Von Willebrand’s disease mimicking postoperative bleeding after tibial nailing for tibial shaft fracture

Von Willebrand’s disease (VWD), or von Willebrand’s syndrome, is a bleeding syndrome characterized by low plasma levels of von Willebrand factor (VWF). VWD is the most common inherited human bleeding disorder. Partial quantitative deficiency of serum VWF is responsible for the majority of VWD cases. The effect of VWF deficiency on orthopedic operations is not well documented in the current literature. VWD may cause persistent blee­ding during the operative and postoperative periods. In the majority of cases, VWD occurs as a single episode, but frequent relapses with chronicity can be seen in a small number of cases. We reported a case of a 22-year-old man with VWD operated with intramedullary nailing due to tibial shaft fracture. The patient had no previous history of surgery, and was unaware of his VWD. The purpose of this study is to report a rare complication of an orthopedic surgical procedure with postsurgical bleeding mimicking tibialis anterior arterial perforation. Orthopedic surgeons must be alert to the possibility of VWD due to postsurgical difficulties and persistent bleeding.

Neuropathic pain as a predictor of neurological disorders regression in patients with spinal cord traumatic injury

Background. Neuropathic pain is one of the principal secondary complications of spinal cord injury. The biological role of neuropathic pain has not been established yet. This type of pain is formed directly in the area of the spinal cord injury; therefore, it can be assumed that its intensity may characterize both degenerative and reparative processes. The aim of this work is to assess the possible relationship between the intensity of neuropa­thic pain in patients with spinal cord injury at cervical subaxial spine and the dynamics of neurological disorder regression. Materials and methods. We have performed a retrospective analysis of patients referred to outpatient department of the Romodanov Neurosurgery Institute of National Academy of Medical Sciences of Ukraine in the period from 2010 to 2020 after a surgical treatment of subaxial cervical spine traumatic injury. The extent of neurolo­gical disorders and the intensity of neuropathic pain were assessed within 5–7 and 11–13 months after surgery. Results. All 102 patients selected for analysis were divided into three groups depen­ding on the intensity of the registered pain sensations: 1) absence of constant pain sensations — 19.6 % of subjects, 2) moderate pain — 56.9 %, 3) severe neuropathic pain — 23.5 %. In the first group, the regression of neurological disorders was 3.5 (95% confidence interval (CI) 2.15–6.15), in the second — 25.0 (95% CI 24.14–29.58), in the third — 13.0 (95% CI 10.87–16.55). The differences are statistically significant (χ2 = 60.4, df = 2, p < 0.0001). In patients with severe neurological disorders, the dynamics of recovery did not correlate with the pain intensity. With ASIA B, the dynamics of group 1 was 8.5 (95% CI 10.56–27.56), of group 2 — 15.0 (95% CI 13.41–18.41), of group 3 — 10.5 (95% CI 7.45–14.89). With ASIA C functional class, the difference is even more pronounced: in group 1, the median was 8.0 (95% CI 0.83–20.83), in group 2 — 32.0 (95% CI 25.41–36.86), in group 3 — 15.5 (95% CI 10.27–27.4). With ASIA D, a similar trend was observed. Conclusions. The worst regression of neurological disorders is observed in patients without clinically significant pain, the best results of neurological dysfunction recovery are found in patients with mode rate neuropathic pain.

Abstracts of the IV Scientific symposium with international participation “Musculoskeletal diseases and age” dedicated to the memory of V.V. Povoroznyuk (October 21–22, 2021, Kyiv, on-line)

No abstract

Experimental Modeling of Osteoporosis in Animals

Experimental studies on animals under conditions of osteopenia and osteoporosis modeling significantly expand the view of the mechanisms of primary and secondary osteoporosis development, help determining the effect of various factors affecting the bone tissue, evaluate the effect of medications, new biomaterials, etc. Osteoporosis is a multifactorial disease; its clinical manifestations depend on a complex interplay of environmental, lifestyle and genetic factors. The review of the literature analyzes the data on the use of animals to assess the features of osteoporosis course when modeling this pathology by surgical and non-surgical methods. The article features the models of osteoporosis which are reproduced on rats and mice being the most accessible objects and the most frequently used by experimenters. The details of modeling the course of such types of osteoporosis as postmenopausal, senile, glucocorticoid-induced, testosterone deficiency (orchiectomy)-induced, immobilization, hypothermia, radiation-induced, etc. are explored. A specific aspect of recent advances in modeling osteoporosis is the creation of transgenic and knockout mice, whose models may be used to detect components of genetic lesions and will certainly contribute to the development of new methods of prevention and therapy of this severe pathology. The similarity and difference of experimental models of osteoporosis describing the pathophysiological changes in humans due to osteoporosis are noted. Emphasis is placed on bioethical norms of working with experimental animals.

Senile osteoporosis: Modern view of the problem

The article summarizes the data on senile osteoporosis and presents a clinical case of this disease. The reference sources on peculiarities of bone remodeling in senile osteoporosis are summarized; low bone formation takes place against the background of a pronounced bone resorption. The article also presents pathomorphological features of bone tissue remodeling resul­ting in pronounced impairments of the compact bone, which increase the risk of fracture. Vitamin D plays a significant role in the complex mechanism of senile osteoporosis. The data on the combined effect of vitamin D and parathormone on bone remodeling are summarized. The paper presents data on other cumulative effects of senile osteoporosis development. Against the background of ­ageing-associated systemic changes, calcium and vitamin D deficiency, increased pro-inflammatory cytokine expression, loca­lized bone disorders develop. An important link to the development of senile osteoporosis is an increased marrow adipose tissue with an intensified adipogenesis, resulting in a decrease of osteoblasts due to the toxic effects of adipokines, reduced differentiation and proliferation of osteoblasts. Age-associated immune-related mechanisms of inflammation, indirectly affecting the bone, are consi­dered. Peculiarities of the senile osteoporosis diagnostics by means of bone mineral density assessment tools are described. Despite the successes achieved in the study of senile osteoporosis development mechanisms, further research is required to explore local and systemic factors affecting bone tissue which are involved in the development of this disease.

Age-related changes in bone tissue in men

The purpose of the study was to establish age-related changes of male bone tissue. Materials and methods. The study was conducted by the Department of Clinical Physiology and Pathology of the Musculoskeletal System of the State Institution “D.F. Chebotarev Institute of Gerontology by the National Aca­demy of Medical Sciences of Ukraine”. It involved 342 healthy men aged 20 to 89 years without osteoporosis and osteoporotic fractures or any pathology with a confirmed impact on bone tissue, as well as any somatic pathology in the sub- and decompensation. The following methods of examination were used: questionnaire, anthropometric measurements, clinical and instrumental examination. Bone mineral density (BMD) was measured by the dual-energy X-ray absorptiometry machine “Prodigy, GEНС Lunar” at the level of the entire skeleton, lumbar spine (L1-L4), proximal femur and femoral neck, distal and ultra-distal forearm bones. Results. We have detected a significant 14.8 % decrease of BMD at the level of femoral neck in the group of men aged 60–69 years, by 20 % in the group of men aged 70–79 years, and by 24.1 % in the group of men aged 80–89 years compared to the men aged 20–29 years; at the same time, at the lumbar spine there was re­gistered a decrease of this parameter by 1.6 % in men aged 60–69 years, by 1.9 % in men of 70–79 years and by 0.8 % in men of 80–89 years, respectively. Among the examined practically healthy men, the bone tissue remained at the normal level relative to age in 67.8 %; osteopenia was detected in 27.8 %, and osteoporosis in 4.4 %. Conclusions. An age-associated BMD reduction was registered at various skeletal sites in the practically healthy men wi­thout any clinically significant factors affecting bone tissue metabolism. The most pronounced BMD loss was observed at the level of fe­moral neck. At the same time, 4.4 % of examined had osteoporosis without any clinical signs.

Life quality of men with ankylosing spondylitis: association with the disease course and the structural and functional state of bone tissue

Background. Multiple peculiarities of ankylosing spondylitis clinical course have a significant influence on the phy­sical, mental and social status of patients. Systemic loss of bone tissue manifesting itself through the development of osteoporosis and its complications is not excluded either. However, currently there is no sufficiently clear information on the influence of osteoporosis or its metabolic components, as well as peculiarities of the disease clinical course on the physical and mental health components in the patients suffering from ankylosing spondylitis. Purpose: to study the quality of life indices using the SF-36 and HAQ questionnaires in men suffering from ankylosing spondylitis and to assess the associations of these indexes with the disease cli­nical course as well as structural and functional state of bone tissue. Materials and methods. 105 men suffering from ankylo­sing spondylitis and 25 practically healthy persons of the appropriate age and sex forming the control group were examined. In order to assess the quality of life indices, the SF-36 and HAQ questionnaires were used. Results. It was established that men suffering from ankylo­sing spondylitis showed reliably lower indices of phy­sical (37.3 ± 1.5 points) and mental (44.2 ± 1.7 points) health components if compared to the control group (99.1 ± 0.3; 97.4 ± 0.7 points respectively). Under conditions of the low bone mineral density, quality of life indices (PCS; MCS) were only 12.2–7.1 % lower than in the patients with a preserved bone mineral density. It was shown that under conditions of the Vitamin D deficiency, quality of life components were significantly worse, specifically on account of the mental health component (р < 0.05). It was also established that the lower quality of life was closely associa­ted with a high activity of the inflammatory process (ASDAS-СRP, BASDAI) and a high dose of glucocorticoids. Conclusions. Men suffering from ankylosing spondylitis show a significant reduction of life quality indices by the SF-36 (PCS; MCS) and HAQ questionnaires, which demonstrate no association with the age of the patients (except for MCS), di­sease form and duration, structural and functional state of bone tissue. However, they are significantly worse in subjects with the Vitamin D deficiency, a high dose of glucocorticoids and high disease activity.

Microglia and mast cells: new targets for the treatment of chronic pain

The article is devoted to the problem of effective ma­nagement of chronic pain. A review of the known mechanisms of development and maintenance of chronic pain and possible me­thods of influence is given. One of the reasons for the lack of chro­nic pain treatment effectiveness in some patients is the use of treatment regimens with drugs acting exclusively on the targets loca­ted in the nerve structures. Today an important role of micro­glia and mast cells in the development and maintenance of chronic pain conditions is well acknowledged. A new class of drugs from the group of acylethanolamides is described. One of the representatives of this group is palmitoylethanolamide. This drug may mo­dulate the activity of microglia and mast cells, thus increasing the pain threshold and the effectiveness of therapy. The use of palmitoylethanolamide in patients with chronic pain can increase the effectiveness of therapy.

Ukrainian FRAX version in the male osteoporosis management

Background. At present, FRAX is a well-known and widely-used risk assessment tool for major osteoporotic fractures. The Ukrainian version of the FRAX algorithm was presented in 2016; with the “intervention threshold” for additional DXA exa­mination and antiosteoporotic treatment of the Ukrainian women published in 2019. However, the data on its possible uses in men are limited. The purpose of the study was to evaluate the possibilities of using the previously developed criteria of the Ukrainian FRAX algorithm in Ukrainian men. Materials and me­thods. We exa­mined 653 outpatients aged 40–88 years (mean age (M ± SD) — 60.5 ± 11.8 years). We analyzed the results both in the general group and in the age subgroups; in particular, with an account of low-trauma fractures, included in the FRAX calculation, and compared them with the corresponding indices of the Ukrainian wo­men. Results. The most frequent (26.6 %) risk factor for osteoporo­tic fractures in the group of Ukrainian men was a history of low-trauma fracture (the corresponding index in women was 51.3 %), its presence being the reason for antiosteoporotic treatment initia­ting. Following upon the risk of major osteoporotic fractures calculated by FRAX, only 6.7 % of men without previous fractures were found to require additional DXA examination in order to re-evaluate the osteoporotic fracture risk, and none had a high fracture risk. 73 % of men without fractures did not have any risk factor inclu­ded in the FRAX algorithm. Conclusions. This study showed a grea­ter need for both antiosteoporotic treatment without DXA assessment and additional densitometric examination for the osteoporotic fracture risk assessment for the Ukrainian women rather than men, along with a special attention to the presence of previous fractures in men, and consideration of other risk factors for osteoporosis, even those not included in this FRAX algorithm.

Modic changes in the lumbar spine: histology, risk factors, clinical presentation and treatment

The article presents a literature review on the ­Modic changes (MCs) in the vertebral endplates, which are frequently detected in patients with chronic low back pain. The etiology of MCs is unknown; however, there are three causes which are considered the most probable today: mechanical, infectious and biochemical. They share a common mechanism of pro-inflammatory molecule migration from the degenerative disk. A close association has been identified and described between the MCs and a non-specific chronic low back pain. Disc degeneration ­exerts a further stress on the endplates and produces microcracks, through which the inflammatory mediators enter the bone marrow and provoke the MCs. At pre­sent, there are no evidence-based treatment protocols for the MCs. A certain progress has been made with antibiotic therapy, injections of steroids and antiresorbents; the effectiveness of anti-TNF-α therapy is being explored. The sporadic reference data on our disposal indicate that patients with MCs and chronic low back pain, along with instability, who do not respond to a conservative treatment, may be referred for the surgical treatment to relieve pain and improve quality of life. However, not all of the presented methods of surgical treatment with chronic back pain are effective in patients with the Mo­dic changes. The divergence of patient treatment outcomes presen­ted by various sources indicates the need for a further research to understand the MC pathogenesis and develop pathogenetic approaches to the treatment of this pathology.