Nikiforos Galanis, Aikaterini Kyriakou, Ioannis Delniotis, James Inklebarger, Pericles Papadopoulos, Eleftherios Tsiridis, Farres Sayegh
Keywords: ACL, Bandage, Infection, Removal, Surgical wound
Background: Data in the literature are limited concerning the impact of different time scheduling, in regards to dressing change frequency, on infectious complications at the surgical site attributable to the dressing procedure itself. Methods: A pilot, randomized trial was conducted to assess the safety of two different dressing removal protocols performed after anterior cruciate ligament reconstruction for deficiency. Patients assigned to “standard” protocol underwent a dressing change on postoperative day 2, 4 and 6. Those assigned to the “revised” protocol underwent a change just on day 6. All patients’ surgical site skin was cultured at baseline and on postoperative day 6 immediately after dressing removal. Results: Forty patients were assigned to the “standard” protocol and forty to the “revised” one. The percentage of culture positive subjects was 2.5% (1/40) in the “standard” protocol group compared to 0% in the “revised” one. No significant differences were found in the number of positive culture subjects between methods. Conclusion: Changing dressing frequently doesn’t seem to provide any additional benefit to the patients, while retaining it doesn’t lead to any increased risk of infection. Moreover, the patient’s inconvenience and increased related cost caused by frequent dressing change suggest that the dressing should be retained for at least 6 days postoperatively. Level of evidence: 2b
Original Article JRPMS, Vol 4, No 2, June 2020, p.35-37
Remnant preserving anterior cruciate ligament reconstruction: evaluation of early graft remodeling by magnetic resonance imaging
Stergios G. Papastergiou, Nikolaos Manidakis, Nikolaos Koukoulias, Eleni Melikidou, Ioannis Christou, Georgios Nitis, Themistoklis Vampertzis
Keywords: Anterior cruciate ligament, Reconstruction, Augmentation, Remnant preservation, Remodeling
Objectives: To evaluate the graft remodeling phase following anterior cruciate ligament reconstruction augmentation with remnant preservation. Methods: Between March and December 2018 19 patients underwent anatomic single bundle anterior cruciate ligament reconstruction using hamstrings with preservation of the intact ligament fibres and the peri-ligamentous symovium when possible. All patients were subjected to magnetic resonance imaging at 2 and 4 months post-operatively. Patient demographics, percentage of intra-operative remnant preservation and graft magnetic signal intensity using the signal/noise quotient method were recorded. Results: 12 patients were male and 7 were female with a mean age of 26. 5 years. A low signal intensity in the mid portion of the graft was observed in those patients where a larger percentage of the ligament and synovium was preserved at 2 months post-operatively. The signal intensity was even lower at the 4 month scan. Conclusions: Remnant preserving anterior cruciate ligament reconstruction seems to lead to quicker graft remodeling as reflected in the post-operative magnetic resonance signal intensity. Graft revascularization and remodeling seem to correlate with the percentage of remnant preservation. These results support the use of fast-track rehabilitation protocols in this set of patients.
Case Report JRPMS, Vol 4, No 2, June 2020, p.38-43
A case of hip joint septic arthritis as a complication of a prostate abscess
Themistoklis Vampertzis, Eirini Iosifidou, Christina Barmpagianni, Dimitrios Takis, Nikolaos Manidakis, Georgios Zervopoulos, Stergios Papastergiou
Keywords: Diabetes mellitus, Hip arthroplasty, Hip joint, Prostate abscess, Septic arthritis
Septic arthritis due to an infection elsewhere in the body is a dangerous disease manifestation. The elderly and particularly those with comorbidities such as diabetes mellitus, arterial hypertension; haemodialysed and the immunocompromised are more susceptible. Infections of the prostate can spread via the blood to cause sepsis and/or affect joints. Although prostatitis can be diagnosed based on common symptoms and tests, chronic infections and abscesses can be silent and asymptomatic, which allows them to spread. We present a case of a silent prostatic abscess which spread to the hip joint causing septic arthritis and joint destruction. This was further complicated by patient incompliance and refusal for an early surgical debridement. As a result, the condition was aggravated and the joint was lost. The important point made is that clinical presentation of septic arthritis is not always alarming. Moreover, care should be taken to recognise the origin of infection, as it can also be occult. Prompt diagnosis and early treatment are vital, as joint destruction is rapid. Additionally, treatment is complex, dangerous and expensive, with high doses of strong antibiotics, surgeries and variable results. Relapses are common in advanced cases and the hazard for progression to sepsis cannot be neglected.
Case Report JRPMS, Vol 4, No 2, June 2020, p.44-47
Solitary osteochondroma of the scapula in late adolescence. A case report
Themistoklis Vampertzis, Efstathios Kalivas, Ioannis K. Christou, Christina Barmpagianni, Athanasios Fotiadis, Georgios Nitis, Stergios Papastergiou
Keywords: Benign bone tumor, Osteochondroma, Scapula, Surgical treatment
Skeletal osteochondromas, also known as Osteocartilaginous exostosis are the most common benign bone tumors, while they represent an overall of about 15% of all bone tumors. They can be isolated findings or part of syndromic pathologies. They are typically seen on long bones, while their occurrence on flat bones is rare. The main concern after their identification is malignant transformation therefore size and cartilage thickness are monitored until the maturation of the skeleton and therefore seize of growth (unless malignant). This case report presents a 16 year old girl diagnosed with a benign isolated osteochondroma of the left scapula. X-Rays and MRI scans were used for diagnosis and for monitoring the progression for one year, while a CT scan aided planning for surgical excision for cosmetic purposes. The tumor was removed and histology confirmed its benign nature. Apart from cosmetic proposes and malignancy indications for excision of benign osteochondromas include pressure effect on surrounding tissue, pain and fracture of stalk. In our case the tumor had a typically benign appearance; nevertheless histological examination is always the gold standard for diagnosis.
Case Report JRPMS, Vol 4, No 2, June 2020, p.48-51
Femoral Head Avascular necrosis following intramedullary Gamma-nailing: A rare complication.
Themistoklis Vampertzis, Ioannis K. Christou, Paraskevas Giannakopoulos, Christina Barmpagianni, Georgios Nitis, Athanasios Fotiadis, Stergios Papastergiou
Keywords: Avascular Necrosis of femoral head, Intertrochanteric fracture, Intramedullary gamma nail, Total hip replacement, Femoral head blood supply
Avascular necrosis of the femoral head affects many patients annually. It results from reduced blood supply and can lead to complete loss of joint. The development of such a complication after certain types of hip trauma such as neck of femur fractures is not uncommon; nevertheless, extra-capsular fractures such as intertrochanteric ones are not a frequent cause of this complication reported at 0.5%. This case report presents the case of a 76 year-old woman who developed femoral head avascular necrosis following the fixation of her intertrochanteric fracture by an intramedullary Gamma nail. The early post-operative period suggestive of full recovery was followed by newlydeveloped symptoms of pain and reduced mobility. The removal of implants only partially alleviated symptoms while avascular necrosis was noted afterwards and was treated by a Total Hip Replacement before progression to involve the acetabulum. What is significant to stress in this case is the rarity of this complication arising after the specific trauma and operative technique. The anatomical location of the fracture does not advocate for a disruption in the femoral head’s perfusion, neither does the fixation by an intramedullary approach. Nevertheless physicians should always be aware of such cases and investigate all patients with post-operative pain and/or reduced range of motion for avascular necrosis, as early recognition is essential.
Οriginal Article JRPMS, Vol 4, No 3, September 2020, p.52-59
Translation, adaptation and validation of the 12-item Oxford hip score into Arabic
Aliaa Khaja, Owayed Almutairi, Abdulaziz Alkudair, Awdhah Alsamhan
Keywords: Arabic version, Cross-cultural, KOOS, Osteoarthritis outcome score, Oxford hip score
Objectives: To determine the ease of using the Arabic translation of the score while rendering the Arabic version valid for clinical use by Arab patients. Methods: 110 patients participated. The internal consistency tests were performed using Cronbach’s alpha. Test-retest reliability (intra-correlation coefficient), convergent construct validity, convergent validity, floor & ceiling effects, and responsiveness was also calculated. In order to measure the level of agreement, Bland-Altman Plot, forest Plots were performed. Results: To test the instrument reliability, Cronbach’s alpha was obtained. It proved excellent for the three testing occasions – α1=0.97 α2=0.97, and α3=0.97. Intra-class correlation coefficient was fair with a score of 0.58 (95% CI 0.38-0.73). Factor analysis was performed to test for factor validity - principal axis factoring, with no rotation. As hypothesized, the factor analysis yielded one factor, which explains 78% of the variance. Floor effect was recorded for 1% of the patients, and showed a ceiling effect of 8%, 2%, and 3% for the first, second, and third weeks of testing respectively. Conclusion: Arabic version of OHS could potentially be used as diagnostic tool for patients with hip problems regarding information about the overall condition of the patient at a given time.
Οriginal Article JRPMS, Vol 4, No 3, September 2020, p.60-67
A CT Based assessment of femoral component external rotation in TKA for osteoarthritic varus knees
Chetan Sood, Ankur Deshwal
Keywords: Osteoarthritis (OA), Posterior Condylar Axis (PCA), Surgical Trans-epicondylar Axis (sTEA), Total Knee Arthroplasty (TKA)
Objectives: A CT based comparative assessment of the femoral component axial rotation (FCAR) achieved in two different design rationales compared to desired distal femoral axial rotation in balanced knees. Methods: 19 males and 31 females randomized in 02 groups of 25 patients each underwent unilateral TKA using two different implant designs (Genesis II & PFC). Posterior Condylar Axis (PCA) Trans-epicondylar Axis (TEA) open angle used to assess axial placement of femoral components per-operatively. CT based evaluation of the TKA done at 06 weeks to assess the FCAR achieved compared to desired value. Results: Mean FCAR for Genesis II group was 3.63 degrees with no difference among the males and females. In PFC group the mean FCAR achieved was 4.07 degrees the mean value was lower in males 3.95 degrees (2.8-6.5) and higher in females 4.16 (2.5-5.2). Mean achieved FCAR achieved in the study is 3.85 degrees. Conclusion: Mean achieved FCAR for the two design rationales showed no statistically significant difference. Mean FCAR in Genesis II group was more than inbuilt 3 degrees and is statistically significant. In a well-balanced knee the mean achieved FCAR in the study is significantly higher (3.85 degrees) than conventional desired 3 degrees.
Review Article JRPMS, Vol 4, No 3, September 2020, p.68-75
Application of the orthopedic implant sonication method to diagnosis of periprosthetic joint infections
Anna Mavrommati
Keywords: Orthopedic implant, PJI, Sonication method
Arthroplasty is one of the most common surgical procedures in Orthopaedic Surgery. Periprosthetic joint infection (PJI) constitutes a rare complication of arthroplasties, but with severe social and economic impact, if the large and growing daily number of arthroplasties is taken into account. PJI diagnosis presents, even today, serious difficulties. Correlation of the specific infection pathogenesis to the microorganism ability to grow in biofilms has opened a new field of research. The method of implant sonication is a relatively recent development, applied to facilitate removal of microbes from the attached biofilm and subsequent cultivation and isolation of them. During the years following the first application of the method, multiple different protocols have been applied with different results, in comparison to the reference method, which is the conventional implant culture. Most studies yield encouraging results, implying superiority of the sonication technique in comparison with classic cultivation methods. In view of these results, the sonication method appears to be a reliable as well as easy to apply, fast and low cost examination technique, offering effective contribution to timely diagnosis of PJI.
Review Article JRPMS, Vol 4, No 3, September 2020, p.76-85
Skeletal radiological findings in thalassemia major
Spyridon G. Adamopoulos, Glykeria M. Petrocheilou
Keywords: Bone, Chelation radiography, Skeletal, Thalassaemia major
Skeletal changes in beta-thalassemia major (βTM) create a wide spectrum of bone radiographic features. The main pathology is extensive marrow proliferation due to ineffective erythropoiesis but the relative skeletal findings are encountered with a progressively reduced frequency and severity nowadays due to the regular hypertransfusion programs. The resulting hemosiderosis and particularly iron chelation therapy have been associated with dysplastic features which are found more often. Skeletal radiological appearances in βTM relate to a complex multifactorial pathogenesis (i.e. marrow expansion, direct iron and chelation toxicity, endocrine complications) and depend on the severity and duration of the disease, the type and effectiveness of treatment and the toxic effects of chelation therapy. Awareness of these findings is very important since early recognition can be an indicator for therapy adaptation.
Mini Review JRPMS, Vol 4, No 3, September 2020, p.86-89
Laboratory animal research of metabolic bone diseases in Greece: Laws and ethics
Konstantina Kafantogia
Keywords: Animal testing, Animal welfare, European legislation, Metabolic bone diseases, Three Rs
In the present article the main legal and ethical considerations that form the framework within which a research laboratory in Greece conducts animal testing for research into metabolic bone diseases are discussed. Preclinical testing procedures with animal models are specifically defined by EU law - and in the case of Greece - by its transposition into Greek legislation by the relevant Presidential Decree. This legislation describes the principle of the three Rs (Replacement, Reduction and Refinement) and turns ethical considerations into firm legal requirements, necessary for both the protection of animal welfare, as well as the safeguarding of the validity of clinical protocols that research - among others - some of the most widespread endocrine diseases of our time, i.e. metabolic bone diseases.