Multidisciplinary management of pyogenic spondylodiscitis: epidemiological and clinical features, prognostic factors and long-term outcomes in 207 patients

PURPOSE

Pyogenic spondylodiscitis (PS) is a potentially life-threatening infection burdened by high morbidity rates. Despite the rising incidence, the proper management of PS is still controversial. Aim of this study was to describe the clinical features of PS and to evaluate the prognostic factors and the long-term outcomes of a large population of patients.

METHODS

207 cases of PS treated from 2008 to 2016 with a 2-year follow-up were enrolled. Clinical data from each patient were recorded. The primary outcome was the rate of healing without residual disability. Secondary outcomes included length of stay, healing from infection, death, relapse, and residual disability. Binomial logistic regression and multivariate analysis were used to evaluate prognostic factors.

RESULTS

Median diagnostic delay was 30 days and the rate of onset neurological impairment was 23.6%. Microbiological diagnosis was established in 155 patients (74.3%) and the median duration of total antibiotic therapy was 148 days. Orthopedic treatment was conservative for 124 patients and surgical in 47 cases. Complete healing without disability was achieved in 142 patients (77.6%). Statistically confirmed negative prognostic factors were: negative microbiological culture, neurologic impairment at diagnosis and underlying endocarditis (p ≤ 0.05). Healing from infection rate was 90.9%, while residual disabilities occurred in 23.5%. Observed mortality rate was 7.8%.

CONCLUSION

The microbiological diagnosis is the main predictive factor for successful treatment. Early diagnosis and multidisciplinary management are also needed to identify underlying aggressive conditions and to avoid neurological complications associated with poorer long-term outcomes. Despite high healing rates, PS may lead to major disabilities still representing a difficult challenge. These slides can be retrieved under Electronic Supplementary material.

New classification for the treatment of pyogenic spondylodiscitis: validation study on a population of 250 patients with a follow-up of 2 years

PURPOSE

Pyogenic spondylodiscitis (PS) is still burdened by a high rate of orthopedic and neurological complications. Despite the rising incidence, the choice of a proper orthopedic treatment is often delayed by the lack of clinical data. The aim of this study was to propose a clinical-radiological classification of pyogenic spondylodiscitis to define a standard treatment algorithm.

METHODS

Based on data from 250 patients treated from 2008 to 2015, a clinical-radiological classification of pyogenic spondylodiscitis was developed. According to primary classification criteria (bone destruction or segmental instability, epidural abscesses and neurological impairment), three main classes were identified. Subclasses were defined according to secondary criteria. PS without segmental instability or neurological impairment was treated conservatively. When significant bone loss or neurological impairment occurred, surgical stabilization and/or decompression were performed. All patients underwent clinical and radiological 2-year follow-up.

RESULTS

Type A PS occurred in 84 patients, while 46 cases were classified as type B and 120 as type C. Average time of hospitalization was 51.94 days and overall healing rate was 92.80%. 140 patients (56.00%) were treated conservatively with average time of immobilization of 218.17 ± 9.89 days. Both VAS and SF-12 scores improved across time points in all classes. Residual chronic back pain occurred in 27 patients (10.80%). Overall observed mortality was 4.80%.

CONCLUSIONS

Standardized treatment of PS is highly recommended to ensure patients a good quality of life. The proposed scheme includes all available orthopedic treatments and helps spine surgeons to significantly reduce complications and costs and to avoid overtreatment.

Clinical factors associated with an increased risk of perioperative blood transfusion in nonanemic patients undergoing total hip arthroplasty

BACKGROUND

The aim of this study was to identify clinical factors associated with an increased need for perioperative blood transfusion in nonanemic patients undergoing total hip arthroplasty.

METHODS

We evaluated eighty-five consecutive nonanemic patients who underwent elective, unilateral, cementless, primary total hip arthroplasty and met our inclusion criteria. We attempted to determine whether clinical parameters influencing perioperative blood loss, such as age, gender, hypertension, and body mass index, were also associated with the need for perioperative blood transfusion.

RESULTS

Perioperative blood transfusion was required in twenty-four (28%) of the eighty-five nonanemic patients. When considered alone, age, gender, hypertension, and body mass index were not significantly associated with an increased risk of perioperative blood transfusion, on the basis of the numbers available. In contrast, there was a significantly increased risk of blood transfusion when two or more of these clinical parameters were present (p = 0.02).

CONCLUSIONS

Our findings indicate that clinical variables such as age, gender, hypertension, and body mass index may have a synergistic effect on the risk of transfusion in patients undergoing elective total hip arthroplasty. The simultaneous analysis of these parameters might help to stratify patients with different risks for transfusion and may increase the efficiency and reduce the cost of blood-ordering practices associated with total hip arthroplasty.

LEVEL OF EVIDENCE

Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Interleukin-6 gene polymorphism and risk of osteoarthritis of the hip: a case-control study

OBJECTIVES

Osteoarthritis (OA) is considered a polygenic disease controlled by the expression of genetic factors. Genes encoding for cytokines have been associated with susceptibility for joint OA and interleukin (IL)-6 gene is also supposed to be involved in the cartilage degradation process. In this case-control study, we evaluated for the first time whether the risk of hip OA might be influenced by the -174 IL-6 gene polymorphism.

METHODS

The distribution of IL-6 genotypes was evaluated in 75 patients affected by hip OA and in 107 age- and sex-matched controls.

RESULTS

The distribution of IL-6 genotypes in (1) patients with hip OA: 33 GG, 30 GC, 12 CC and (2) control subjects: 34 GG, 40 GC, 33 CC. The frequency of the CC genotype was significantly higher in control patients (P=0.02). Logistic regression analysis indicated that the presence of the CC genotype is independently associated with a decreased risk of OA (odds ratio 0.4 [95% confidence interval 0.1-0.9], P=0.04).

CONCLUSIONS

Primary OA of the hip has an important genetic component and variations of genes encoding for inflammatory cytokines, such as IL-6, may play an important role in the series of events responsible for the pathophysiology of OA.

Efficient bone formation by gene transfer of human LIM mineralization protein-3

LIM mineralization protein (LMP) is a novel positive regulator of the osteoblast differentiation program. In humans, three different LMP splice variants have been identified: LMP-1, LMP-2, and LMP-3. Gene transfer of human LMP-1 (hLMP-1) induces expression of genes involved in bone formation, including certain bone morphogenetic proteins (BMPs), promotes bone nodule formation in vitro, ectopic bone formation in vivo, and is therapeutic in animal models of posterior thoracic and lumbar spine fusion. To examine the osteoinductive properties of the LMP-3 in vitro and in vivo, we have generated plasmid and adenoviral vectors expressing codon-optimized hLMP-3. Here we demonstrate that gene transfer of hLMP-3 induces expression of the bone-specific genes osteocalcin, osteopontin, and bone sialoprotein and induced bone mineralization in preosteoblastic and fibroblastic cells. We also demonstrate that hLMP-3 is able to induce bone mineralization and the expression of the bone-specific genes, BMP-2, OSX, RunX2, and alkaline phosphatase in human mesenchymal stem cells in a dose-dependent manner. Finally, we demonstrate that direct gene transfer of hLMP-3 into murine skeletal muscle results in ectopic bone formation more efficiently than BMP-2. These results demonstrate that hLMP-3 gene transfer can be used to promote bone formation in cell culture and in vivo as or more efficiently than BMP-2, thus establishing feasibility and efficacy of direct gene delivery of hLMP-3 to produce bone in vivo. These results suggest that gene transfer of hLMP-3 could be developed as a bone-inductive therapeutic agent for clinical applications.

Onset of Berger disease after Staphylococcus aureus infection: septic arthritis after anterior cruciate ligament reconstruction

Septic arthritis is rare in patients undergoing knee arthroscopic surgery. If the infection is due to Staphylococcus aureus, patients might experience fever, severe clinical syndromes, and extra-articular manifestations, including vasculitis and glomerulonephritis. We describe a case of onset of immunoglobulin A nephropathy (Berger disease) after S aureus septic arthritis complicating an anterior cruciate ligament surgical reconstruction. The patient had no previous history of renal disease, and renal function returned to normal after resolution of the knee infection. S aureus infection has been associated with several glomerular diseases, but this is the first report of the infection causing immunoglobulin A nephropathy. In addition, this is the first description of Berger disease after arthroscopic treatment, providing evidence that this disease might complicate the clinical course of orthopedic surgery.

Deep venous thrombosis and pulmonary embolism after knee arthroscopy in athletes carrying the thrombophilic factor lupus anticoagulant

In patients undergoing arthroscopic knee surgery, deep venous thrombosis and pulmonary embolism are rare and there is not clear indication as to the necessity of thromboprophylactic treatment in these patients. However, the role of coagulation disorders in thrombotic events following arthroscopy is unknown. We report 2 cases of massive deep venous thrombosis and pulmonary embolism after knee arthroscopy in athletes carrying the thrombophilic factor lupus anticoagulant, but with no personal or familial history of thrombotic diseases. A few days after the arthroscopic intervention, both patients presented with deep venous thrombosis and 1 developed a severe pulmonary embolism. Blood examination showed that both athletes were lupus anticoagulant-positive. This is the first description of an association between venous thromboembolism, knee arthroscopy, and a prothrombotic condition. This report suggests that screening for hypercoagulability might be useful in athletes undergoing even minimally invasive orthopaedic surgery and that in cases of venous thromboembolism after knee arthroscopy, a prothrombotic disorder should be suspected.

Angiotensin-converting enzyme gene polymorphism may influence blood loss in a geriatric population undergoing total hip arthroplasty

OBJECTIVES

To evaluate how angiotensin-converting enzyme (ACE) gene polymorphism is associated with perioperative blood loss in hip arthroplasty in a geriatric population.

DESIGN

A case-control study of subjects consecutively undergoing total hip arthroplasty.

SETTING

A department of orthopedic surgery in Italy.

PARTICIPANTS

One hundred five patients, mean age +/- standard deviation 68.6 +/- 10.4, undergoing total hip arthroplasty.

MEASUREMENTS

ACE gene polymorphism was analyzed using polymerase chain reaction. Decrement of hemoglobin (Hb) and hematocrit (Ht) was calculated as the difference between the preoperative and the lowest postoperative value, measured 1, 2, and 3 days after surgery. Total blood loss was calculated as the sum of intra- and postoperative blood loss.

RESULTS

Patients carrying the deletion homozygous and insertion/deletion heterozygous genotypes of the ACE gene show a higher decrement of Hb (P <.01) and Ht (P <.01) and higher total blood loss (P <.007) after hip surgery than subjects carrying the insertion (II) homozygous. The role of ACE gene polymorphism seems hypertension independent. Logistic regression analysis showed that II genotype reduces total blood loss.

CONCLUSIONS

This is the largest study evaluating the distribution of ACE gene genotypes in patients undergoing hip arthroplasty and the first investigating the association between bleeding and ACE gene polymorphism. Our data suggest that II genotype is associated with lower total blood loss.

Teriparatide anabolic therapy as potential treatment of type II dens non-union fractures

Odontoid fractures account for 5% to 15% of all cervical spine injuries and 1% to 2% of all spine fractures. Type II fractures are the most common fracture pattern in elderly patients. Treatment (rigid and non-rigid immobilization, anterior screw fixation of the odontoid and posterior C1-C2 fusion) remains controversial and represents a unique challenge for the treating surgeon. The aims of treatment in the elderly is to quickly restore pre-injury function while decreasing morbidity and mortality associated with inactivity, immobilization with rigid collar and prolonged hospitalization. Conservative treatment of type II odontoid fractures is associated with relatively high rates of non-union and in a few cases delayed instability. Options for treatment of symptomatic non-unions include surgical fixation or prolonged rigid immobilization. In this report we present the case of a 73-year-old woman with post-traumatic odontoid non-union successfully treated with Teriparatide systemic anabolic therapy. Complete fusion and resolution of the symptoms was achieved 12 wk after the onset of the treatment. Several animal and clinical studies have confirmed the potential role of Teriparatide in enhancing fracture healing. Our case suggests that Teriparatide may have a role in improving fusion rates of C2 fractures in elderly patients.

Bioplasty for vertebral fractures: preliminary results of a pre-clinical study on goats using autologous modified skin fibroblasts

The debate is still ongoing about the long term effects of the mininvasive vertebral augmentation techniques and their usefulness in treating more complex cases where a bone inducing effect more than a merely bone substitution would be suitable, such as the vertebral fractures in young patients. We previously developed a clinically relevant gene therapy approach using modified dermal fibroblasts for inducing bone healing and bone formation in different animal models. The aim of this study is to show the feasibility of a minimally invasive percutaneous intrasomatic ex vivo gene therapy approach to treat thoracolumbar vertebral fractures and anterior column bone defects in a goat model.

Minimally invasive surgery for the treatment of thoraco lumbar pyogenic spondylodiscitis: indications and outcomes

OBJECTIVE

Pyogenic spondylodiscitis (PS) is a non-specific infection affecting intervertebral disks and adjacent vertebral bodies. Once considered a rare condition in developed countries, the incidence of PS has been increasing alarmingly and still represents a challenge for clinicians and orthopedic surgeons. New minimally invasive techniques have been proposed but the proper indications for these different approaches remain controversial. The aim of this study was to describe the available minimally invasive surgical techniques and to evaluate their proper indications through a review of recent literature.

MATERIALS AND METHODS

Over 30 articles of recent scientific literature have been reviewed and analyzed. Studies were searched through the PubMed database using the key words: spondylodiscitis, minimally invasive, and surgical treatment. The most interesting and valid techniques and results have been reported. Despite the exclusion of case reports, all the available studies have been conducted on small groups of patients. Indications for each technique have been reported according to a clinical-radiological classification of PS.

RESULTS

Six of the most widely used minimally invasive surgical techniques have been described.  High success rates have been reported in terms of preventing the progression of spondylodiscitis into more destructive forms, reduction of time and operative hospitalization, faster pain relief, early mobilization, and achievement of microbiological diagnosis.

CONCLUSIONS

The role of minimally invasive surgery in the treatment of PS is rapidly expanding. Reducing surgery-related morbidity in these frail patients is possible and often necessary. However, while more and more new techniques are being proposed, still few clinical data are available. Clinical comparison studies with open traditional surgery should be encouraged, and more attention should be paid to long-term outcomes. For the present, the indications for minimally invasive procedures should, therefore, be evaluated on a case by case basis and on clinical and radiological findings.

10-Year Clinical, Functional, and X-ray Follow-Up Evaluation of a Novel Posterior Percutaneous Screw-Rod Instrumentation Technique for Single-Level Pyogenic Spondylodiscitis

Medical treatment with antibiotic therapy remains the mainstay of treatment for pyogenic spondylodiscitis (PS). Nevertheless, orthopaedic treatment is also very important in relieving pain, preventing neurological damage, and avoiding development of spinal deformities (e.g., scoliosis, kyphosis) due to spinal instability. Rigid thoracolumbosacral orthosis (TLSO) bracing is often needed in patients with PS, and average duration of treatment of 3 to 4 months. However, TLSO bracing can be poorly tolerated and limit ability of the patient to go back to a normal life. In 2004 our group developed an alternative surgical treatment to TLSO bracing by percutaneous posterior screw-rod bridge instrumentation of the infected level. This treatment allows early and free mobilization of the patients and is associated with faster recovery, lower pain scores and improved quality of life as previously reported. Herein, we report the clinical outcome of the first 3 patients who have completed the 10 years follow-up mark after the procedure. A case report is also described and details of the procedure are provided.

Pregnancy-associated osteoporosis (PAO) with multiple vertebral fragility fractures: diagnosis and treatment in a young primigravid woman

PAO is an uncommon condition affecting pregnant women during last trimester or early post-delivery period; it is often asymptomatic or presents with pain related to some acute fragility fractures. The diagnosis is often delayed or missed, the etiology remains unknown and no guidelines about treatment have been published. We present one case of PAO in a 33-year-old primigravid woman presenting acute worsening back pain. Our patient was treated with a TLSO brace, oral 25 (OH)-vitamin D supplementation and Teriparatide for 6 months. A short review of the literature has been included and useful advice about how to suspect and diagnose this uncommon disease were given in order to recognize and treat such a debilitating and severe condition for young mothers as best as possible, based on the available scientific evidences.

[An effective method to prevent deep venous thrombosis in total hip arthroplasty: a study in patients with and without risk factors for thrombotic disease]

PURPOSE

The aim of this study was to determine a safe and effective method of prophylaxis for thromboembolis diseases after THA.

MATERIALS AND METHODS

This study was conducted on 157 patients consecutively admitted to our Department of Orthopedics to undergo elective THA from October 2000 o May 2001. We have preoperatively investigated plasma levels of homocysteine, AT III activity, Fibrinogen levels, Anticardiolipin antibodies, and circulating vWFag D-dimer levels were measured by Asserachrom D-dimer ELISA preoperatively and on day 4 postoperatively. Thromboprophylactic regimen was based on a prolonged subcutaneous administration of nadroparin (for 40 days after surgery) and was used in all patients, with a dose based on body weight. Compression ultrasonography was udes as screening test for the diagnosis of deep venous thrombosis and performed in each patient on postoperative day 4, 15, and 30.

RESULTS

Although all patients enrolled in this study showed increased risk for thrombotic disease, none oh them developed either symptomatic or asymptomatic deep venous thrombosis. No complications were observed, including major bleeding or abnormalities of laboratory tests.

CONCLUSIONS

Our study indicates that prolonged thromboprophylaxis with nadroparin for 40 days postoperatively, associated with early mobilization, is an effective and safe protocol of antithrombotic prophylaxis in patients operated for THA with and without risk factors for thrombotic disease.

Surgical treatment of tuberculous spondylodiscitis

BACKGROUND

Most patients affected by spinal tuberculosis can be successfully treated conservatively with chemotherapy, external bracing and prolonged rest. Nevertheless, kyphotic deformity, spinal instability and neurological deficit remain a common complication associated with conservative approach.

AIM

To illustrate different indications and treatment modalities for tuberculous spondylodiscitis, focusing on the role of surgery as an adjuvant of effective chemotherapy in the management of selected patients.

MATERIALS AND METHODS

Various early and late surgical procedures are recommended to treat spinal tuberculosis. The Authors analyzed surgical indications, approaches, complications and outcomes comparing their experience with available Literature.

RESULTS

Conservative management is preferable in patients without vertebral instability and deformity; in presence of abscesses, invasive radiological techniques in combination with abscess drainage and chemotherapy are recommended. In patients with vertebral collapse, kyphotic deformity or abscess formation, vertebral instability or neurological deficits, anterior radical debridement, anterior strut grafting and anterior instrumentation is an optimal standardized procedure. In patients with involvement of more than two vertebral levels or lumbosacral junction and in those whose sagittal alignment is markedly deformed with segmental kyphosis, and in patients who have difficulty in undergoing anterior instrumentation, posterior instrumentation is recommended in combination with anterior radical debridement and anterior strut grafting in one or two staged procedures.

CONCLUSIONS

Since surgery for spinal tuberculosis is demanding, it should be performed only after taking into account the risks and benefits in operable patients. Various surgical procedures are recommended to treat spinal tuberculosis but the common goals are to eradicate the infection and to prevent or to treat neurologic deficits or spinal deformity.

Medical and surgical treatment of pyogenic spondylodiscitis

BACKGROUND

Pyogenic vertebral osteomyelitis (PVO) represents approximately 2-7% of all cases of osteomyelitis. The approach to the treatment of PVO may be conservative, which includes antibiotic therapy and orthopaedic treatment, or surgical.

AIM

To overview conservative and surigical approaches to PVO.

METHODS

A literature review was performed using the Pubmed database to identify studies published in the last 20 years, addressing the treatment of PVO.

RESULTS

Empirical antibiotic treatment of PVO, while waiting for the results of cultures or in culture-negative cases, should include broad spectrum agents in association with agents active on Staphylococcus (S.) aureus. Based on local epidemiological data, antibiotics active on methicillin resistant S. aureus (MRSA) should be included. Once an organism has been identified, antibiotics should be initially administered intravenously but the optimal duration of antimicrobial therapy is unclear. Studies have reported that the incidence of treatment failure was higher when i.v. therapy was administered for less than 4 weeks. Rifampin is widely used in the combination therapy of PVO, but no controlled trials are available to define weather this approach is beneficial. Many PVO need a surgical treatment and can represent a real challenge for the orthopaedic surgeon. Anterior and posterior cervical, thoracic, lumbar approaches and the relatives surgical strategies are reported in this review. Moreover, recently the mininvasive posterior stabilization have been proposed as a efficient alternative to open surgery in elderly with severe comorbidities. Possible advantages and limitations of this technique are also reported.

CONCLUSIONS

Further research is needed in order to define the optimal duration of antibiotic therapy, and the benefits and limitations of open or mini-invasive surgical techniques.