Search

Aim: This pilot case series examined feasibility of anterior radiofrequency approach under combined ultrasound and fluoroscopy guidance to control pain from avascular necrosis of the hip. Patients & methods: Data on 11 consecutive patients were collected on longevity of cooled radiofrequency ablation (CRFA), pain relief and opioid use. Results: The average age was 56 (28-66), BMI 29.5 (16.5-34), in four women and three men. Their average opioid use was 92 mg MS04 equivalents (median 35 mg). The pain score decreased to 3.3 after the CRFA. Five patients claimed more than 50% of pain relief. The average time interval of greater than 50% of pain relief from the CRFA was 70-250 days. Conclusion: CRFA may be an effective treatment of chronic pain from avascular necrosis.

Background: Osteonecrosis of the jaw is a very delicate side effect of Denosumab. The aim of this retrospective study was to assess the occurrence rate of Denosumab-related osteonecrosis of the jaw (DRONJ) at the Cancer Institute of Lorraine (ICL) and to highlight necrosis risk factors., Methods: To that purpose, we analyzed the medical records of 249 consecutive patients treated with Denosumab at the ICL during the past 5 years. Patients who received orofacial radiotherapy or a previous treatment with a bisphosphonate were excluded. The P-value was set at .005., Results: A total of 141 patients treated at the ICL between January 2010 and December 2015 were included. All patients were treated with XGEVA ® . Of the 141 patients included in the study, 10 developed DRONJ. The incidence of DRONJ increases with the duration of follow-up as follows: 3% at 1 year, 7% at 2 years, and 8% from 30 months on. No risk factor for necrosis could be identified except the realization of prior dental extraction (P = .025)., Conclusion: Our results raise important questions about the dental management of these patients, in particular, concerning the healing period between dental extractions and the initiation of Denosumab., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Medication-related osteonecrosis of the jaw (MRONJ) is an important complication in patients treated with antiresorptive agents such as bisphosphonates and the receptor activator of nuclear factor κB ligand inhibitor (denosumab). Treatment of MRONJ is extremely difficult, which makes it a distressing long-term complication., Objectives: We report a case of intractable facial pain due to MRONJ that was successfully controlled with selective percutaneous controlled radiofrequency thermocoagulation of the Gasserian ganglion., Setting: A 68-year-old woman with breast cancer was diagnosed as having MRONJ. She was very distressed because of jaw pain and infections secondary to MRONJ. Her quality of life (QOL) was severely decreased. Since alleviation of the MRONJ could not be expected within the patient's life expectancy, it was decided to investigate the usefulness of selective percutaneous controlled radiofrequency thermocoagulation of the Gasserian ganglion to control the pain., Results: After the procedure, the anesthesia was obtained in the distribution of the third branch of the trigeminal nerve, and the pain completely disappeared. Although hypoesthesia was provoked as a complication, it was tolerated by the patient and she was very satisfied. Up to the time of death, there was no recurrence of pain or worsening of the MRONJ., Discussion: This procedure is a common technique for treating trigeminal neuralgia. Its effect is immediate and long lasting, although it provokes hypoesthesia in treated division, and it is also suited for cancer patients in terminal stage. This case suggests that the procedure was useful for improving the patient's QOL.

Sesamoid osteonecrosis is a disabling condition resulting in severe forefoot pain, for which there are limited treatment options. We present a 52-year-old man with 1-year history of pain, aggravated by walking and playing tennis. On examination, pain was localised to plantar aspect of the first metatarsophalangeal joint. Imaging revealed evolving end-stage avascular necrosis of lateral sesamoid with early secondary degenerative changes. Previous exhaustive conservative treatment had been unsuccessful in alleviating his pain. As an alternative to surgery, radial extracorporeal shock wave therapy (rESWT) was proposed. Treatment protocol was 2000 pulses at frequency of 5 Hz, and pressure was varied from 1.2 to 1.8 bar according to patient tolerance. A total of eight sessions were delivered. At completion of treatment, the patient reported minimal discomfort to no pain and was able to return to playing tennis with no recurrence. We propose rESWT to be an effective novel conservative treatment for sesamoid osteonecrosis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Pulsed electromagnetic fields (PEMF) stimulation has been used successfully to treat nonunion fractures and femoral head osteonecrosis, but relatively little is known about its effects on preventing steroid-induced osteonecrosis. The purpose of the study was to investigate the effects of PEMF stimulation on the prevention of steroid-induced osteonecrosis in rats and explore the underlying mechanisms., Methods: Seventy-two male adult Wistar rats were divided into three groups and treated as follows. (1) PEMF stimulation group (PEMF group, n = 24): intravenously injected with lipopolysaccharide (LPS, 10 μg/kg) on day 0 and intramuscularly injected with methylprednisolone acetate (MPSL, 20 mg/kg) on days 1, 2 and 3, then subjected to PEMF stimulation 4 h per day for 1 to 8 weeks. (2) Methylprednisolone-treated group (MPSL group, n = 24): injected the same dose of LPS and MPSL as the PEMF group but without exposure to PEMF. (3) Control group (PS group, n = 24): injected 0.9% saline in the same mode at the same time points. The incidence of osteonecrosis, serum lipid levels and the mRNA and protein expression of transforming growth factor β1 (TGF-β1) in the proximal femur were measured 1, 2, 4 and 8 weeks after the last MPSL (or saline) injection., Results: The incidence of osteonecrosis in the PEMF group (29%) was significantly lower than that observed in the MPSL group (75%), while no osteonecrosis was observed in the PS group. The serum lipid levels were significantly lower in the PEMF and PS groups than in the MPSL group. Compared with the MPSL and PS groups, the mRNA expression of TGF-β1 increased, reaching a peak 1 week after PEMF treatment, and remained high for 4 weeks, then declined at 8 weeks, whereas the protein expression of TGF-β1 increased, reaching a peak at 2 weeks after PEMF treatment, and remained high for 8 weeks., Conclusions: PEMF stimulation can prevent steroid-induced osteonecrosis in rats, and the underlying mechanisms involve decreased serum lipid levels and increased expression of TGF-β1.

Background: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an adverse side effect associated with bisphosphonate (BP) therapy, especially when parenteral BP administration is used. Patients affected by BRONJ present wide areas of exposed necrotic bone, particularly after surgical oral procedures. The main symptom is pain that is poorly controlled by common analgesic drugs. Recently, many studies have pointed to the beneficial effect of low-level laser therapy (LLLT) in pain reduction for many pathological conditions. The purpose of this study is to investigate whether LLLT could be helpful in managing BRONJ by reducing the problems associated with this condition and the use of analgesic drugs., Methods: Twelve patients affected by BRONJ were monitored at the Complex Operative Unit of Oral Pathology. Among these patients, only seven referred to pain in necrotic areas and were recruited for LLLT. Laser applications were performed with a double diode laser simultaneously emitting at two different wavelengths (λ = 650 nm and λ = 904-910 nm, spot size = 8 mm). All of the patients were irradiated with a fluence of 0.053 J/cm(2) for 15 min five times over a period of 2 weeks, in a non-contact mode, ∼1 mm from the pathologic area. The patient's maximum and minimum pain was recorded using a numeric rating scale (NRS) evaluation before and after the treatment. Statistical analysis was performed using the Kruskal-Wallis test., Results: Six patients showed significant pain reduction, and only one patient indicated a worsening of the symptoms, which was probably related to a reinfection of the BRONJ site, which occurred during the study. A statistically significant difference (p < 0.05) was found between the NRS rates before and after the protocol., Conclusions: This pilot study suggests that LLLT may be a valid technique to support the treatment of BRONJ-related pain, even though the low number of cases in this study does not permit any conclusive consideration.

Objective: The aim of this study was to detail the clinical efficacy of low-level laser therapy (LLLT) for the management of bisphosphonate-induced osteonecrosis of the jaws (ONJ-BP)., Background: ONJ-BP is the correct term, recently emerged, to describe a significant complication in a subset of patients receiving drugs such as zoledronic acid, pamidronate, and alendronate. No definitive standard of care has been set for ONJ-BP and no definitively agreed guidelines have been provided. There is currently no consensus on the correct approach to the issue., Materials and Methods: The investigators studied a prospective cohort of 20 patients affected by ONJ-BP, who received biostimulation with a pulsed diode laser (GaAs). Patients were exposed to a 904-nm infrared laser (50 kHz, 28.4 J/cm(2) energy density, 40% duty cycle, spot size 0.8 cm). Outcome variables were the size of lesions, edema, visual analogue score of pain, presence of pus, fistulas, and halitosis. Preoperative results were compared with the postoperative outcome and statistically evaluated., Results: Four weeks after LLLT, a statistically significant difference was observed for reported pain (p = 0.0001), clinical size (p = 0.0034), edema (p = 0.0005), and presence of pus and fistulas (p = 0.0078 and p = 0.03, respectively)., Conclusion: This study suggests that LLLT would appear to be a promising modality of treatment for patients with ONJ-BP, providing that clinical efficacy is safe and well tolerated, especially by those patients who require conservative treatment. Of course, this needs to be addressed further in larger and randomly controlled studies in different clinical settings.

Osteonecrosis of the jaw (ONJ) in patients on long-term bisphosphonate Therapy (BPT) has been reported with increasing frequency in literature over the past 4 years. Therapy for this condition is still a dilemma. Temporary suspension of BPT offers no short-term benefits; hyperbaric oxygen has no proven efficacy and therefore is not recommended. Intermittent or continuous antibiotic therapy with surgical debridement can be beneficial to palliate the symptoms. Er:YAG laser can be used to eliminate necrotic bone portions by partial or total resection as an alternative to conventional rotary devices. In our study, 91 patients affected by ONJ-BP lesion, for a total of 115 ONJ sites were observed between January 2004 and May 2008 (Department of Odontostomatology, University of Parma). Fifty-five ONJ sites were considered for this study in four different groups, retrospectively identified on the basis of treatment performed (G1-G4). G1: 13 ONJ-BP sites were treated with medical therapy (amoxicillin 1gr x 3/die per os with metronidazole 250 mg x 2/die per os) for at least 2 weeks; G2: 17 ONJ-BP sites received medical treatment in association with cycles of low-level laser therapy (LLLT) applications performed using an Nd:YAG laser (1,064 nm) once a week for 2 months; G3: 13 ONJ-BP sites were surgically treated (sequestrectomy of necrotic bone, debridement, corticotomy/surgical removal of alveolar and/or cortical bone); G4: 12 ONJ-BP sites were treated with surgical therapy performed using an Er:YAG laser (2,940 nm) in association with LLLT. Clinical success has been defined for each treatment performed as: (a) complete mucosal healing free from signs and symptoms (classified as stage "0") or (b) transition from a higher to a lower stage (Ruggiero staging) for at least 3 months. All the ONJ-BP sites treated with Er:YAG laser (G4 group) had a clinical improvement (100%) and 87.5% of sites had a complete mucosal healing with a mean follow-up of 13 months. The result obtained in the G4 is extremely significant in comparison with those obtained by medical treatment alone or in a traditional surgical approach. Thanks to the high degree of affinity of this wavelength for water and hydroxyapatite, both soft and bone tissues can be easily treated. This technique can also be used for conservative operations whereby necrotic bone is vaporized until healthy bone is reached. In addition, an additional advantage of the Er:YAG laser is its bactericidal and possible biostimulatory action, accelerating the healing of both soft tissues and bone tissues, in comparison to conventional treatments. In conclusion, from our experience, it is possible to observe that an early conservative surgical approach with Er:YAG laser associated with LLLT, for BP-induced ONJ could be considered as more efficient in comparison with medical therapy or other conventional techniques.

Objective: This case report describes the treatment of a 63-year-old patient with spontaneous osteonecrosis of the knee (SONK)., Background Data: SONK usually appears in the elderly patient without the typical risk factors for osteonecrosis. It is characterized by acute and sudden pain, mostly occurring at the medial side of the knee joint. Symptoms usually worsen with physical activity and improve with rest. Besides physical therapy, limited weight-bearing and the use of analgesics and nonsteroidal anti-inflammatory drugs, we propose low-level laser therapy (LLLT) as a conservative treatment option., Methods: LLLT was carried out using laser needles emitting radiation with wavelengths of 685 and 885 nm, and a power density of 17.8 W/cm(2). Therapy sessions lasted 60 min and were performed daily over a period of 3 mo. The total irradiation dose emitted by 8 laser needles in 60 min of treatment was 1008 J., Results: Magnetic resonance imaging revealed distinct restitution of the spongiosa edema 5 wk after treatment onset, and the final check-up at 35 wk demonstrated complete restoration of integrity., Conclusion: The present case report provides the first indication that laser-needle therapy may be a promising tool for complementary and alternative therapeutic intervention for those with SONK.

Objective: To research an efficient treatment for the management of bisphosphonate-associated osteonecrosis., Background Data: Necrosis of the jawbone has recently been described in association with systemic bisphosphonate therapy with drugs including zoledronic acid, pamidronate, and alendronate. The extent and clinical characteristics of bisphosphonate-associated osteonecrosis (BON) of the jaw are extremely variable, and range from the presence of fistulae in the oral mucosa or orofacial tissues, to large exposed areas of necrotic bone within the oral cavity. Clinical signs and symptoms commonly reported include pain, swelling, the presence of pus, loose teeth, ill-fitting dentures, and paresthesias of the inferior alveolar nerve when the necrosis affects the mandible. Fractures have also been reported. The treatment of BON of the jaw is still controversial since no therapy has proven to be efficacious as shown by the literature on the subject., Materials and Methods: In this study we report results achieved with 28 patients affected by BON of the jaw, who received treatment with the Nd:YAG laser alone or in combination with conventional medical or surgical treatment. Clinical variables such as severity of symptoms, presence of pus, and closure of mucosal flaps before and after therapy were evaluated to establish the effectiveness of laser irradiation. The 28 patients with BON were subdivided into four groups: eight patients were treated with medical therapy only (antibiotics with or without antimycotics and/or antiseptic rinses), six patients were treated with medical and surgical therapy (necrotic bone removal and bone curettage), six patients were treated with medical therapy associated with laser biostimulation, and eight patients were treated with medical therapy associated with both surgical therapy and laser biostimulation., Results: Of the 14 patients who underwent laser biostimulation, nine reported complete clinical success (no pain, symptoms of infection, or exposed bone or draining fistulas), and three improved their symptomatology only, with a follow-up of between 4 and 7 mo., Conclusions: While the results reported in this study are not conclusive, they indicate that laser therapy has potential to improve management of BON.

Bisphosphonate-associated osteonecrosis was first reported in 2003 and is getting common. Size of lesions, symptoms, and duration of time between starting bisphosphonates and the development of bone necrosis vary. There is currently no effective treatment. We describe our preliminary results with 19 patients affected by bisphosphonate-associated osteonecrosis of the jaws who were treated conventionally with surgical or medical treatment alone or in combination with neodimium: yttrium-aluminium-garnet (Nd:YAG) laser. Clinical variables such as symptoms, presence of pus, and closure of mucosal flaps before and after treatment were evaluated to establish the effect of the laser irradiation. We treated nine patients with laser biostimulation with or without surgical treatment, and in this group there were eight clinical successes and one symptomatic improvement, with a clinical finding better than ones without laser biostimulation (ten patients, five clinical successes, and one symptomatic improvement).

Skeletal localizations are a rare complication in hairy cell leukaemia patients, with an estimated incidence of 3%. These lesions, mainly osteolytic, can occur at various sites and are almost always symptomatic. Localized radiation therapy (RT) has been extensively used as effective palliative treatment in such cases, with different total doses and fractionation schedules. In this article, a systematic review of all reported cases with osseous complications is presented, to underline the role of RT and to define the most appropriate approach in this subset of patients., ((c) 2007 Wiley-Liss, Inc.)

A 62-year-old man complained of a pain in his leg four months after radical surgery for a bronchial adenocarcinoma. Skeletal scintigraphy showed increased uptake of isotope in the lower femur and upper tibia corresponding to an abnormal area on the plain radiographs. Bone metastases were thought to be the most likely cause of these findings. Since the appearances were not entirely typical, bone biopsy was undertaken to confirm the diagnosis. This showed ischaemic necrosis of bone, related to a previous acute arterial occlusion. In view of the serious implications for a patient if an erroneous diagnosis of metastatic disease is made following potentially curative treatment for cancer, such a diagnosis should be proven, not assumed. Bone biopsy should be considered when solitary skeletal lesions develop in radically treated cancer patients with no other evidence of metastasis.

In order to evaluate the clinical and radiological aspects of fresh lunate fractures, a follow-up investigation was carried out. In the past thirty-one years (1956-1986), seventeen patients were found to have fresh lunate fractures. Eleven of these cases were clinically and radiologically reexamined, with observation intervals ranging from 1.25 to 31.33 years. The authors found no radiologic evidence of lunatomalacia, osteonecrosis, or osteoarthrosis. Two cases of chip-fractures had not healed, but the bone structure was normal. Clinically, none of the patients presented with pain, muscular atrophy, or reduced power of grip. None of the patients had changed occupation as a result of the fracture.