This study was performed to determine the differences in grade of synovitis and expression of NF-κB and iNOS in knee synovial membrane between early and advanced stage of osteoarthritis (OA). Thirty synovial membrane intra-operative biopsies of patients (ten controls, ten with early and ten with advanced OA according to Kellgren-Lawrence radiological score) were immunohistochemically (NF-κB and iNOS) and hystologically (Krenn synovitis score) analyzed and correlated to WOMAC clinical score and pain duration. Krenn synovitis score of patients with radiologically early OA was significantly higher than in patients with advanced OA (p < 0.001). NF-κB expression in both synovial intima (p < 0.001) and subintima (p < 0.001) was also higher in early OA. iNOS expression in subintima was significantly higher in early than in advanced OA (p < 0.001), while in intima iNOS showed no statistical difference between groups (p = 0.07). The lymphocytic nodules, located in synovial subintima, were significantly higher in advanced OA when compared to early OA (p = 0.006) and the control group (p < 0.001). These results suggest that in early OA, there is a localized inflammation of the synovial membrane with high expression of NF-κB and iNOS. In advanced OA, number of expressed factors is reduced, with the exception of intima cells that highly express iNOS, reflecting the ongoing localized inflammatory process of lower degree. In advanced OA, the density of the resident cells is reduced and lymphocytic nodules appear, confirming the important role of adaptive immunity in later OA stage. Clinical significance of this study is better understanding possibilities of preventive measures for synovitis and OA advancement. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1990-1997, 2017.
This report is a unique case of three stress fractures in a 14-year-old active female basketball player and we emphasize the importance of triple-phase bone scanning in differential diagnosis of the stress fracture. According to radiographic examination and laboratory tests, which were normal, the stress fracture of the right fibula was strongly suspected while making the diagnosis. Despite the treatment applied, recurrence, and deterioration of the symptoms were presented. Repeated laboratory test results were again normal, but the presence of an abundant periosteal reaction on the plain radiographs was confusing, so osteomyelitis or Ewing sarcoma of the fibula was suspected. We decided to perform a three-phase bone scanning; its findings were critical for the judgment and we diagnosed three stress fractures involving both fibulae. Final confirmation of the diagnosis of the bilateral fibular stress fractures in our case, however, was done by computed tomography examination.
Williams et al 1 proposed a radiographic protocol consisting of CT scans obtained at 3, 6, and 12 months, with an additional scanning at 24 months if a solid fusion was not seen earlier in evaluating lumbar interbody fusions (LIF) (with special emphasis on using the recombinant human bone morphogenetic protein-2 [rhBMP-2] as a bone graft substitute). The question is why the scannings were scheduled at those intervals, especially because no patient is likely to show healing of the fusion as early as 3 months after surgery, and why they were performed in all patients, even in those who were pain-free and with successful clinical status. 2 LIF using rhBMP-2 can result in transient bone resorption of vertebral bodies or cystic changes within the endplates adjacent to the implant. 3 All reported or unreported but later discovered 4 bone resorptions occurred when the rhBMP-2Ϫsoaked collagen sponge was in direct contact with the bone of vertebral bodies, 3 creating local rapid increase of rhBMP-2, which resulted in transient osteoclastic resorption preceding bone formation (T. Smoljanovic et al, unpublished data, 2008). Depending on the size of the contact area between the rhBMP-2Ϫsoaked collagen sponges and the endplates, the size of resorptions of vertebral bodies varied. A larger area of direct contact was created either by placing of additional rhBMP-2Ϫsoaked sponges between different interbody spacers or by the construction of interbody spacers that allowed direct contact of the vertebral endplates and the rhBMP-2Ϫsoaked sponge within them, as in the case of femoral ring allografts. The incidence of reported vertebral bone resorptions after the use of rhBMP-2 in direct contact with vertebral bodies varied from 7% to 100%.Most reported bone resorptions of vertebral bodies were first noticed by CT, usually 3 months after the LIF assisted by rhBMP-2 (T. Smoljanovic et al, unpublished data, 2008). The changes usually were not visible on plain radiographs at the time. The resorptions were observed as unanticipated adverse findings without pain during scheduled follow-up examinations in more than half of the reports. In the remaining studies, patients with pain in the early postoperative period (1-3 months) and patients in whom significant graft subsidence had occurred on plain radiographs underwent CT, which then revealed bone resorptions.Because the resorptions of vertebral bodies after the LIF using rhBMP-2 resulted in many cases with spacer subsidence, loss of correction, spacer dislodgment, and nonunions, the importance of early CT follow-up, even in asymptomatic patients, is significant, at least until surgeons are able to avoid larger areas of direct contact between the rhBMP-2Ϫsoaked collagen sponge and the bone of vertebral bodies or until the manufacturers improve the carrier of rhBMP-2. Positive early findings of cystic changes within the endplates after the LIF using rhBMP-2 will determine the restriction of activity for the patient. The residual loss of correction and nonunions will depend on the size of th...
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