Acute periprosthetic knee infection: is there still a role for DAIR?

BACKGROUND AND AIM OF THE WORK

Periprosthetic knee infection is a rare complication associated with prosthetic failure; incidence change from 0,4-2% of primary total knee replacement and 5.6% in revisions. Indications for debridment, antibiotics and implant retention (DAIR) are early acute infections or acute delayed infection. Aim of the work is to check if this technique is still a successful in early infections.

METHODS

We have analyzed recent literature data on DAIR and all DAIR procedures in our clinic in the last 10 years, the mean time between onset of symptoms and surgery, the mean antibiotic therapy duration and results we have obtained. We evaluate the diagnostic process and different treatments in early knee periprosthetic infections, especially the DAIR approach.

RESULTS

If correct indications are followed, DAIR has a success rate in 31-100% of the cases; if it is applied in late chronic infection the success rate is 28-62%. In our experience DAIR has an 80% success rate: in 20 patients treated with DAIR we had 4 failures.

CONCLUSIONS

DAIR can be considered a successful treatment, but it depends from individual patient factors, from the microorganisms involved, from the duration of antibiotic therapy and from correct choice in timing and in execution of DAIR by the orthopedic surgeon.

Growth Plate Lesions of Fattening Bulls

Lameness related to growth plate lesions is an important problem in the beef industry. This article describes the macroscopic and microscopic lesions in the distal metatarsal physis of bulls from an association of farmers in northeastern Italy. The metatarsal bones of 62 bulls (12 with severe lameness and 50 without lameness), average age 16.44 ± 1.72 months, were examined at the abattoir. The animals came from the same geographic area and shared intensive husbandry practices and a diet based on maize starch. A total of 124 metatarsal bones were sectioned, and the distal metaphyseal growth plate was grossly examined. Twenty-three cases, including 12 lame and 9 nonlame animals with visible lesions on macroscopic examination, and 2 controls (a total of 46 physes) were examined microscopically. Eight of 12 bulls with severe lameness had a chronic purulent physitis in at least 1 limb. Segmental thickening of the hypertrophic zone, consistent with osteochondrosis (OC), was present contralaterally ( n = 3 cases) and bilaterally ( n = 3 cases) in 6 of these animals. In the group of nonlame bulls, 19 of 50 (38%) had similar segmental thickening of the physis consistent with OC. In the remaining bulls, minor findings included partial closure of the physis and a variable degree of metaphyseal hyperemia. A high incidence of OC was found in both lame and nonlame fattening bulls. It is likely that lame animals were clinically more severe due to secondary hematogenous implantation of bacteria, resulting in a purulent physitis and severe lameness that required emergency slaughter in some cases.

Causes of Failure of Anterior Cruciate Ligament Reconstruction and Revision Surgical Strategies

Purpose

Long-term outcomes of anterior cruciate ligament (ACL) reconstruction are good or excellent; however, 0.7%–20% of patients suffer from recurrent instability due to graft failure. The purpose of this paper was to analyse failure aetiology and the possibilities of revision surgical strategies, with a description of our experience. We obtained optimal and good results in most of our patients.

Materials and Methods

We retrospectively reviewed 42 patients who underwent revision surgery (43 revisions) due to relapsing instability after ACL reconstruction between 2006 and 2015. We used allografts in 39 cases and autografts in 4 cases.

Results

The 85.7% of the patients obtained optimal results (normal knee; group A) and the 7.2% obtained good results (nearly normal knee; group B) according to the International Knee Documentation Committee score. The most frequent failure causes were traumatic events, non-anatomic tunnel placement, and lack of graft incorporation.

Conclusions

A correct revision surgery requires accurate patient evaluation and knee imaging. Preoperative planning starts with the identification of the cause of failure of the primary reconstruction. Then, the most suitable procedure should be determined for each case. It is also important to accurately inform the patient of all the complexity of an ACL revision surgery even if it is a procedure with high rates of excellent and good outcomes.

Extracapsular vs standard approach in hip arthroscopy

BACKGROUND

Over the last decades, the arthroscopic treatment of hip pathology has highly grown thanks to the evolution of surgical and diagnostic techniques and instrumentation development. Furthermore the higher life expectancy and functional request make younger patients to be evaluated more frequently for non-arthrosic hip pathologies like labral lesion, FAI, cartilage tears. Treatment substantially has to be chosen between arthroscopy and arthrotomy. This study pretends to compare the clinical outcome between two different arthroscopic access techniques: the traditional one and the extrarticolar one (OUT-IN) we are using regularly in our clinic.

METHODS

From 2012 to 2014, 37 patients with FAI were treated with traditional technique (Group A) and 28 with extra-articular access (Group B). Indication to surgery treatment was given on the basis of radiological imaging (Pelvis Rx, Hip Rx in AP, Frog Leg view, Dunn view, Pelvic MRI) (8, 9), dynamic range of motion, clinical examination and functional scores (MHHS, MHOT). Pain was scored with NRS.  Minimum follow up for each patient was 12 month with clinical controls and functional score recording at 3-6-12 month after surgery. Complications or iatrogenic lesions were assessed.

RESULTS

At 12 month after surgery there was no statistically significant differences in hip R.O.M., MHHS and MHOT (33) score. We observed an higher number of iatrogenic lesions and complications in the group A (standard technique) than group B.

CONCLUSIONS

Hip arthroscopy is a viable and reproducible alternative technique when treating articular lesion such as femur-acetabular impingement and it is demonstrated by the increase of functional score. We can furthermore appreciate that an extra-articular access technique leads to a vary good outcome both in hip R.O.M. and functional scores and has a very low number of complications and iatrogenic lesions.

Histopathological aspects and staging systems in non-traumatic femoral head osteonecrosis: an overview of the literature

BACKGROUND

The pathogenesis of non traumatic osteonecrosis of the femoral head (ONFH) has not yet been established. The literature shows a variable nomenclatura for this condition that often leads to confusion. Several risk factors have been identified but histopathological and radiological outcomes are common.

PURPOSE

To provide the overview on the current knowledges about the nomenclatura, etiology, disease progression, relationship between histopathological changes and imaging techniques in order to stage the disease accurately. Etiology and pathogenesis: Genetic predisposition, metabolic factors, local factors affecting blood supply such as vascular damage, increased intraosseous pressure and mechanical stress are involved in this desease. The final results are bone ischemia and infarction getting bone deathand FH collapse. Histopathological aspects and staging systems: Several staging systems have been developed to stage ONFH based on imaging techniques.The  subchondral collapse, the size or quantification of the lesion, and the lesion location within the femoral head are identified as the most important prognostic factors in ONFH disease. Histological analysis plays a critical role to evaluate the quality of necrotic area and the differences between microscopic, macroscopic and imaging outcomes were detected.

CONCLUSIONS

an ideal staging system is necessary to stage ONFH desease to detect several aspects, but itìs more difficult to create. At the present time we summarize some aspects that are advisable to focus during ONFH for the correct treatment.

The role of intraoperative frozen section in arthroplasty revision surgery: our experience

BACKGROUND AND AIM OF THE WORK

Due to the increasing the number of hip and knee replacement in the future will be increasing the number of cases of prosthetic revision. Our aim is to test the validity of extemporaneous exam for differentiation between septic and aseptic loosening of prosthetic.

METHODS

159 patients underwent surgery for the prosthesis revision from 2008 to 2014 An intraoperative histological examination was performed during all the surgeries and multiple samples were taken for the conclusive histological examination and culture.

RESULTS

Sensitivity of the intraoperative histological examination resulted 38,3% (IC 0,26; 0,51); specificity 82,5% (IC 0,73; 0,90), where positive predictive value was 57,5% (IC 0,41; 0,73) and negative predictive value 68,4% (IC 0,59; 0,76).

CONCLUSIONS

In the absence of a universally accepted method to diagnose infection in patients with mobilization of the prosthesis, intraoperative histological examination is, in spite of everything, a method easy to perform and reproduce, it shows high specificity and sensitivity in the presence of highly virulent pathogens.

Arthroscopic rotator cuff repair with or without PrP: our experience

BACKGROUND AND AIM OF THE WORK

Arthroscopical rotator cuff repair has good results, but the rate of tendon healing is 80% in small tears with a decrease to 30% in large and massive tears. Platelets are an endogenous source of growth factors present during rotator cuff healing. Aim of the work is checking if Cascade Autologous Platelet System may improve rotator cuff healing in small sovraspinatus tears.

METHODS

Each patient enrolled in cases  has surgical arthroscopical repair of sovraspinatus  small tear and then treated with intraoperatory Cascade. Patients of control group undergoing the same surgery with traditional arthroscopic repair. Follow-up time was at 3, 6, 12 month from surgery with evaluation of ROM, strength, Constant score, NRS. RMN was repeated at 12 month from surgery with evaluation of sovraspinatus tendon thickness, signal intensity, fat degeneration and muscle atrophy.

RESULTS

Between 2010 and 2013, 18 patients have undergone sovraspinatus repair in arthroscopic surgery  with intraoperatory Cascade and 18 patients with traditional arthroscopic repair. Only sovraspinatus tendon thickness and  signal intensity were  statistically difference in the cases group. In ROM, strength, Constant score, NRS, fat degeneration and muscle atrophy were not a statistically difference compared with controls.

CONCLUSIONS

In small sovrapinsatus tears Cascade Autologous Platelet System did not result in improved ROM, strength, Constant score, NRS, tendon fat degeneration and muscle atrophy. Only sovraspinatus  tendon thickness and  signal intensity were improved.

Design evolution in total knee replacement: which is the future?

Total knee replacement (TKR) procedures have evolved in the last 40 years to guarantee improvements implants life and an excellent joint function. The goals for the future evolutions are make easier prosthesis implantation and promote precision. The demand for TKR will rise for the life length increase and for the risk factors impact increase. Design evolution in total knee replacement has to satisfy these new necessities: anatomic congruence, range of motion, less material wear and better resistance to the weight bearing and to the stresses. This paper analyzes design evolution, materials development and future purposes in total knee arthroplasty. At the beginning, TKR history is treated; then we compare several prosthetic designs developed during years. At last the paper speak about recent innovations, like CAD (computer aided design) for example, born to reach the most important goal in the future: better TKR design, is the one that better imitate natural knee characteristics, and that is able to integrate it-self with capsule-ligaments and muscle-tendons patient structures.

Arthroscopic treatment of isolated subscapolaris lesions: our experience

BACKGROUND AND AIM OF THE WORK

Subscapularis tendon lesions, in particular the isolated ones, are often not recognized and undervalued, so in the literature they are described with a variable incidence. Aim of the work is presenting our experience with the short to medium term follow up results of the arthroscopic repair of isolated subscapularis lesions.

METHODS

We retrospectively analyzed 311 shoulder arthroscopies performed by a single senior surgeon, from which we have found 10 isolated subscapularis lesions. After the arthroscopic repair of subscapularis tendon the patients have been evaluated with a median follow up of 17.7 months with specific tests for the subscapularis (Napoleon's and lift off tests) and clinical scores (Constant and UCLA scores).

RESULTS

We have obtained the tests negativization with an internal rotation level up to D8. The Constant score reached 86.7 with a median improvement of 49.4 points. The UCLA score at the last follow up was 30.8 with a median improvement of 20.1 points.

CONCLUSIONS

Isolated subscapularis lesions are uncommon and often they are not correctly diagnosed. Arthroscopy has a decisive role in both the diagnostic and therapeutic side, with good short to medium term results.

Persistence ofCandida albicansCandidemia in Non-Neutropenic Surgical Patients: Management of a Representative Patient in the Absence of Second-Line Treatment Guidelines

Primary treatment failure and mortality in non-neutropenic patients with candidemia is high according to clinical trial experience. Current guidelines are mainly useful only for first line treatment strategies.We describe treatment failure and persistent protracted Candida albicans candidemia without clinically evident ocular involvement nor catheter recolonization in a malnourished non-neutropenic surgical patient with peritonitis. Primary antifungal treatment failure with fluconazole and secondary treatment failure with caspofungin occurred in the absence of evident Candida seeding the eye, valvular endocardium, or the intravascular catheter. Switch to liposomal amphotericin B was followed by clinical and microbiological cure. In patients with multiple risk factors for the acquisition of candidemia and life-threatening clinical conditions, the possibility of primary/secondary failure of new potent antifungal regimens may be initially neglected. Additional multicenter controlled clinical data are needed to guide the timing and choice of secondary antifungal treatment regimens in non-neutropenic candidemia patients.

A prospective survey of febrile events in hematological malignancies

The Hema e-Chart prospectively collected data on febrile events (FEs) in hematological malignancy patients (HMs). The aim of the study was to assess the number, causes and outcome of HM-related FEs. Data were collected in a computerized registry that systematically approached the study and the evolution of FEs developing in a cohort of adult HMs who were admitted to 19 hematology departments in Italy from March 2007 to December 2008. A total of 869 FEs in 3,197 patients with newly diagnosed HMs were recorded. Fever of unidentified origin (FUO) was observed in 386 cases (44.4%). The other causes of FE were identified as noninfectious in 48 cases (5.5%) and infectious in 435 cases (50.1%). Bacteria were the most common cause of infectious FEs (301 cases), followed by fungi (95 cases), and viruses (7 cases). Mixed agents were isolated in 32 episodes. The attributable mortality rate was 6.7% (58 FEs). No deaths were observed in viral infection or in the noninfectious groups, while 25 deaths were due to FUO, 16 to bacterial infections, 14 to fungal infections, and three to mixed infections. The Hema e-Chart provided a complete system for the epidemiological study of infectious complications in HMs.

Human cases of West Nile Virus Infection in north-eastern Italy, 15 June to 15 November 2010

In 2010, for the third consecutive year, human cases of West Nile virus (WNV) infection, including three confirmed cases of neuroinvasive disease and three confirmed cases of West Nile fever, were identified in north-eastern Italy. While in 2008 and 2009 all human cases of WNV disease were recorded in the south of the Veneto region, cases of WNV disease in 2010 additionally occurred in two relatively small northern areas of Veneto, located outside those with WNV circulation in the previous years. WNV IgG antibody prevalence in blood donors resident in Veneto was estimated as ranging from 3.2 per 1,000 in areas not affected by cases of WNV disease to 33.3 per 1,000 in a highly affected area of the Rovigo province. No further autochthonous human cases of WNV disease were notified in Italy in 2010. The recurrence of human cases of WNV infection for the third consecutive year strongly suggests WNV has become endemic in north-eastern Italy.

Human cases of West Nile Virus infection in north-eastern Italy, 15 June to 15 November 2010

In 2010, for the third consecutive year, human cases of West Nile virus (WNV) infection, including three confirmed cases of neuroinvasive disease and three confirmed cases of West Nile fever, were identified in north-eastern Italy. While in 2008 and 2009 all human cases of WNV disease were recorded in the south of the Veneto region, cases of WNV disease in 2010 additionally occurred in two relatively small northern areas of Veneto, located outside those with WNV circulation in the previous years. WNV IgG antibody prevalence in blood donors resident in Veneto was estimated as ranging from 3.2 per 1,000 in areas not affected by cases of WNV disease to 33.3 per 1,000 in a highly affected area of the Rovigo province. No further autochthonous human cases of WNV disease were notified in Italy in 2010. The recurrence of human cases of WNV infection for the third consecutive year strongly suggests WNV has become endemic in north-eastern Italy.

Conserved T cell and natural killer cell function in treatment-experienced adults receiving tenofovir plus didanosine as nucleoside reverse transcription inhibitor backbone

Anti-retroviral treatment (ART) usually results in efficient control of virus replication and in immune reconstitution. Among potential adverse effects, impairment of immune responses in terms of CD4(+) T cell counts has been attributed to some ART regimens, as with didanosine-tenofovir. We studied the functional integrity of adaptive and innate immunity during didanosine-tenofovir-containing ART. Two groups of extensively pretreated patients completing at least 48 weeks of ART containing either lamivudine-didanosine (n = 21) or tenofovir-didanosine (n = 25) were identified. In addition to standard clinical immune and virological parameters, we performed a flow cytometric analysis of natural killer (NK) cells, of memory and naive CD4(+) T cells and of T cell receptor alphabeta(+) T cells co-expressing inhibitory NK receptors. Functional analysis consisted in specific and total interferon-gamma production by NK cells and of recall antigen proliferation of peripheral blood mononuclear cells. Comparable clinical immunological reconstitution and virological control were confirmed in the two groups of patients in the absence of clinically relevant adverse effects. The proportion of CD4(+)CD45RA(+) T cells and of functionally inhibited killer immunoglobulin-like receptor T cell receptor alphabeta(+) cells, the proliferation to recall antigens as well as NK cell phenotype and function as determined by interferon-gamma production in patients treated with tenofovir-didanosine were comparable to those treated with a different regimen. Thus, no differences in functional innate or adaptive immune reconstitution are detected in drug-experienced human immunodeficiency virus-infected patients on tenofovir-didanosine nucleoside reverse transcription inhibitor regimens.

A fatal case of invasive fungal sinusitis by Scopulariopsis acremonium in a bone marrow transplant recipient

A fatal case of Scopulariopsis acremonium sinus infection in an allogeneic hematopoietic stem cell transplant patient is reported. Rapid vascular diffusion of the fungus to the major head vessels was observed, which led to subsequent repeated cerebral ischemia and death. The presence of hyphae in the right carotid wall might be considered an indirect sign of fungal blood diffusion in the absence of positive blood cultures. The infection developed during the course of prolonged voriconazole prophylaxis, which was found to be effective in the in vitro antifungal drug assay. This finding induced us to consider the capacity of this drug to reach infected paranasal sinuses, and the need in cases such as this of a combined systemic and local pharmacological therapy or a combined medical and surgical approach.

Clinical experience with eperisone in the treatment of acute low back pain

AIM

A muscle contracture is the main responsible for low back pain and it consists of a persistent and involuntary muscle shortening, but it may be also the consequence of back pain thus fostering the painful condition. The goals of a pharmacological treatment for acute low back are, therefore, not only the relief of pain, but also the reduction of muscle spasm and inflammation, since nociception often results from local secondary inflammation and muscle spasm. Although systematic reviews have shown that muscle relaxants are effective in the management of non-specific low back pain, the use of these compounds is often limited by adverse effects on central nervous systems (CNS), such as drowsiness. Thus, the effects of eperisone, a new muscle relaxant agent with no CNS adverse effects, have been investigated.

METHODS

A total of 100 patients (38 males and 62 females) with acute low back pain and moderate contracture of the spinal muscles arisen since less than 48 h were enrolled in the study. After physical examination, these patients were treated with eperisone 50 mg every 8 h for 10 consecutive days and were visited again after 3 days and at the end of treatment.

RESULTS

Only 4 patients (4%) were obliged to stop treatment because of minor gastrointestinal adverse reactions. The administration of eperisone resulted in a prompt reduction of both spontaneous and provoked pain, as well as in a progressive decontracture of spinal muscles, as suggested by a reduction in resistance to passive movement, antalgic rigidity and ''hand-to-floor'' distance.

CONCLUSION

Eperisone is thus a muscle relaxant agent, with a mechanism of action slightly different from that of other muscle relaxants. In addition to an inhibition of mono- and multisynaptic reflexes in the spinal cord and supra-spinal structures, eperisone regulates the blood supply to skeletal muscles; this action is noteworthy since a muscle contracture may compress the small blood vessels and induce an ischemia leading to release of nociceptive compounds. Most importantly, eperisone is devoid of detrimental effects on CNS.

Therapeutical aspects and outcome of HIV/HCV coinfected patients treated with pegylated interferon plus ribavirin in an Italian cohort

BACKGROUND

One-third of HIV-infected individuals suffer from chronic hepatitis C virus infection (HCV) in Europe. Recommendations from HCV-HIV International Panel advise current treatment with pegylated interferon plus ribavirin. We assessed the impact of interferon and ribavirin combination in 43 patients between 2002 and 2006.

PATIENTS AND METHODS

All coinfected patients treated for HCV during the 5-year period were included in retrospective data collection. CD4+ T-lymphocyte count, HAART discontinuation, reasons for treatment interruption and factors correlated to sustained virological response (SVR) were monitored.

RESULTS

The mean age was 41 +/- 6.7 years; the risk factor for coinfection was intravenous drug abuse in 32/43 (74%). The baseline CD4+ T-lymphocytes cell count was > 500 in 51% (22/43). Genotype 3a represented 51% (22/43); 37% were on HAART at baseline (16/43) and half of patients showed high HCV RNA levels (> 800,000 IU/ml). High rates of treatment discontinuation were observed (27/43, 63%), caused by voluntary interruptions in 52% (14/27) and virological failure in 26% (7/27). The overall population had an SVR of 30%; genotypes 3a and 1 had SVR of 38% and 24%, respectively. The SVR was significantly lower in three groups: high HCV RNA viral load (chi2 = 6, p < 0.0025), CD4+ T-lymphocyte historical nadir <350 cells/mm3 (chi2 = 3.26, p < 0.01) and genotype 1 with high viral load (chi2 = 4.8, p < 0.005).

CONCLUSIONS

Although factors such as HCV viral load rates and genotype 1 have been confirmed to threaten the response to therapy, we observed a significant response rate when patients had a history of CD4+ T-lymphocyte nadir >350 per mm3. The high dropout rates due to voluntary discontinuations complicated the patients' case management.

[An unusual case of severe arterial hypertension and acute renal failure in an obese young adult]

We report a case of type-B aortic dissection occurring in a 38-year-old obese man, whose past medical history was positive for arterial hypertension and apparently negative for chronic kidney disease. The patient had severe refractory hypertension and acute renal insufficiency due to renal vascular impairment. The correct diagnosis was delayed because the clinical presentation was atypical, initially mimicking an acute abdominal inflammatory process (such as acute pyelonephritis) with secondary sepsis, and there was no major hemodynamic impairment. Percutaneous management (endografting of the thoracic aorta to seal the thoracic intima tear and renal revascularization by PTA+stenting) led to remission, albeit partial, of the acute renal insufficiency and to target blood pressure achievement with use of multiple antihypertensive agents. Follow-up at 12 months showed stable renal function, normal endograft placement and normal aortic diameter at CT examination. The percutaneous endovascular management of aortic dissection is a valid alternative to traditional surgery, with less morbidity and mortality; when the renal circulation is impaired by the aortic dissection, aortic endografting and renal revascularization by PTA+stenting, where appropriate, may allow at least partial reversal of renal insufficiency and target blood pressure achievement.

Neurological manifestation of tick-borne encephalitis in North-Eastern Italy

Tick-borne encephalitis (TBE) is an infectious zoonotic disease, moving from Central Europe to other countries and still rare in Italy. The disease, produced by the European subtype virus, typically takes a biphasic course with neurological disorders of different severity during its second phase. We report the first three TBE cases in Friuli Venezia Giulia (FVG), characterised by extremely variable clinical features. Knowledge of these different presentations will assist physicians in increasing their level of attention to TBE also in this region, where no cases of TBE had been reported in the past, despite the fact that it borders countries with high prevalence of the infection.