Cic edizioni internazionali
Clinical Cases in mineral and bone metabolism

Effect on Trabecular Bone Score (TBS) of Tissue-Selective Estrogen Complex (TSEC) in early post-menopausal women: case report

Original Article, 315 - 320
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Early post-menopause is a critical period for bone metabolism.
It is well known hormonal status strongly influences skeletal health in association with other clinical risk factors. Different hormonal replacement therapies used to treat vasomotor symptoms, including classical HRT (Hormonal Replacement Therapy consisting of estrogens plus progestin for women with intact uteri), ERT (Estrogen Replacement Therapy without progesteron for women without uteri) or Tibolone, can precociously protect bone from loss of Bone Mineral Density (BMD), bone quality and vertebral and non vertebral fragility fracture risk. The Tissue-Selective Estrogen Complex (TSEC), a new pharmacological compound composed by conjugated estrogens (CE), 0.45 mg/day associated with 20 mg/day bazedoxifene (BZA) recently approved for treatment of menopausal symptoms, resulted an effective and safe therapy even in order to preserve bone. However, there are still few data about the possible effects of TSEC assumption on bone quality parameters other than serum bone turnover markers. Trabecular Bone Score (TBS) is a new direct measure of bone quality obtained from dual-energy X-ray absorptiometry (DXA) analysis. It offers an innovative parameter to add to BMD assessment a reproducible numerical evaluation of bone integrity on the basis of standard DXA. The combination of
both methods could give more information about bone health analyzing skeletal status from different aspects and help clinicians to better document the impact of pharmacological therapies. Here, we describe two clinical cases regarding two young postmenopausal women treated with TSEC and their short-term response to therapy concerning BMD and TBS score.

Sport and physical activity in patients with hereditary multiple exostoses

Original Article, 321 - 326
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Background. The purpose of this observational clinical study was to assess the type of sports and physical activities in patients with hereditary multiple exostoses (HME).
Methods. The data of 170 patients with HME, older than 12 years, were evaluated and recorded. Sport and physical activities were evaluated with the University of California at Los Angeles (UCLA) Activity score and the Tegner
Activity scale. The association of gender, number of exostoses, and physical activities were evaluated and correlated.
Results. Mean number of exostoses in our patient group (mean age 31.34 years old) resulted 39.49 ± 34.33. Mean Tegner score resulted 3.77 ± 2.78, while mean UCLA was 5.44 ± 2.61. Comparing the clinical outcomes of the male group (MG), composed of 56 patients with the female group (FG), consisting of 114 patients, we found a significant difference between Tegner, UCLA and age (p < 0.05), with no significant differences for number of exostoses (p > 0.05). In our cohort we reported a significant negative correlation between number of exostoses and Tegner score (R= -0.233, p-value= 0.002) and between UCLA score and number of exostoses (R= -0.285, p-value < 0.001).
Conclusions. HME impacts negatively on physical and sports activity of patients: in particular, the increase in the number of exostoses reduces the activity. Male patients are also more active then female as regards sports activity.

Underdiagnosis of osteoporosis in different ethnic groups when bone mineral density is measured in a single area

Original Article, 327 - 333
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The aim of the present review was to assess the difference in osteoporosis (OP) prevalence, when measuring the DXA bone mineral density (BMD) of the lumbar spine (LS) or the femoral neck (FN). To reach it, 15 reports on the simultaneous determination of both areas were reviewed, including results obtained as of the age of 50, periodically assessed every 5 to 10 years and at least up to 79 years of age. The WHO definition of osteoporosis (Tscore ≤ -2.5) was used in all studies. Results from men and women were included in six studies; only women values were reported in eight of them, and only men, in one.
Results. The prevalence of OP in women measuring only the LS rose from 12.1% in the 6th decade to 39.7% in the 8th decade, while as regards the FN, it rose from 3.0% to 30.2% among the same age groups. In all studies on the 6th and 7th decades, OP prevalence was greater in the LS compared to the FN. In the 8th decade (70-79 y.o), only in 3 out of 14 studies, prevalence was greater in the FN compared to the LS. Failure to diagnose OP when measuring only the FN was 9.1% in the 6th, 16.2% in the 7th and 9.5% in the 8th decade.
In six studies, the Authors reported not only the OP prevalence of each area but also the prevalence at any site, allowing to determine underdiagnosis when measuring only the LS or the FN. Underdiagnosis was significantly greater when measuring only the FN than when measuring only the LS. The results in women were: 6th decade: 76.4 ± 8.3% vs 11.3 ± 9.1% p<0.001; 7th decade: 65.0 ± 6.3% vs 15.9 ± 6.9% p <0.001 and 8th decade: 37.2 ± 13.1% vs 20.1 ± 5.8% p <0.02. As expected, OP prevalence in men is lower than its prevalence in women.
There is a failure to diagnose OP in men when measuring only the FN ranging from 3.2% in the 6th decade to 1.3% in the 8th. There was a great dispersion of the results, and no clear predominance from one area to the other was observed. The underdiagnosis of OP, evaluating only the FN, or the LS calculated in four studies showed no significant differences in any of the three decades reported.
Conclusion. The present review confirms that, especially in women from different ethnic groups or regions neglecting the measurement of the BMD of the LS, leads to a significant underdiagnosis of osteoporosis. This result reinforces the guidelines of the ISCD about measuring both the lumbar spine and the upper femur for a more accurate assessment of osteoporosis prevalence.

Approach in aromatase inhibitors - induced osteoporosis: results from an Italian multicenter observational study

Original Articles, 334 - 339
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Background. Breast cancer (BC) is one of the most frequent cancer worldwide with about 25% of new cases in female population. Aromatase inhibitors (AIs) are recommended by
National and International guidelines as treatment for women affected by BC estrogen receptor-positive tumors.
However, these drugs, blocking the enzyme converting androgens into estrogens, might result in reduction of bone mineral density (BMD). Although since 2012 the use of antiresorptive drugs was recommended for AIs-associated bone loss, only few patients received this treatment in real practice. Therefore, we aimed to assess the appropriateness of the management of AIs-associated bone loss by oncologists and bone specialists in BC women.
Methods. In this Italian multicenter retrospective study, we included women affected by BC referred to 11 Italian Centers for Osteoporosis from two Italian regions (Lazio and Campania) in a 2 year-period (from March 2013 to February 2015). We evaluated the difference in terms of appropriateness of bone health management according to the 2012 European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO), Position Paper between oncologists and bone specialists (endocrinologists,
physiatrists, rheumatologists, internists, geriatrists, and gynecologists).
Results. We included 300 women affected by BC, mean aged 63.26 ± 9.48 years, 182 (60.67%) treated with anastrozole, 87 (29.00%) with letrozole, and 31 (10.33%) with exemestane.
Anti-osteoporotic drugs were prescribed in 87 patients (29.0%) by oncologists and in 216 patients (72.0%) by bone specialists. We found that only 44.67% were appropriately managed in terms of bone health by the oncologists, compared to 71.17% of cases by bone specialists.
Conclusions. This Italian multicenter retrospective study showed a more appropriate management of AIs-induced osteoporosis by bone specialists, demonstrating a key role of these physicians in the bone health management of BC patients.

The clinical safety and possibility of immediate implant placement in aggressive periodontitis patients in maxillary esthetic zone: an empty systematic review

Mini-review, 340 - 344
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Purpose. To determine the clinical possibility and success of immediate implantation in aggressive periodontitis patients.
Methods. In August 2017, Pubmed, Cochrane central database, web of sciences, Lilacs and hand search were searched with no restrictions for language, publication date or follow-up period. All types of prospective studies reporting the prognosis of immediate implant placement were included. Outcomes were implant survival rate, complications during placement and postoperatively and marginal bone loss around implants.
Results. After screening of the titles, abstracts and full text of the reported studies, none of those met the a priori inclusion criteria.
Conclusion. There was no sufficient evidence regarding the survival rate of immediately placed dental implants in aggressive periodontitis. Long-term prospective double armed clinical studies are recommended.

Bilateral atypical femoral fractures in macroprolactinoma with hypopituitarism: a case report

Case report, 345 - 347
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Several case series have indicated that atypical femoral fractures (AFF) are associated with prolonged used of anti-resorptive agents. However, very few reports have demonstrated relationship between AFF and other osteoporosis-related conditions. We report a 63-year-old man with an unremarkable past medical history who suffered bilateral AFFs. He was never exposed to any antiresorptive therapy. Prolactin-producing pituitary adenoma
was diagnosed from very high serum prolactin level and a pituitary macroadenoma from MRI findings. Other pituitary functions revealed hypopituitarism (growth hormone deficiency, hypogonadotropic hypogonadism, central hypothyroidism and secondary adrenal insufficiency).
His bone mineral density showed osteoporosis by a dual-energy X-ray absorptiometry. The osteoporosis was considered to be secondary from growth hormone deficiency and hyperprolactinemia-induced hypogonadism. Interestingly, the measurement of bone
markers revealed suppressed bone resorption. To our knowledge, this is the first report of bilateral AFFs in a male patient who was diagnosed with osteoporosis from macroprolactinoma and hypopituitarism. This highlights that other factors, besides the use of anti-resorptive agents, can be related to AFF. Suppression of bone resorption markers in such conditions might be one of the main contributing factors.

Spinal deformities in neurofibromatosis type 1

Mini-review, 348 - 352
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Neurofibromatosis type 1 (NF-1) is a multisystemic, autosomal genetic disorder of neural crest origin. It is characterized by extremity deformities such as congenital anterolateral bowing and pseudarthrosis of tibia, fibula and forearm, as well as hemihypertrophy. Spine deformities in NF-1 including scoliosis, kyphosis and atlantoaxial instability can be present in 2-36% of the patients. Scoliosis is the most common musculoskeletal manifestation.
This review article presents the most common spine deformities in NF-1, and discusses the classification, imaging, treatments and complications of these deformities.

Treatment of osteoarthritis: focus on glucosamine

Mini-review, 353 - 357
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Osteoarthritis (OA) is a common, degenerative disorder responsible for a high proportion of disability among the aging population. Progressing over many years, the management of OA requires multiple, successive treatment modalities. While there are many different treatments available to manage the symptoms of OA, few demonstrate reliable evidence for the long-term management of OA, and are without safety concerns. A long-term goal of OA management is to prevent or delay development of the disease with agents that have a disease-modifying effect. Symptomatic slow-acting drugs for OA (SYSADOAs) are a diverse group of medications that induce a symptomatic effect with slow onset of action, and in some cases, may induce a joint structure modifying effect in the
long term. Among the SYSADOAs, the evidence is greatest for prescription-grade patented crystalline glucosamine sulfate (pCGS), which has demonstrated efficacy in control of OA pain, increase in physical function, and delay in joint structure changes in the long term.

Refractory hypercalcemia after idiopathic rhabdomyolysis

Case report, 358 - 363
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A 56-year-old female patient presented an episode of severe idiopathic rhabdomyolysis complicated with acute kidney injury during which a transitory drop in corrected serum calcium was documented. After resolution, the patient was discharged from hospital and returned forty seven days later complaining of weakness and limited ambulation. On examination, symmetric proximal upper and lower limb weakness was found. Blood analysis revealed corrected serum calcium of 15.8 mg/dl prompting immediate medical treatment. Our initial approach ruled out most common etiologies of hypercalcemia and considering the previous episode of rhabdomyolysis, a bone scintigraphy scan with alendronate (99mTc-ABP) and a SPECT-CT were performed, revealing abnormal deposition of radiotracer over affected muscle groups.
Serum calcium kept increasing to critical levels despite initial maneuvers, requiring multiple hemodialysis sessions over a period of sixty four days, after which normal serum calcium levels were eventually achieved.
Control bone scan showed clearance of abnormal deposits and the patient was discharged showing no recurrence of symptoms. A biphasic calcium response occurs in a small number of cases following an episode of rhabdomyolysis and acute kidney injury. Duration of the hypercalcemic phase may be variable, and treatment should be supportive until safe levels are maintained.

Severe scoliosis in a Colombian patient with childhood hypophosphatasia

Case report, 364 - 367
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Hypophosphatasia (HPP) is a rare inherited disorder of bone and mineral metabolism. In this report, we describe the clinical manifestations and the molecular analysis of a Colombian patient with childhood HPP. In this patient, a homozygous c.892G>A (p.E298K) mutation was detected in the ALPL gene. At 7 years of age, the right thoracic curve measured 30°, which progressed to 40° by the age of 9 years. To our knowledge, only few cases of scoliosis have been reported in HPP. Given this association, we suggest to consider the diagnosis of HPP in all patients with idiopathic infantile scoliosis of rapid progression.

Teriparatide in cervical fracture consolidation

Case report, 368 - 370
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The occurrence of high cervical (C1-C2) fractures in the elderly has high rates of morbidity and mortality. Propo - sed treatments include both surgical fixation and conservative treatment. The first has a high mortality rate (up to 45%) and the second is ineffective in up to 78% of cases in fracture consolidation. In non-consolidated fractures, there is an indication of surgical fixation or prolonged rigid external immobilization, which, regardless of the choice of treatment, brings risk, discomfort and low quality of life to the patient. Our report shows the case of a woman of 80 years, treated with osteoanabolic medication (teriparatide) for 12 weeks, obtaining full consolidation and symptom resolution. There are several experimental and clinical studies suggesting a potential role of
Teriparatide in the consolidation of fractures. Our report suggests that this medication may play an important role in the conservative consolidation of high cervical fractures in the elderly.

Incidental finding of osteopetrosis complicated with osteomyelitis

Case report, 371 - 374
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Osteopetrosis is a sporadic hereditary bone disorder showing variable clinical features and is characterized by an increase in bone density and reduction of marrow spaces that result from a defect in the function of osteoclasts and, consequently, a decrease in bone turnover. This disease is usually divided into three categories: severe infantile malignant autosomal recessive, intermediate mild autosomal recessive, and benign autosomal dominant. The prognosis of the first two types of osteopetrosis is poor and it is characterized by an early onset, mostly within the first decade of life, and early death. The benign-type is characterized by a later onset usually in adulthood and a longer life span. Ten percent of osteopetrosis cases develops osteomyelitis and is commonly caused by tooth extraction or pulpal necrosis.
The reported case is incidental finding of intermediate recessive osteopetrosis complicated by chronic osteomyelitis.

Hungry bone syndrome presenting as pathological fracture in a young boy

Case report, 375 - 380
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Hungry bone syndrome is a profound and prolonged hypocalcemia which follows parathyroidectomy. Radiological evidence of hyperparathyroidism is a known risk factor. It is more commonly reported in females with Indian studies showing higher incidence in age less than 45 as compared to 5th and 6th decade in the developed nations. We report a case of hungry bone syndrome presenting as pathological fracture of both femur following surgical removal of hyperfunctioning parathyroid adenoma in a young Indian boy of 13 years. Serological studies showed serum calcium as low as 6.09 mg/dl and DEXA score -4.2. Following diagnosis, high dose calcium supplementation was given which improved serum calcium levels over 3 months with radiological evidence of bone remineralisation and healing. We bring to notice the importance of timely recognition of this uncommon but serious adverse effect of parathyroidectomy and need for stringent treatment with calcium to prevent further bone loss and promote bone healing.

Rare multifocal eosinophilic granuloma involving maxilla and mandible. A case report

Case report, 381 - 384
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One of the clinical forms of Langerhans cell histiocytosis (LCH) is eosinophilic granuloma which has more predilection in children and young adults. The reported case is of eosinophilic granuloma in a 25-year-old male involving anterior mandible and posterior maxilla and appearing as destructive lesions involving gingiva and alveolar bone. EG should be considered as a differential diagnosis whenever there is a bony destructive lesion involving alveolar bone of the Jaws. Early diagnosis and surgical intervention will resolve the lesion.

Teriparatide treatment for an atypical femoral fracture in a patient with calcinosis cutis associated with juvenile
dermatomyositis: a case report

Case report, 385 - 388
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Calcinosis cutis is a late and an unresolved complication of juvenile dermatomyositis. It sometimes causes significant debility with severe pain, joint contracture, skin ulcers. There are several reports that bisphosphonates therapy may affect calcinosis cutis. However longterm use of bisphosphonates is associated with an increased risk of an atypical femoral fracture. We present a case of atypical femoral fracture in a 27-year-old male due to long-term bisphosphonate therapy and adjunctive denosumab for calcinosis cutis associated with juvenile dermatomyositis. To our knowledge, there were no other reports of atypical femoral fractures with calcinosis cutis associated with juvenile dermatomyositis. Our patient was treated with surgery and teriparatide although two case reports documenting the worsening of calcinosis cutis with teriparatide exist. Short-term teriparatide use did not worsen the calcinosis cutis in terms of clinical symptoms and radiological signs, and the atypical femoral fracture healed; however, an increase in bone alkaline phosphatase and tartrate-resistant acid phosphatase 5b was detected.

Surgical approach to rare case of recurrent pheochromocytoma and bones metastatic paraganglioma

Case report, 389 - 393
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Background. Paraganglioma/Pheochromocytoma (PGL/PCC) are neuroendocrine tumors characterized by association of paraganglioma and pheochromocytoma.
PGLPCC are caused by mutations in a series of genes involved in cell metabolism. These genetic conditions can be both sporadics or less frequently hereditaries, usually diagnosed in younger patients. PCC-PGL incidence is about 1 in 300,000. PGL type 4 represents 5% of all PCC-PGL, it’s related to SDHB mutations and has higher risk for malignancy than the other types. Malignancy is defined by presence of metastases that arise in sites devoid of chromaffin tissue such as bone. Malignant PGLs are extremely rare.
Case presentation. The patient is a 37-year-old-female affected by paraganglioma in left paravertebral region and pheochromocytoma in the left adrenal gland (PPGL type 4). Pheocromocytoma was suspected after sporadic episode of hypertensive crisis and in 2012 a diagnosis was obtained. Genetic analysis were performed and showed mutation of SDHB gene. The patient underwent a left adrenalectomy to remove left pheochromocytoma.
In October 2016 laboratory tests and instrumental exams showed recurrence of pheochromocytoma in left adrenal loggia, a metastases involving D10 and other small osteolytic areas spread in vertebral column and other bones.
Meantime the patient complained lumbar and intercostal pain, blood pressure was always in normal range. A surgical intervention of nerve decompression was needed urgently. Our intervention consisted in metastasis excision with apposition of bone cement and stabilization of column through polyaxial pedicle screw and bar.
Outcomes. After surgery the patient showed improvement of symptoms, after two months was reported a regression of pain.
Discussion. Our case report is a rare example of malignant PGLPCC with pheochromocytoma recurrence and paraganglioma metastatic lesions spread in bones (specially in vertebral column) and other organs whereas PGL4 is generally benignant. Few are similar cases described
in literature. In particular our report is exceptional for the multiples metastatic lesions spread in bones like sternum, right femurs, iliac wings and vertebras.
This case confirmed that the surgery plays a significant role in the management of malignant PGLPCC. Our case remarks the need to carefully follow this kind of patients after diagnosis both to identify recurrence and/or secondary localizations of disease. Strict control of a set of markers in the blood flow is cost-effective and primary.
Our case confirm the need, in these rare cases, to perform MIBG scintigraphy and PET total body in addition to standard imaging techniques to improve our ability to recognize recurrences when suspected. We recommend a multidisciplinar approach to ensure rapid recognition of disease and to choose the most appropriate treatment. For this reason it is demanding to report these cases to better understand this rare disease and all its multiple forms.

Mazabraud’s syndrome: a case report

Case report, 394 - 396
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Fibrous dysplasia of bone (FD) is a benign bone disease, rare, not hereditary, and characterized by an abnormal proliferation of fibroblasts and deficient differentiation of osteoblasts, leading to the replacement of trabecular
bone tissue by fibrous connective tissue. In some cases, the bone lesions are presented together with various extra-skeletal manifestations constituting specific syndromes.
Mazabraud’s syndrome represents the infrequent combination of one or more intramuscular myxomas and fibrous dysplasia. The acknowledgment would make it possible to differentiate myxomas, which are benign tumors, from malignant mesenchymal tumors with myxoid material, and in this way reduce the need for unnecessary biopsies and/or surgeries.

A case of hypercalcemic parathyroid crisis in a patient with normocalcemic hyperparathyroidism

Case report, 397 - 399
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We present a man with normocalcemic primary hyperparathyroidism who developed hypercalcemic parathyroid crisis following years of normal blood calcium levels. The patient was a 59-year-old male with a history of recurrent nephrolithiasis. Initial PTH was 70 ng/L (13-54) with serum calcium of 2.44 mmol/L (2.1-2.5), albumin 39 g/L, and phosphate 0.70 mmol/L (0.8-1.5). Many repeat serum total calcium levels were normal. 24-hour urine calcium was within normal limits at 6.82 mmol/day. He was followed with regular
monitoring of serum calcium and PTH, and remained asymptomatic and normocalcemic for 8 years until he suddenly presented feeling unwell and was found to have a serum calcium of 4.05 mmol/L and PTH of 585 ng/L. He was referred to hospital and treated with intravenous fluids and pamidronate. Sestamibi scan revealed a large MIBI-avid soft tissue nodule, highly suspicious for a parathyroid adenoma. Six weeks later, he underwent right unilateral parathyroidectomy. Pathology demonstrated a 2.2x 2.0 x2.1 cm benign parathyroid adenoma. Postoperatively he has remained normocalcemic with normal PTH.
Normocalcemic primary hyperparathyroidism is not clearly associated with adverse clinical outcomes and longitudinal studies suggest it rarely progresses to overt hypercalcemia.
This is the first case of normocalcemic primary hyperparathyroidism that evolved to hypercalcemic crisis.
We postulate an infarct of the large parathyroid adenoma resulting in sudden marked increase in PTH secretion. Normocalcemic hyperparathyroidism may not have a benign course if associated with a large parathyroid adenoma. Progression to severe hypercalcemia may occur suddenly in rare cases.

A Platelet Rich Plasma (PRP) and bovine xenograft combination placed in a jaw bone defect after surgical removal of a compound odontoma associated with an impacted lower canine using piezoelectric surgery: a case report

Case report, 400 - 406
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Odontomas are nonaggressive, hamartomatous developmental malformations or lesions of odontogenic origin appearing as small, solitary, or multiple radiopaque lesions found on routine radiographic examinations.
These lesions are often associated with impacted permanent teeth and their surgical management represents the most common therapeutic modality.
The present case report describes a minimally invasive surgical procedure to remove a compound odontoma localized in the anterior mandibular area associated with an impacted permanent mandibular canine and supernumerary
tooth. We are preserving the deciduous canine using piezoelectric surgery, then filling the bony defect with particulate bovine xenograft mixed with autologous PRP. The related literature is also being reviewed in this article.

Pharmacological therapy of sarcopenia: past, present and future

Mini-review, 407 - 415
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Sarcopenia, defined as the loss of muscle mass and function, has important consequences in terms of increasing frailty, disability, and social and healthcare costs. The diagnosis of sarcopenia should be considered in all patients presenting a decline in physical function, muscle strength and general health conditions.
Given that the progressive reduction of muscle mass and strength occurs also in aging, the switch towards a pathological condition has been established by combining diagnostic cut-offs and risk factors for reduced mobility, poor quality of life, and increased morbidity and mortality.
On the other hand, the introduction of different criteria for the diagnosis of sarcopenia has hindered the development of guidelines for the management of this disorder.
The objective of the treatment of muscle wasting is to maintain or improve muscle mass, and both mechanical and metabolic muscle functions.
The management of sarcopenia should be multifactorial and interdisciplinary, including exercise, particularly muscle strengthening training, intake of proteins and vitamin D, and treatment of diseases causing muscle loss.
To date there are no drugs that have been specifically approved for the treatment of sarcopenia (or other conditions causing reduced muscle function) although many substances are commonly used for this purpose.
Several drugs have been studied to improve muscle mass and function, such as testosterone, estrogens, selective modulators of the androgen receptor (SARMs), ghrelin, anti-cytokines (IL-1, IL-6,TNF-α), and myostatin inhibitors. Identification of novel molecules targeting specific biological pathways whose stimulation or inhibition produces net anabolic effects on skeletal muscle might be a significant step forward for the treatment of muscle disorders.

Revision surgery for acetabular nonunion: role and challenges to preservation of hip joint

Original Article, 416 - 422
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Introduction. The non-union of the acetabulum is a very frequent complication in the Letournel classified associated fractures which involve mainly the posterior column.
Both the diagnosis and the treatment are very difficult. In this short work we are presenting the revisitation of our case histories of 21 acetabular nonunions.
Material. The study population is divided in 13 males and 8 females with an average age of 47.6 years (range 22-75).
The diagnosis of nonunion was made at about 5.2 months (3-6) after surgery. In 16 cases the nonunion was due to the conservative treatment and in 5 cases to surgery. All of then were Letournel classified associated fractures. All patients underwent revision surgery with plates and screws and implant of allogenic bone splints and autogenic morcelized bone taken from the iliac crest, after about 2.3 weeks (1-3) from the diagnosis of acetabular nonunions. The chosen criteria for patient assessment, during clinical and radiological follow-ups were: quality of life measured with the Short Form (12) Health Survey (SF-12), the functionality of the hip and quality of life measured with the Harris Hip Score (HHS) and by the Majeed Score (MJ), bone healing and post surgery complications.
Results. All patients showed a relative increase of the SF-12, HHS, MJ scores after revision surgery. On average, all patients manifested heterotopic ossification and hip arthrosis within 24 months after revision surgery. All patients within 24 months from the revision surgery received total hip prosthesis. Only 1 patient manifested an infection after the PTA.
Conclusion. The acetabular nonunions, although rare, represent a devastating complication for the patient’s quality of life and the revision surgery. Revision surgery, unfortunately, does not offer great satisfaction in the functional recovery and long-term quality of life, but has to allow an anatomic dignity of the acetabulum and a subsequent prosthetization in safety of these patients.

Reliability and value of external modular fixation (Hoffmann II®) in the management of humeral shaft fracture

Original Article, 423 - 427
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Introduction. Many studies have reported conflicting results regarding external fixation for displaced proximal humeral fractures. The aim of this study is to evaluate the outcome of humeral shaft fractures treated with external fixation which, in our opinion, can be considered a valid method not only in emergency but also for the definitive management.
Methods. A total of 37 patients aged 21-82 years with proximal humeral shaft fractures, classified according to AO classification were treated with External Fixator Hoffman II from January 2011 to January 2014 with a mean follow-up of 11.5 months. For the clinical evaluation the Constant Shoulder Score was used.
Results. 75.7% of patients reported excellent results and satisfaction after this type of surgery.
Conclusion. From the results of our study it is concluded that the treatment of humeral shaft fractures with external fixators provide similar results as those of other techniques. The technique is simple, has a short learning curve and is associated with minimal complications because of its minimal invasive nature.

Vol. XV (No. 3) 2018 September - December

  1. From the Editor-in-Chief
    Brandi M.L.
  2. Effect on Trabecular Bone Score (TBS) of Tissue-Selective Estrogen Complex (TSEC) in early post-menopausal women: case report
    Lello S., Capozzi A., Scambia G.
  3. Sport and physical activity in patients with hereditary multiple exostoses
    D'Ambrosi R., Caldarini C., Massari G., Facchini R.M., Ragone V.
  4. Underdiagnosis of osteoporosis in different ethnic groups when bone mineral density is measured in a single area
    Mastaglia S.R., Bagur A., Mautalen C.A.
  5. Approach in aromatase inhibitors - induced osteoporosis: results from an Italian multicenter observational study
    Migliaccio S., de Sire A., Marocci C., Fornari R., Paoletta M., Greco E.A., Amar I.D., Moretti A., Ronzoni S., Gimigliano F., Vinicola V., Chiacchiararelli F., Guadalascara F., Pastore R., Falaschi P., Minisola G., Falla O., Castellitto D., Lenzi A., Villa P., Iolascon G.
  6. The clinical safety and possibility of immediate implant placement in aggressive periodontitis patients in maxillary esthetic zone: an empty systematic review
    Yussif N.M., Rahman A.R.A., Darhous M.
  7. Bilateral atypical femoral fractures in macroprolactinoma with hypopituitarism: a case report
    Charoensri S., Pongchaiyakul C.
  8. Spinal deformities in neurofibromatosis type 1
    Lykissas M.G., Mavrogenis A.F., Megaloikonomos P.D., Gelalis I.D., Lykomitros V.
  9. Treatment of osteoarthritis: focus on glucosamine
    Rovati L.C.
  10. Refractory hypercalcemia after idiopathic rhabdomyolysis
    Rodríguez-Quintero J.H., Ramos-Pineda A., Salas-Villela R., Gotés-Palazuelos J.
  11. Severe scoliosis in a Colombian patient with childhood hypophosphatasia
    Zarante Bahamón A.M.
  12. Teriparatide in cervical fracture consolidation
    Cordeiro Albino C., Porcelli Savarani C., Aguiar Moreira C.
  13. Incidental finding of osteopetrosis complicated with osteomyelitis
    Ibrahim A.K., Sansare K., Karjodkar F.R:
  14. Hungry bone syndrome presenting as pathological fracture in a young boy
    Chandra A., Hussain Z., Prasad Assat R., Chandra Meena R.
  15. Rare multifocal eosinophilic granuloma involving maxilla and mandible. A case report
    Shawky Shaker I., Salah Mohamed N.
  16. Teriparatide treatment for an atypical femoral fracture in a patient with calcinosis cutis associated with juvenile dermatomyositis: a case report
    Yoshitani J., Kabata T., Yamamoto N., Shimizu M., Kajino Y, Takagi T., Ohmori T., Ueno T., Tsuchiya H.
  17. Surgical approach to rare case of recurrent pheochromocytoma and bones metastatic paraganglioma
    Cosseddu F., Sacchetti F., Shytaj S., Grossi S., Citarelli C., De Gori M., D'Arienzo A., Capanna R.
  18. Mazabraud’s syndrome: a case report
    Ramírez Stieben R. S., Lifton S.
  19. A case of hypercalcemic parathyroid crisis in a patient with normocalcemic hyperparathyroidism
    Lithgow K., Pasieka J., Kline G.
  20. A Platelet Rich Plasma (PRP) and bovine xenograft combination placed in a jaw bone defect after surgical removal of a compound odontoma associated with an impacted lower canine using piezoelectric surgery: a case report
    Ayoub Al-Delayme R.M.
  21. Pharmacological therapy of sarcopenia: past, present and future
    Iolascon G., Moretti A., de Sire A., Liguori S., Toro G., Gimigliano F.
  22. Revision surgery for acetabular nonunion: role and challenges to preservation of hip joint
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