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Ku YC, Al-Malak M, Kosyk MS, Khalaf R, Jo D, Mulvihill L, Lammers J, Rampazzo A, Gharb BB. Evaluation of predictive factors of septic wrist to avoid overdiagnosis. J Plast Reconstr Aesthet Surg 2024; 92:254-263. [PMID: 38579374 DOI: 10.1016/j.bjps.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND The existing diagnostic criteria for septic wrist are nonspecific, exposing patients with noninfectious etiologies to surgical morbidity. This study aimed to identify predictors differentiating septic wrist from other etiologies. METHODS An institutional review board-approved retrospective review was conducted on patients with a presumed diagnosis of septic wrist (2003-2022). Bivariate and multiple regression analyses were performed to identify correlation between confirmed septic wrist and comorbidities (autoimmune diseases, immunosuppression, crystalline arthropathy, intravenous [IV] drug use, smoking), penetrating trauma, fever, multi-joint involvement, inflammatory markers (erythrocyte sedimentation rate [ESR]/C-reactive protein [CRP]/white blood cells [WBC]), serum uric acid level, blood cultures, imaging findings, and synovial fluid analysis. Categorical data were reported as median [interquartile range]. RESULTS Hundred and sixty-eight (58 females and 110 males) patients were included. The median length of hospitalization and follow-up were 6[7] days and 1[3] months. Eighty-nine (53%) patients had septic wrist confirmed with Gram stain/culture, 48 (29%) patients received alternative diagnoses, and 31 (18%) patients had undetermined diagnoses. Concomitant septic wrist and crystalline arthropathy were identified in 9 patients (6.6% of total patients). Out of the 48 patients who received alternative diagnoses, 12 (25%) underwent open drainage. Elevated synovial WBC count (95,409.4 ± 85,926.2) showed a trend of association with septic wrist (p = 0.08). Negative synovial crystals (p = 0.01), positive blood culture (p = 0.04), negative history of crystalline arthropathy (p = 0.08), and multi-joint involvement (p = 0.05) were identified as predictors of septic wrist with a combined sensitivity of 87.5%, specificity of 86.2%, and area under the curve 0.93. CONCLUSIONS Current diagnostic criteria for septic wrist have low specificity. Negative history of crystalline arthropathy, multi-joint involvement, absence of synovial crystals, and positive blood culture are helpful indicators for predicting septic wrist in patients presenting with a painful, erythematous, and swollen wrist.
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Affiliation(s)
- Ying C Ku
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland 44195, OH, USA
| | - Mazen Al-Malak
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland 44195, OH, USA
| | - Mychajlo S Kosyk
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland 44195, OH, USA
| | - Ryan Khalaf
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland 44195, OH, USA
| | - Diane Jo
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland 44195, OH, USA
| | - Lianne Mulvihill
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland 44195, OH, USA
| | - Jacob Lammers
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland 44195, OH, USA
| | - Antonio Rampazzo
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland 44195, OH, USA
| | - Bahar Bassiri Gharb
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland 44195, OH, USA.
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Filippi L, Camedda R, Frantellizzi V, Urbano N, De Vincentis G, Schillaci O. Functional Imaging in Musculoskeletal Disorders in Menopause. Semin Nucl Med 2024; 54:206-218. [PMID: 37914617 DOI: 10.1053/j.semnuclmed.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
Menopause-related musculoskeletal (MSK) disorders include osteoporosis, osteoarthritis (OA), sarcopenia and sarco-obesity. This review focuses on the applications of nuclear medicine for the functional imaging of the aforementioned clinical conditions. Bone Scan (BS) with 99mTc-labeled phosphonates, alone or in combination with MRI, can identify "fresh" vertebral collapse due to age-associated osteoporosis and provides quantitative parameters characterized by a good correlation with radiological indices in patients with OA. 18F-NaF PET, particularly when performed by dynamic scan, has given encouraging results for measuring bone turnover in osteoporosis and allows the evaluation of subchondral bone metabolic activity in OA. FDG PET can help discriminate between pathological and nonpathological vertebral fractures, especially by applying appropriate SUV-based thresholds. In OA, it can effectively image inflamed joints and support appropriate clinical management. Preliminary evidences suggest a possible application of FDG in sarco-obesity for the detection and quantification of visceral adipose tissue (VAT). Further studies are needed to better define the role of nuclear medicine in menopause-related MSK disease, especially as regards the possible impact of new radiopharmaceuticals (ie, FAPI and RGD peptides) and recent technological advances (eg, total-body PET/CT scanners).
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Affiliation(s)
- Luca Filippi
- Nuclear Medicine Unit, Department of Oncohaematology, Fondazione PTV Policlinico Tor Vergata University Hospital, Rome, Italy.
| | - Riccardo Camedda
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Viviana Frantellizzi
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza University of Rome, Rome, Italy
| | - Nicoletta Urbano
- Nuclear Medicine Unit, Department of Oncohaematology, Fondazione PTV Policlinico Tor Vergata University Hospital, Rome, Italy
| | - Giuseppe De Vincentis
- Department of Radiological Sciences, Oncology and Anatomo-Pathology, Sapienza University of Rome, Rome, Italy
| | - Orazio Schillaci
- Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
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Dunham K, Tsoeriero P, Wollstein R. The Use of Ultrasound to Differentiate Between Gout and Infection in the Wrist. Curr Rheumatol Rev 2022; 18:168-171. [DOI: 10.2174/1573397118666220225150046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/11/2021] [Accepted: 12/24/2021] [Indexed: 11/22/2022]
Abstract
Background:
Gout is a common condition and its prevalence is increasing. In the wrist, acute gouty arthritis is difficult to distinguish from infection and may occur concomitantly. Though aspiration is helpful, it is not always technically feasible or definitive. Imaging may assist in the differential diagnosis.
Case Presentation:
Two cases are described in which the use of ultrasound evaluation assisted in the diagnosis and ultimate treatment.
Conclusion:
Ultrasound can be a helpful adjunct in the diagnosis of arthritis of the wrist, helping to tailor treatment in complex cases.
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Affiliation(s)
- Kevin Dunham
- Department of Radiology New York University School of Medicine, New York, NY, USA
| | - Paul Tsoeriero
- Department of Orthopedic Surgery, New York University School of Medicine, New York, NY, USA
| | - Ronit Wollstein
- Department of Orthopedic Surgery, New York University School of Medicine, New York, NY, USA
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Coe J, Igwilo R, Sirichand S, Cheney L, Corpuz M. Missed diagnosis of septic arthritis due to invasive pneumococcal disease. IDCases 2022; 30:e01644. [DOI: 10.1016/j.idcr.2022.e01644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022] Open
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Lautenbach M, Tenbrock A, Bock M, Millrose M, Kim S, Eisenschenk A. [Osteitis/Osteomyelitis of the Hand and Wrist]. HANDCHIR MIKROCHIR P 2021; 53:282-289. [PMID: 34134160 DOI: 10.1055/a-1394-6332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Osteomyelitis of the hand and wrist is uncommon compared to the infections of the long bones but not rare. There is poor evidence on many answers to questions concerning this disease. This includes careful consideration of the prevalence, pathogenesis, microbiology, diagnostic methods and the conservative, medical and surgical treatment. The emergence of the disease can subdivided in post-traumatic, postoperative, spread from contiguous infections and hematogenous. The individual patient-specific risk must be considered. Early diagnosis and correct management are essential to preserve bony structures and the articular function of the hand. A two-step surgical procedure is usually necessary, but uncertainties about the optimal treatment are still existing. Satisfactory control rates of the infection and successful bone reconstructions can be achieved. But complications, a limited range of motion and amputations of finger parts can still not be avoided in all cases.
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Affiliation(s)
- Martin Lautenbach
- Krankenhaus Waldfriede Berlin; Abteilung Handchirurgie, obere Extremität und Fußchirurgie, Zentrum für Orthopädie und Unfallchirurgie, Rheumaorthopädie
| | - Arne Tenbrock
- Krankenhaus Waldfriede Berlin; Abteilung Handchirurgie, obere Extremität und Fußchirurgie, Zentrum für Orthopädie und Unfallchirurgie, Rheumaorthopädie
| | - Markus Bock
- Krankenhaus Waldfriede Berlin; Abteilung Handchirurgie, obere Extremität und Fußchirurgie, Zentrum für Orthopädie und Unfallchirurgie, Rheumaorthopädie
| | - Michael Millrose
- BG Unfallklinik Murnau; Abteilung für Unfallchirurgie und Sporttraumatologie
| | - Simon Kim
- Ernst-Moritz-Arndt Universitat Greifswald; Klinik und Poliklinik für Unfall-, Wiederherstellungschirurgie und Rehabilitative Medizin
| | - Andreas Eisenschenk
- Unfallkrankenhaus Berlin; Abteilung für Hand-, Replantations- und Mikrochirurgie
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A critical review of the available evidence on the diagnosis and clinical features of CPPD: do we really need imaging? Clin Rheumatol 2020; 40:2581-2592. [PMID: 33231775 DOI: 10.1007/s10067-020-05516-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 02/08/2023]
Abstract
Imaging has been playing an important role in the pathogenetic and clinical characterisation of many rheumatic diseases, especially in the most recent years with the advent of many new, highly technological and promising techniques. Calcium pyrophosphate deposition disease (CPPD) benefited also from these new techniques, most of which can readily identify calcium crystals. Nowadays, imaging is used mainly to identify crystals in joints but given the complexity of CPPD, imaging should be used with an "holistic" approach in order to gain insights in the pathogenesis, spectrum of clinical manifestations and natural history of the disease. Furthermore, overlap or association of CPPD with other prevalent diseases of the elderly makes the differential diagnosis challenging. In this review, we provide a critical review of the current knowledge on the use of imaging both for the identification of crystals and for its application in clinical practice as an aid for determining the impact of the disease on patients.Key Points• CPPD is a complex disease with a wide spectrum of clinical manifestations and understanding of pathogenetic mechanisms and clinical phenotypes is essential for correct characterisation• Imaging has made important advances regarding identification of CPPD in recent years, and new, more sophisticated techniques are under investigation• Imaging has the potential to improve our knowledge on pathogenesis and clinical phenotypes of CPPD• Imaging techniques have to be tested thoroughly for reliability, discrimination and sensitivity to change before they can be implemented in clinical trials.
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Low SL, Jennings JD, Clippinger BB, Landfair GL, Criner-Woozley KT, Ilyas AM. Predictors of Septic Wrist: A Dual-Center 10-Year Review of Risk Factors. J Hand Microsurg 2020; 12:19-26. [PMID: 32280177 PMCID: PMC7141905 DOI: 10.1055/s-0039-1693068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 05/02/2019] [Indexed: 10/26/2022] Open
Abstract
Introduction Expeditious and accurate diagnosis of septic wrist arthritis is essential to prevent further cartilage damage, systemic infection, osteomyelitis, and loss of limb. There is limited literature on the incidence and clinical factors that are predictive of septic wrist arthritis. Objective We aimed to investigate the incidence of septic wrist arthritis and identify risk factors and laboratory values associated with septic wrist arthritis. Materials and Methods Data were collected on adult patients presenting with a painful, swollen wrist to two level 1 urban hospitals from 2004 to 2014. Demographics, comorbidities, and laboratory values of patients who had wrist aspiration were collected. Results There was an overall incidence of 0.4%. Increased synovial white blood cells (WBC), being febrile, positive blood cultures, and smoking were significantly associated with septic wrist arthritis on univariate analysis. Synovial WBC was also found to be significant on multivariate analysis. A synovial WBC of 87,750 cells/µL had an optimal sensitivity and specificity of 73% and 86%, respectively, for diagnosing septic wrist arthritis. Conclusion Synovial WBC can be a useful diagnostic tool for septic wrist arthritis. In addition, positive blood cultures, being febrile, and smoking history can help predict septic wrist arthritis in patients with presenting with painful, swollen wrists.
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Affiliation(s)
- Sara L. Low
- Department of Orthopaedic Surgery, Einstein Medical Center, Philadelphia, Pennsylvania, United States
| | - John D. Jennings
- Department of Orthopaedic Surgery, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Benjamin B. Clippinger
- Department of Orthopaedic Surgery, Einstein Medical Center, Philadelphia, Pennsylvania, United States
| | - Germanuel L. Landfair
- Department of Orthopaedic Surgery, Einstein Medical Center, Philadelphia, Pennsylvania, United States
| | | | - Asif M. Ilyas
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
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Sendi P, Kaempfen A, Uçkay I, Meier R. Bone and joint infections of the hand. Clin Microbiol Infect 2020; 26:848-856. [PMID: 31917233 DOI: 10.1016/j.cmi.2019.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/10/2019] [Accepted: 12/14/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little guidance is currently available for standardized diagnostic protocols and therapeutic recommendations for bone and joint infections (BJIs) of the hand. OBJECTIVES To summarize the available data in the scientific English-language literature on the diagnosis and treatment of native BJIs of the hand. To illustrate these concepts from a narrative point of view in areas where there is lack of evidence. SOURCES We performed a systematic PubMed and Internet search of studies that investigated hand BJIs in adult patients. CONTENT Few studies have systematically investigated and validated diagnostic concepts, classifications or surgical treatment protocols. Most concepts derive from traditional intra-institutional experience, expert opinions and extrapolations from infections in large joints and long bones. Similarly, there is no uniformly accepted infection definition of BJIs of the hand. The best-documented literature is available for microbiological findings and antibiotic treatment duration in uncomplicated native joint arthritis of the fingers. Retrospective studies and one prospective randomized trial suggest that post-surgical targeted antibiotic therapy of 2 weeks results in a microbiological cure rate of ≥88%. IMPLICATIONS Studies on diagnostic workup and infection definition and classification are urgently needed to compare inter-institutional outcome results and generate guidelines for the best patient care. For uncomplicated pyogenic arthritis of native joints, current evidence suggests that a 2-week course of antibiotic therapy following surgery cures the infection.
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Affiliation(s)
- P Sendi
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Switzerland; Department of Orthopaedics and Traumatology, University Hospital Basel, University of Basel, Switzerland; Institute of Infectious Diseases, University of Bern, Bern, Switzerland.
| | - A Kaempfen
- Clinic for Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - I Uçkay
- Infectiology, Balgrist University Hospital, Zürich, Switzerland
| | - R Meier
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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