Lateral inverted osteochondral fracture of the talus (LIFT) is a rare variant of stage IV osteochondral lesion of the talus (OLT), where the fragment is inverted in situ by 180°. The management of ...LIFT lesion is very challenging and early recognition crucial, given that treatment options depend on the articular cartilage condition and sufficiency of the adjacent bone of the displaced fragment. We describe two LIFT cases referred from other institutions after unsuccessful conservative treatment of OLT. They presented with pain, swelling and tenderness over the anterolateral aspect of the right ankle. We recognized the LIFT lesion on the magnetic resonance imaging scans in patient 2, while in patient 1 the orientation of the fragment was recognized upon direct visualization during operative treatment. Both patients underwent arthroscopic procedure. Due to articular cartilage damage and insufficiency of the adjacent bone of the fragment, both patients were treated with excision fol-lowed by microfracture. Treatment of the LIFT lesion should start arthroscopically to allow clear evaluation of the osteochondral fragment, assessment of the talar defect and identification, as well as treatment of associated disorders. If the articular cartilage appears intact with sufficient subchondral bone, fixation of the fragment is optimal management, otherwise excision and microfracture can be the treatment of choice.
Izvantjelesna terapija udarnim valom ima brojne fiziološke učinke, poput smanjenja bola i poticanja cijeljenja tkiva, zbog čega danas ima široku primjenu u mišićno-koštanoj patologiji. Postoje dva ...osnovna oblika udarnog vala, fokusirani i radijalni, a razlikuju se po tome što fokusirani udarni val najveću energiju postiže u žarištu na željenoj dubini, dok se kod radijalnog udarnog vala najveća energija stvara na mjestu ulaska u tretiranu regiju tijela, te slabi daljnjim prodiranjem u tkivo. Sam mehanizam djelovanja udarnog vala nije do kraja razjašnjen, a pretpostavlja se da mehanička stimulacija dovodi do stanične migracije, proliferacije, diferencijacije ili apoptoze stanica, s tim da visoka razina energije može djelovati i razorno, umjesto da posluži kao mehanički stimulus, zbog čega je nužna prilagodba energije, ovisno o tretiranom području. Modulacija bola objašnjava se „gate control“ teorijom i hiperstimulacijskom analgezijom. Osim ustaljenih indikacija poput epikondilitisa, tendinopatija, plantarnog fascitisa, kalcificirajućeg tendinitisa, udarni val danas nalazi sve širu primjenu, te se upotrebljava i u terapiji spasticiteta, poremećenog cijeljenja kosti, kronične križobolje, smrznutog ramena, osteoartritisa koljena, sindroma trkačke potkoljenice, škljocavog prsta, sindroma bolnoga trohantera, te kod sindroma miofascijalne boli. Međutim, potrebno je provesti dodatna istraživanja kako bi se utvrdila stvarna vrijednost i mjesto udarnog vala u liječenju navedenih bolesti i stanja.
Extracorporeal shockwave therapy has numerous physical effects, such as pain reduction and tissuehealing induction, which gives its way for therapeutic implementation in various musculoskeletalconditions. There are two main forms of shockwaves, focused and radial, the main difference being thatfocused shockwaves achieve the highest energy at certain tissue depth, while radial shockwaves have thehighest energy at the entry point into the tissue. The underlying mechanism is still not fully elucidated, butit is presumed that mechanical stimuli cause cellular migration, proliferation, differentiation and apoptosis.Given in mind that this high energy can be disruptive instead being a mechanical stimulus, which calls forindividual energy adjustment depending on the structure treated. Pain modulation is explained according tothe gate control theory and hyperstimulation analgesia. Besides standard indications such as epicondylitis,tendinopathies, plantar fasciitis and calcific tendinitis, shockwave therapy is nowadays used more broadly,such as for treating spasticity, disrupted bone healing, chronic low back pain, frozen shoulder, kneeosteoarthritis, medial tibial stress syndrome, trigger finger, greater trochanteric pain syndrome andmyofascial pain syndrome. However, further research is needed to determine the exact value and place ofextracorporeal shockwave therapy in treating these conditions.
Fibroblast growth factor 23 (FGF23) has been casually linked to numerous hypophosphatemic bone diseases, however connection with bone loss or fragility fractures is still a matter of debate. The ...purpose of this review is to explore and summarise the known actions of FGF23 in various pathological bone conditions. Besides implication in bone mineralisation, elevated FGF23 showed a pathological effecton bone remodelling, primarily by inhibiting osteoblast function. Unlike the weak association with bone mineral density, high values of FGF23 have been connected with fragility fracture prevalence. This review shows that its effects on bone are concomitantly present on multiple levels, affecting both qualitative and quantitative part of bone strength, eventually leading to impaired bone strength and increased tendency of fractures. Recognising FGF23 as a risk factor for the development of bone diseases and correcting its levels could lead to the reduction of morbidity and mortality in specific groups of patients.
•Chronic liver disease and hepatic osteodystrophy have detrimental impact on bone strength.•Liver transplant candidates showed high prevalence of spinal fragility fractures.•Combination of standard ...X-ray imaging and DXA is needed for adequate bone evaluation in pretransplant period.•Bone specific alkaline phosphatase could be useful for detecting hepatic osteodystrophy in liver transplant candidates.
Existing data on fragility spinal fractures prevalence in liver transplant candidates are scarce and inconsistent. This may be due to other comorbidities, besides hepatic osteodystrophy (HO), that contribute to bone loss and fragility fracture prevalence in chronic liver disease (CLD).
The aim of this study was to investigate the prevalence of spinal thoracic and lumbar fragility fractures among cirrhotic, non-chronic kidney disease (CKD), non-diabetic liver transplant candidates and to explore their relationship with clinical characteristics, laboratory markers and dual-energy x-ray absorptiometry (DXA) results.
This cross-sectional observational study was conducted at Merkur University Hospital, Croatia, between February 2019 and May 2023. Adult patients with liver cirrhosis referred for liver transplantation were included. Patients with acute infection, CKD, diabetes mellitus, malignancies, inflammatory bone diseases and those on corticosteroid or antiresorptive therapy were excluded. Clinical, laboratory and radiological assessment was carried out and patients were accordingly allocated into non-fractured and fractured group for the purpose of statistical analysis.
A total of 90 patients were included in the study. There was 123 fractures, 87 (70.7 %) in the thoracic and 36 (29.3 %) in the lumbar region. Eighty-nine (72.4 %) fractures were grade 1, 31 (25.2 %) were grade 2 and 3 (2.4 %) were grade 3. Patients in the fractured group were significantly older (p < 0.001). No significant differences between fractured and non-fractured group according to laboratory and DXA parameters were noted. Subgroup with lumbar fractures had significantly lower bone mineral density values at L1-L4 region. Statistically significant negative correlation between bone specific alkaline phosphatase (BALP) and hip total BMD (rho = -0.414, p < 0.001) and spine total BMD (rho = -0.258, p = 0.014) values was found.
Present study confirmed detrimental impact of CLD and HO on bone strength. DXA measurement correlated with the presence of lumbar fragility fractures. A combination of standard X-ray imaging and DXA is needed for adequate bone evaluation in pretransplant period and BALP could be useful for detecting HO in CLD. Searching for other risk factors and implementing bone turnover markers and additional imaging techniques for bone loss evaluation in liver transplant candidates is needed.
Spondyloarthropathy refers to any joint disease of the vertebral column, but the term is mainly used for a specific group of disorders called seronegative spondyloarthropathies (SpAs). The axial ...skeletal involvement, peripheral and extra-articular manifestations and an association with the major histocompatibility complex class I human leukocyte antigen-B27 (HLA B27) are commonly shared features of SpAs. Klippel–Feil syndrome (KFS) is a rare congenital disorder characterized by the fusion of one or more cervical vertebrae, accompanied by various skeletal and extra-skeletal anomalies. We report a case of an adult male patient with HLA B27 positivity presenting with chronic cervical spine pain accompanied by morning stiffness and periodic night pain, with radiologically confirmed ankylosis and fusion of several cervical segments. His medical history included urogenital abnormalities operated in childhood and mild mitral prolapse. Initially suspected diagnosis of an early axial form of SpA was rejected after thorough workup. Instead, the nature of vertebral defects along with the past medical history of urogenital and cardiac abnormalities pointed towards the diagnosis of KFS. HLA B27 presence can be a confounder in patients presenting with spinal pain and that is why the differential diagnosis of CSD-s and SpA can be challenging in some patients.
Naphthalanotherapy (NT) is a therapeutic procedure that uses mineral oil obtained from petroleum. The aim of this study was to investigate the influence of the duration of NT combined with an ...individually adjusted rehabilitation program (IARP) on pain, morning stiffness (MS), fatigue, and physical function in patients with psoriatic arthritis (PsA). A total of 29 consecutive patients with PsA were divided into two groups. Group 1 (n=17) participated in a two-week and Group 2 (n=12) in a three-week intervention program. Pain (using the Visual Analogue Scale - VAS), fatigue (VAS and Functional Assessment of Chronic Illness Therapy-Fatigue - FACIT-F), duration of MS (minutes), and physical function (Health Assessment Questionnaire - HAQ) were assessed before and after therapy. Statistical analysis was performed using SPSS version 20, with P<0.05. There was a significant improvement in VAS-pain, VAS-fatigue, MS, HAQ, and FACIT-F before vs after therapy: Group 1:5.88±1.62 vs 3.94±1.25, P=0.001; 6.59±1.73 vs 4.35±1.73, P=0.001; 35.47±31.64 vs 23.71±29.30, P=0.001; 1.43±0.78 vs 1.23±0.74, P=0.001; 25.88±10.89 vs 30.71±10.65, P=0.009; Group 2: 6.17±1.27 vs 3.92±1.44, P=0.001; 6.50±1.93 vs 3.75±1.71, P=0.001; 38.42±32.00 vs 21.25±17.31, P=0.006; 1.47±0.79 vs 0.93±0.54, P=0.008; 25.00±9.87 vs 36.83±7.20, P=0.001, respectively. Regarding the length of the therapy, significant difference was reached only in FACIT-F (P=0.009). Two-week and three-week NT combined with IARP are equally efficient in reduction of pain and MS, as well as in improving physical function in patients with PsA. The three-week program showed an additional effect on reducing fatigue assessed by the FACIT-F score.
Inflammatory back pain and stiffness are the leading symptoms of ankylosing spondylitis (AS). AS progression leads to substantial functional impairment and can reduce quality of life (QoL). The aim ...of this study was to determine the impact of disease activity on QoL, fatigue, functional status and physical activity.
One hundred and fifty AS patients were included in the study, their body mass index (BMI) was calculated and they completed questionnaires regarding disease activity (The Bath Ankylosing Spondylitis Disease Activity Index, BASDAI) functional status (The Bath Ankylosing Spondylitis Functional Index, BASFI) spinal mobility (The Bath Ankylosing Spondylitis Metrology Index, BASMI), physical activity (the International Physical Activity Questionnaire, IPAQ), functional disability (The Health Assessment Questionnaire Disability Index, HAQ-DI), fatigue (The Functional Assessment of Chronic Illness Therapy - fatigue, FACIT-F) and QoL (The Short Form Survey-36, SF-36).
Patients with inactive disease (BASDAI<4) had significantly better HAQ scores (p=0.001), SF-36 mental component scores - MCS (65.68±19.54 inactive vs. 46.89±21.78 active disease, p=0.001), SF-36 physical component scores - PCS (median score 56.25 inactive vs. 30.00 active disease, p=0.001) and FACIT-F scores (38.49±10.62 inactive vs. 26.21±10.81 active disease, p=0.001). There was no significant difference in patient's physical activity or BMI regarding disease activity (p=0.564 and p=0.162 respectively). Also, there was no significant difference in BASDAI, BASMI or BASFI scores regarding different BMI categories (p=0.818, p=0.474, p=0.436, respectively).
AS activity increased fatigue, impaired functional ability and QoL, especially the physical component. Although more than half (61.4%) of our patients were categorized as pre-obese or obese according to BMI, this was not related to disease activity, spinal mobility or daily functioning scores. Reported physical activity level had no effect on disease activity. Disease activity influences the course of AS and QoL assessment should be implemented into regular AS evaluation in order to improve treatment outcome.
Lateral inverted osteochondral fracture of the talus (LIFT) is a rare variant of stage IV osteochondral lesion of the talus (OLT), where the fragment is inverted in situ by 180degrees. The management ...of LIFT lesion is very challenging and early recognition crucial, given that treatment options depend on the articular cartilage condition and sufficiency of the adjacent bone of the displaced fragment. We describe two LIFT cases referred from other institutions after unsuccessful conservative treatment of OLT. They presented with pain, swelling and tenderness over the anterolateral aspect of the right ankle. We recognized the LIFT lesion on the magnetic resonance imaging scans in patient 2, while in patient 1 the orientation of the fragment was recognized upon direct visualization during operative treatment. Both patients underwent arthroscopic procedure. Due to articular cartilage damage and insufficiency of the adjacent bone of the fragment, both patients were treated with excision followed by microfracture. Treatment of the LIFT lesion should start arthroscopically to allow clear evaluation of the osteochondral fragment, assessment of the talar defect and identification, as well as treatment of associated disorders. If the articular cartilage appears intact with sufficient subchondral bone, fixation of the fragment is optimal management, otherwise excision and microfracture can be the treatment of choice.Okrenuti kostanohrskavicni fragment na lateralnoj plohi talusa (engl. lateral inverted osteochondral fracture of the talus, LIFT) je rijedak oblik IV. stupnja kostanohrskavicnog ostecenja talusa (engl. osteochondral lesion of the talus, OLT), pri cemu je kostanohrskavicni fragment okrenut u lezistu za 180degrees. Rano prepoznavanje LIFT-a je od presudne vaznosti, jer lijecenje ovisi o ocuvanosti zglobne hrskavice i pripadajuce kosti okrenutog kostanohrskavicnog fragmenta. U nasem radu prikazuj emo dva slucaja LIFT-a koji su upuceni iz drugih ustanova nakon neuspjesnog lijecenja OLT-a konzervativnim metodama. Kod oba bolesnika simptomi su bili bol, oteklina i osjetljivost anterolateralnog dijela desnog gleznja. Ostecenje LIFT je kod drugog bolesnika prepoznato tek na snimkama magnetne rezonance u nasoj ustanovi, dok je kod prvog bolesnika orijentacija fragmenta prepoznata tek za vrijeme operativnog zahvata. Oba bolesnika podrvgnuta su artroskopskom zahvatu. Buduci da su kod oba bolesnika zglobna hrskavica i pripadajuca kost kostanohrskavicnog fragmenta bile znatno ostecene, odlucili smo se za njihovo odstranjenje. Potom smo ocistili nastali defekt na talusu i nacinili mikrofrakture. Danas se savjetuje operativno lijecenje LIFT-a zapoceti artroskopski, jer se na taj nacin omogucava tocna procjena ocuvanosti kostanohrskavicnog fragmenta te se mogu lijeciti pridruzena unutarzglobna ostecenja. Ako je zglobna hrskavica fragmenta ocuvana i ima dovoljno pripadajuce kosti, metoda izbora je fiksacija kostanohrskavicnog fragmenta, dok je u suprotnom moguce odstraniti kostanohrskavicni fragment i naciniti mikrofrakture.Key words: Talus - injuries; Cartilage, Articular; Cartilage Diseases; Conservative Treatment; Magnetic Resonance Imaging; Arthroscopy; Case ReportsKljucne rijeci: talus - ozljede; hrskavica, zglobna; hrskavica, bolesti; konzervativno lijecenje; magnetska rezonancija, snimanje; artroskopija; prikazi slucaja
Calcific shoulder tendinitis (CST) is characterized by hydroxyapatite crystals deposition in the rotator cuff tendons. Therapeutic exercises have been the mainstay of CST treatment, and evidence for ...therapeutic ultrasound (T-US) utilization and efficacy is lacking.
This study aimed to determine whether 4500 J T-US combined with therapeutic exercises is superior to therapeutic exercises alone regarding calcification size reduction and symptom improvement in chronic symptomatic CST.
This is a double-blind, placebo-controlled study.
This study was conducted at a University Department for Rheumatic Diseases and Rehabilitation of a University Hospital.
Patients with chronic CST were analyzed.
After eligibility allocation, 46 patients with sonographically confirmed CST were divided into two groups (56 shoulders, 26 per group). Both groups performed the same therapeutic exercises for half an hour under physiotherapist supervision. In the treatment group T-US (4500 J, 10 minutes per session at a frequency of 1 MHz and an intensity of 1.5 W/cm
), and in the placebo group, sham T-US was applied for 4 weeks. Patients were assessed for: calcification size, shoulder pain, global health (GH), shoulder mobility (ROM), handgrip strength, Health Assessment Questionnaire Disability Index (HAQ-DI), Shoulder Pain and Disability Index (SPADI), and overall rehabilitation satisfaction.
All assessed variables improved in both groups. A significantly greater reduction in calcification size was recorded in the treatment group compared to placebo: -10.92% (IQR 4.61% to 19.38%) versus -5.04% (2.30% to 7.22%), P=0.008. There was a significantly greater decrease in HAQ-DI, reduction of VAS GH, and an increase in hand grip strength in the treatment group, while no significant differences were observed for other parameters between the groups.
Our results showed that adding the 4500 J T-US to therapeutic exercises in chronic symptomatic CST therapy resulted in greater calcification size reduction immediately following the treatment, as well as hand grip strength, HAQ-DI, and VAS GH improvement.
4500 J T-US combined with therapeutic exercises is more effective in reducing calcification size than therapeutic exercises alone in the treatment of chronic symptomatic CST.
Electromyography (EMG) and nerve conduction studies (NCS) are an unpleasant and sometimes painful examinations. Pain can reduce patient's compliance and have a negative effect on the examination ...results. Different studies report that music affects pain perception by acting as a distractor, by inducing positive emotional valence or through the concept of convergence of different sensory modalities. The aim of this study was to explore the effect of music and different environmental and sociodemographic factors on pain perception during EMG and NCS.
Sixty patients with suspected neuromuscular disease were randomized into music and control group. Specific questionnaire assessed sociodemographic characteristics, medical history, examination waiting time, examination extent and biometeorological forecast. The numerical rating scale was used for the evaluation of pain. The examiner evaluated patient's compliance after the examination.
NCS was less painful for patients in the music group (p=0.03), as well as for more cooperative patients (p=0.011). For patients who previously underwent EMG/NCS, present NCS was more painful (p=0.001), regardless of the music intervention (p=0.019). EMG was more painful for older patients (p=0.041). Patients with lower level of education reported lower pain during NCS (p=0.026). Gender, financial satisfaction, biometeorological forecast, diabetes, depression or malignant disease, use and dosing of analgesics or antidepressants, symptoms, examination waiting time and the examination extent had no effect on pain perception.
Music significantly decreased the perception of pain associated with NCS, but not the EMG portion of the examination. During EMG pain level was not significantly reduced, but the median of pain was still lower. Generally, the pain level during NCS, unlike the one during EMG, was affected by patients' compliance, level of education and painful predetermination. We propose using music during EMG/NCS because it can make the examination more comfortable for the patient and thus contribute to better quality of this examination.
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