Clavicular Malignancies: A Borderline Surgical Management

Thyroid Malignancy and Cutaneous Lichen Amyloidosis: Key Points Amid RET Pathogenic Variants in Medullary Thyroid Cancer/Multiple Endocrine Neoplasia Type 2 (MEN2)

We aimed to provide an updated narrative review with respect to the RET pathogenic variants and their implications at the clinical and molecular level in the diagnosis of medullary thyroid cancer (MTC)/multiple endocrine neoplasia (MEN) type 2, particularly with respect to the presence of cutaneous lichen amyloidosis (CLA). We searched English-language, in extenso original articles with no timeline nor study design restriction that were published on PubMed. A traditional interplay stands for CLA and MTC in MEN2 (not MEN3) confirmation. While the connection has been reported for more than three decades, there is still a large gap in understanding and addressing it. The majority of patients with MEN2A-CLA have RET pathogenic variants at codon 634; hence, it suggests an involvement of this specific cysteine residue in both disorders (most data agree that one-third of C634-positive subjects have CLA, but the ranges are between 9% and 50%). Females seem more prone to MEN2-CLA than males. Non-C634 germline RET pathogenic variants included (at a low level of statistical evidence) the following: RET V804M mutation in exon 14 for MTC-CLA (CLA at upper back); RET S891A mutation in exon 15 binding OSMR variant G513D (familial MTC and CLA comprising the lower legs to thighs, upper back, shoulders, arms, and forearms); and C611Y (CLA at interscapular region), respectively. Typically, CLA is detected at an early age (from childhood until young adulthood) before the actual MTC identification unless RET screening protocols are already applied. The time frame between CLA diagnosis and the identification of RET pathogenic variants was between 5 and 60 years according to one study. The same RET mutation in one family is not necessarily associated with the same CLA presentation. In MTC/MEN2 subjects, the most affected CLA area was the scapular region of the upper back. Alternatively, another hypothesis highlighted the fact that CLA is secondary to long-term prurit/notalgia paresthetica (NP) in MTC/MEN2. OSMR p. G513D may play a role in modifying the evolutionary processes of CLA in subjects co-harboring RET mutations (further studies are necessary to sustain this aspect). Awareness in CLA-positive patients is essential, including the decision of RET testing in selected cases.

Superficial Vein Thrombosis in an Asymptomatic Case of Cholangiocarcinoma with Recent History of COVID-19

The COVID-19 pandemic brought into prominence several emergent medical and surgical entities, but, also, it served as trigger and contributor for numerous apparently unrelated ailments such as arterial and venous thromboembolic complications. Additional risk factors for these thrombotic traits may be concurrent (known or unknown) malignancies, including at hepatic level. Among these, cholangiocarcinoma (CCA), a rare cancer of intra- and extra-hepatic biliary ducts, represents a very aggressive condition that typically associates local and distant advanced stages on first presentation requiring a prompt diagnosis and a stratified management. This neoplasia has been reported to present a large spectrum of paraneoplastic syndromes in terms of dermatologic, renal, systemic, neurologic, endocrine, and cardiovascular settings, that, overall, are exceptional in their epidemiologic impact when compared to other cancers. Our aim was to introduce a most unusual case of CCA-associated distant thrombosis in a male adult who initially was considered to experience COVID-19-related thrombotic features while having a history of obesity and bariatric surgery. This is a hybrid type of paper: this clinical vignette is accompanied by two distinct sample-focused analyses as a basis for discussion; they each had different methods depending on their current level of statistical evidence. We only included English-published articles in PubMed, as follows: Firstly, we conducted a search of reports similar to the present case, regarding distant vein thrombosis in CCA, from inception until the present time. We performed a literature search using the keywords "cholangiocarcinoma", "thrombosis", and "Trousseau's syndrome" and identified 20 cases across 19 original papers; hence, the current level of evidence remains very low Secondly, we searched for the highest level of statistical evidence concerning the diagnosis of venous thrombosis/thromboembolism in patients who underwent COVID-19 infection (key search terms were "COVID-19", alternatively, "coronavirus", and "SARS-CoV-2", and "thrombosis", alternatively, "thromboembolism") and included the most recent systematic reviews and meta-analyses that were published in 2024 (from 1 January 2024 until 8 July 2024). After excluding data on vaccination against coronavirus or long COVID-19 syndrome, we identified six such articles. To conclude, we presented a probably unique case of malignancy with an initial manifestation consisting of recurrent superficial vein thrombosis under anticoagulation therapy, with no gastrointestinal manifestations, in a patient with a notable history for multiple episodes of SARS-CoV-2 infection and a prior endocrine (gastric) surgery. To our knowledge, this is the first identification of a CCA under these specific circumstances.

The Constellation of Risk Factors and Paraneoplastic Syndromes in Cholangiocarcinoma: Integrating the Endocrine Panel Amid Tumour-Related Biology (A Narrative Review)

Cholangiocarcinomas (CCAs), a heterogeneous group of challenging malignant tumours which originate from the biliary epithelium, are associated with an alarming increasing incidence during recent decades that varies between different regions of the globe. Thus, awareness represents the key operating factor. Our purpose was to overview the field of CCAs following a double perspective: the constellation of the risk factors, and the presence of the paraneoplastic syndromes, emphasizing the endocrine features amid the entire multidisciplinary panel. This is a narrative review. A PubMed-based search of English-language original articles offered the basis of this comprehensive approach. Multiple risk factors underlying different levels of statistical evidence have been listed such as chronic biliary diseases and liver conditions, inflammatory bowel disease, parasitic infections (e.g., Opisthorchis viverrini, Clonorchis sinensis), lifestyle influence (e.g., alcohol, smoking), environmental exposure (e.g., thorotrast, asbestos), and certain genetic and epigenetic interplays. With regard to the endocrine panel, a heterogeneous spectrum should be taken into consideration: non-alcoholic fatty liver disease, obesity, type 2 diabetes mellitus, and potential connections with vitamin D status, glucagon-like peptide 1 receptor, or the galanin system, respectively, with exposure to sex hormone therapy. Amid the numerous dermatologic, hematologic, renal, and neurologic paraneoplastic manifestations in CCAs, the endocrine panel is less described. Humoral hypercalcaemia of malignancy stands as the most frequent humoral paraneoplastic syndrome in CCAs, despite being exceptional when compared to other paraneoplastic (non-endocrine) manifestations and to its reported frequency in other (non-CCAs) cancers (it accompanies 20-30% of all cancers). It represents a poor prognosis marker in CCA; it may be episodic once the tumour relapses. In addition to the therapy that targets the originating malignancy, hypercalcaemia requires the administration of bisphosphonates (e.g., intravenous zoledronic acid) or denosumab. Early detection firstly helps the general wellbeing of a patient due to a prompt medical control of high serum calcium and it also provides a fine biomarker of disease status in selected cases that harbour the capacity of PTHrP secretion. The exact molecular biology and genetic configuration of CCAs that display such endocrine traits is still an open matter, but humoral hypercalcaemia adds to the overall disease burden.

Enhancing Outcomes in Prosthetic Joint Infections: The Significance of the Periprosthetic Joint Infection Tumor, Node, and Metastasis (PJI-TNM) Classification and Biodegradable Antibiotic Beads

BACKGROUND AND OBJECTIVES

Periprosthetic joint infections (PJIs) that occur after hip and knee arthroplasty have a major influence on patient outcomes and healthcare expenses. This study assesses the effectiveness of the PJI tumor, node, and metastasis (PJI-TNM) categorization system and the latest developments in local antibiotic delivery methods for the treatment of PJIs.

MATERIALS AND METHODS

The study involved a retrospective analysis of 23 patients who received treatment for septic hip or knee prostheses at the SUUB Orthopedics and Traumatology Clinic between January 1, 2022, and February 10, 2024. Approval was gained following ethical considerations. Patients were categorized using the PJI-TNM system, and their therapy was customized based on the severity of the infection. The surgical procedures involved either one-stage or two-stage revisions, utilizing vancomycin and gentamicin antibiotic-loaded calcium sulfate beads to administer antibiotics locally. Data pertaining to demographics, clinical characteristics, and microbiology were gathered and examined.

RESULTS

The study comprised 14 male and 9 female patients, with an average age of 68 years. The presence of chronic infections was mostly seen, indicating the development of mature biofilm. Prevalent coexisting medical conditions included diabetes, obesity, and heart failure. The duration of infection control measures was, on average, six months, and 65% of patients reported experiencing enhanced mobility. Acute infections with positive antibiotic responses underwent one-stage modifications. For the majority of patients, a treatment approach involving two-stage modifications, which includes the use of antibiotic-loaded spacers followed by the installation of a prosthesis, proved to be beneficial.

CONCLUSIONS

The PJI-TNM classification system improves the management of PJI by offering a systematic method for customized therapy. Calcium sulfate beads, which are biodegradable carriers for antibiotics, provide notable advantages, especially for individuals with severe comorbidities. Continuous progress in diagnostic techniques and localized administration of antibiotics is essential for enhancing the therapy of PJI and improving patient outcomes.

Predictive Factors for Total Knee Arthroplasty: An Observational Study

Introduction Knee osteoarthritis (KOA) is the most common form of osteoarthritis. It is diagnosed based on clinical symptoms, physical examination, and imaging, most frequently by knee X-ray in at least two views. In front of a patient with early KOA, all the predictive factors and risk factors that can be modified, but also that can lead to a rapid evolution of the symptoms and the need for total knee arthroplasty (TKA), must be taken into account and identified. There were a series of prognostic factors associated with KOA, such as age, sex, BMI, degree of physical activity, decrease in bone mineral density, C-reactive protein, malalignment, clinical severity at baseline, and previous traumas. The treatment of KOA is varied and involves pharmacological and non-pharmacological measures and surgical treatment in the final stages of evolution. Materials and methods In the University Emergency Hospital of Bucharest, Bucharest, Romania, patients with KOA presented to the Department of Orthopedics and Traumatology, and those who required surgical treatment, such as TKA, arthroscopy, or non-surgical treatment, were enrolled. We conducted a descriptive and prospective observational study that included 70 patients clinically and imaging diagnosed with KOA. The inclusion criteria consisted of a patient over 45 years old with knee pain and radiological signs of KOA. The exclusion criteria referred to patients with recent traumatic history, signs of active osteoarticular infection, the lack of radiological changes of KOA that imposed the differential diagnosis, patients known to have rheumatological diseases in the Algic phase, and patients in whom it was not possible to collect complete required data. Results Patients who required TKA were older (65.12 ± 8.19 years) than patients who required other therapeutic interventions (52.55 ± 3.63 years), the difference of 12.57 years being statistically significant (t = -8.882, p ≤ 0.001). Women were more than three times more likely to require TKA than men (80.85% vs. 52.17%, OR = 3.87, CI [1.29, 11.56]). Patients with HBP were more than four times more likely to require TKA than patients without HBP (78.57% vs. 42.86%, OR = 4.88, CI [1.42, 16.82]). Patients with elevated ESR were more than 26 times more likely to require TKA than patients with normal ESR (96.67% vs. 52.50%, OR = 26.23, CI [3.25, 211.67]). There are statistically significant differences between the non-TKA group (mean rank = 60.20) and TKA patients' score (mean rank = 25.62) (U = 6.000, Z = -6.606, p ≤ 0.001). Thus, patients who required TKA had a significantly lower KSS score than patients who required other treatments. Conclusion According to the data obtained in the studied group of patients, the characteristics of the patient at high risk of requiring TKA are the following: a female patient over 65 years of age who associates hypertension, high ESR, and fibrinogen values ​​with KSS score and KSS function with low values, recording an average value of 56.70.

Enchondroma in the Fibular Diaphysis: A Case Report

Chondroma is a benign tumor formation that occurs through the proliferation of cartilaginous tissue. It can be located centrally (enchondroma) or peripherally, often appears between 10-30 years of age, and is commonly discovered incidentally. This case report describes a 46-year-old woman presenting with pain in the left calf and partial functional impotence. The onset of her symptoms was affirmatively marked by a mild skiing-related trauma. Following protocol, X-ray imaging (antero-posterior and lateral views) of the calf was performed, with the only finding being a solitary bony lesion, with internal calcifications, sclerotic margin and radiolucent internal matrix. Facing the uncertainty of diagnosis from a clinical and radiographic standpoint, it was decided to admit the patient for further evaluation and start the standard protocol of imaging investigations - computed tomography, magnetic resonance imaging, and bone scintigraphy - and determine the subsequent therapeutic behavior. Differential diagnosis between enchondroma and low-grade chondrosarcoma can be difficult due to their histopathological similarity. The therapy of choice in enchondroma comprises non-surgical treatment (observation) if the lesion remains unaltered in imaging, or curettage/filling with bone substitutes/allografts, but considering the advanced age and interruption of the bone cortex in our case, we opted for curative surgical treatment.

Diabetes Mellitus in Non-Functioning Adrenal Incidentalomas: Analysis of the Mild Autonomous Cortisol Secretion (MACS) Impact on Glucose Profile

Non-functioning adrenal incidentalomas (NFAIs) have been placed in relationship with a higher risk of glucose profile anomalies, while the full-blown typical picture of Cushing's syndrome (CS) and associated secondary (glucocorticoid-induced) diabetes mellitus is not explicitly confirmed in this instance. Our objective was to highlight the most recent data concerning the glucose profile, particularly, type 2 diabetes mellitus (T2DM) in NFAIs with/without mild autonomous cortisol secretion (MACS). This was a comprehensive review of the literature; the search was conducted according to various combinations of key terms. We included English-published, original studies across a 5-year window of publication time (from January 2020 until 1 April 2024) on PubMed. We excluded case reports, reviews, studies on T1DM or secondary diabetes, and experimental data. We identified 37 studies of various designs (14 retrospective studies as well 13 cross-sectional, 4 cohorts, 3 prospective, and 2 case-control studies) that analysed 17,391 individuals, with a female-to-male ratio of 1.47 (aged between 14 and 96 years). T2DM prevalence in MACS (affecting 10 to 30% of NFAIs) ranged from 12% to 44%. The highest T2DM prevalence in NFAI was 45.2% in one study. MACS versus (non-MACS) NFAIs (n = 16) showed an increased risk of T2DM and even of prediabetes or higher fasting plasma glucose or HbA1c (no unanimous results). T2DM prevalence was analysed in NFAI (N = 1243, female-to-male ratio of 1.11, mean age of 60.42) versus (non-tumour) controls (N = 1548, female-to-male ratio of 0.91, average age of 60.22) amid four studies, and two of them were confirmatory with respect to a higher rate in NFAIs. Four studies included a sub-group of CS compared to NFAI/MACS, and two of them did not confirm an increased rate of glucose profile anomalies in CS versus NFAIs/ACS. The longest period of follow-up with concern to the glycaemic profile was 10.5 years, and one cohort showed a significant increase in the T2DM rate at 17.9% compared to the baseline value of 0.03%. Additionally, inconsistent data from six studies enrolling 1039 individuals that underwent adrenalectomy (N = 674) and conservative management (N = 365) pinpointed the impact of the surgery in NFAIs. The regulation of the glucose metabolism after adrenalectomy versus baseline versus conservative management (n = 3) was improved. To our knowledge, this comprehensive review included one of the largest recent analyses in the field of glucose profile amid the confirmation of MACS/NFAI. In light of the rising incidence of NFAI/AIs due to easier access to imagery scans and endocrine evaluation across the spectrum of modern medicine, it is critical to assess if these patients have an increased frequency of cardio-metabolic disorders that worsen their overall comorbidity and mortality profile, including via the confirmation of T2DM.

Brown Tumors: The Hidden Face of Primary and Renal Hyperparathyroidism Amid Real-Life Settings

Brown tumors, an exceptional bone complication of severe primary (PHP) or renal (secondary) hyperparathyroidism (RHP), are caused by long-standing, elevated parathormone (PTH)-induced osteoclast activation causing multinucleated giant cell conglomerates with hemosiderin deposits in addition to the local production of cytokines and growth factors. We aim to present an adult case series including two females displaying this complication as part of a multidisciplinary complex panel in high PTH-related ailments. The approach was different since they had distinct medical backgrounds and posed a wide area of challenges amid real-life settings, namely, a 38-year-old lady with PHP and long-term uncontrolled hypercalcemia (with a history of pregnancy-associated PHP, the removal of a cystic jaw tumor, as well as a family and personal positive diagnosis of polycystic kidney disease, probably a PHP-jaw tumor syndrome), as well as, a 26-year-old woman with congenital single kidney and chronic renal disease-associated RHP who was poorly controlled under dialysis and developed severe anemia and episodes of metabolic acidosis (including one presentation that required emergency hemodialysis and was complicated with convulsive seizures, followed by resuscitated respiratory arrest). Both subjects displayed a severe picture of PHP/RHP with PTH levels of >1000 pg/mL and >2000 pg/mL and elevated serum bone turnover markers. Additionally, they had multiple brown tumors at the level of the ribs and pelvis (asymptomatically) and the spine, skull, and pelvis (complicated with a spontaneous cervical fracture). As an endocrine approach, the control of the underlying parathyroid disease was provided via surgery in PHP (for the postparathyroidectomy hungry bone syndrome) via medical intervention (with vitamin D analogs) in RHP. Additionally, in this case, since the diagnosis was not clear, a multidisciplinary decision to perform a biopsy was taken (which proved inconclusive), and the resection of the skull tumor to confirm the histological traits. This series highlights the importance of addressing the entire multidisciplinary panel of co-morbidities for a better outcome in patients with PHP/RHP-related brown tumors. However, in the instance of real-life medicine, poor compliance and reduced adherence to recommendations might impair the overall health status. Thus, sometimes, a direct approach at the level of cystic lesion is taken into consideration; this stands for a narrow frame of decision, and it is a matter of personalized decision. As seen here, brown tumors represent the hidden face of PHP/RHP, primarily the complex and severe forms, and awareness is essential even in the modern era.

Endocrine Petrified Ear: Associated Endocrine Conditions in Auricular Calcification/Ossification (A Sample-Focused Analysis)

Petrified ear (PE), an exceptional entity, stands for the calcification ± ossification of auricular cartilage (CAC/OAC); its pathogenic traits are still an open matter. Endocrine panel represents one of the most important; yet, no standard protocol of assessments is available. Our objective was to highlight most recent PE data and associated endocrine (versus non-endocrine) ailments in terms of presentation, imagery tools, hormonal assessments, biopsy, outcome, pathogenic features. This was a comprehensive review via PubMed search (January 2000-March 2024). A total of 75 PE subjects included: 46 case reports/series (N = 49) and two imagery-based retrospective studies (N = 26) with CAC/OAC prevalence of 7-23% (N = 251) amid routine head/temporal bone CT scans. Endocrine PE (EPE): N = 23, male/female ratio = 10.5; average age = 56.78, ranges: 22-79; non-EPE cohort: N = 26; male/female ratio = 1.88, mean age = 49.44; ranges: 18-75 (+a single pediatric case).The longest post-diagnosis follow-up was of 6-7 years. The diagnosis of PE and endocrine anomalies was synchronous or not (time gap of 10-20 years). A novel case in point (calcified EPE amid autoimmune poly-endocrine syndrome type 2 with a 10-year post-diagnosis documented follow-up) was introduced. We re-analyzed EPE and re-classified another five subjects as such. Hence, the final EPE cohort (N = 50) showed: adrenal insufficiency was the most frequent endocrine condition (36%) followed by hypopituitarism (22%) and hypothyroidism (18%); 39% of the patients with adrenal failure had Addison's disease; primary type represented 72% of all cases with hypothyroidism; an endocrine autoimmune (any type) component was diagnosed in 18%. We propose the term of "endocrine petrified ear" and a workflow algorithm to assess the potential hormonal/metabolic background in PE.

Personalized Management of Malignant and Non-Malignant Ectopic Mediastinal Thyroid: A Proposed 10-Item Algorithm Approach

We aimed to analyze the management of the ectopic mediastinal thyroid (EMT) with respect to EMT-related cancer and non-malignant findings related to the pathological report, clinical presentation, imaging traits, endocrine profile, connective tissue to the cervical (eutopic) thyroid gland, biopsy or fine needle aspiration (FNA) results, surgical techniques and post-operatory outcome. This was a comprehensive review based on revising any type of freely PubMed-accessible English, full-length original papers including the keywords "ectopic thyroid" and "mediastinum" from inception until March 2024. We included 89 original articles that specified EMTs data. We classified them into four main groups: (I) studies/case series (n = 10; N = 36 EMT patients); (II) malignant EMTs (N = 22 subjects; except for one newborn with immature teratoma in the EMT, only adults were reported; mean age of 62.94 years; ranges: 34 to 90 years; female to male ratio of 0.9). Histological analysis in adults showed the following: papillary (N = 11/21); follicular variant of the papillary type (N = 2/21); Hürthle cell thyroid follicular malignancy (N = 1/21); poorly differentiated (N = 1/21); anaplastic (N = 2/21); medullary (N = 1/21); lymphoma (N = 2/21); and MALT (mucosa-associated lymphoid tissue) (N = 1/21); (III) benign EMTs with no thyroid anomalies (N = 37 subjects; mean age of 56.32 years; ranges: 30 to 80 years; female to male ratio of 1.8); (IV) benign EMTs with thyroid anomalies (N = 23; female to male ratio of 5.6; average age of 52.1 years). This panel involved clinical/subclinical hypothyroidism (iatrogenic, congenital, thyroiditis-induced, and transitory type upon EMT removal); thyrotoxicosis (including autonomous activity in EMTs that suppressed eutopic gland); autoimmune thyroiditis/Graves's disease; nodules/multinodular goiter and cancer in eutopic thyroid or prior thyroidectomy (before EMT detection). We propose a 10-item algorithm that might help navigate through the EMT domain. To conclude, across this focused-sample analysis (to our knowledge, the largest of its kind) of EMTs, the EMT clinical index of suspicion remains low; a higher rate of cancer is reported than prior data (18.8%), incident imagery-based detection was found in 10-14% of the EMTs; surgery offered an overall good outcome. A wide range of imagery, biopsy/FNA and surgical procedures is part of an otherwise complex personalized management.

Garrè Sclerosing Osteomyelitis of the Clavicle: Clinical Results after Clavicular Resection

(1) Background: Chronic non-bacterial osteomyelitis (CNO), also known as sclerosing osteomyelitis of Garrè, is a rare inflammatory bone disease with a specific clinical picture, uncertain pathogenesis, and no consensus on an effective treatment. Most frequently affecting other long bones, CNO may rarely involve the clavicle. The aim of this study was to present the results of a series of patients affected by CNO of the clavicle treated with total and partial clavicula resection. In addition, a literature review of different types of treatment of CNO was performed. (2) Methods: We retrospectively reviewed three patients with Sclerosing Osteomyelitis of Garre' of the clavicle treated with partial resection of the clavicle (one) and with total clavicular resection (two). (3) Results: Patients (two female and one male) were an average age of 35.7 years at the time of the operation. At the 4-year follow-up, the mean active ROM was: 143° forward flexion, 133° abduction, 42° external rotation with an internal rotation of two patients at the interscapular level and one patient at the lumbosacral junction. The mean ASES score was 92/100 (range 87-100). In the literature review, after screening the abstracts and full texts for eligibility, 34 studies met the inclusion criteria. Conclusions: Partial or total clavicular resection resulted an effective treatment of CNO of the clavicle. The procedure seems to be particularly indicated after the failure of more conservative treatments.

Application of graphene oxide in tumor targeting and tumor therapy

Graphene oxide (GO), as a kind of two-dimensional sp2 carbon nanomaterials, has attracted great attention in many fields in the past decade. Due to its unique physical and chemical properties, GO is showing great promise in the field of biomedicine. For GO, all the atoms on its surface are exposed to the surface with ultra-high specific surface area, and a variety of groups on the surface, such as carboxyl, hydroxyl and epoxy groups, can effectively bind/load various biomolecules. Due to the availability of these groups, GO also possesses excellent hydrophilicity and biocompatibility for the modification of the desired biocompatible molecules or polymers on the surface of GO. The nano-network structure and hydrophobicity of GO enable it to load a large number of hydrophobic drugs containing benzene rings and it has been widely used as a multi-functional nano-carrier for chemotherapeutic drug or gene delivery. This review article will give an in-depth overview of the synthesis methods of GO, the advantages and disadvantages of GO used in nano-drug delivery system, the research progress of GO as a stimulus-responsive nano-drug carrier, and the application of these intelligent systems in cancer treatment.

The Role of Serum and Peritoneal Biomarkers in Predicting Sepsis and Septic Multiorgan Failure in Patients With Secondary Peritonitis

Purpose Secondary peritonitis is still one of the most important causes of severe sepsis in the world; therefore, it is of utmost importance to identify biomarkers that could be employed for the purpose of selecting patients at high risk for developing life-threatening complications after emergency surgery. In view of this quest, our study seeks to reveal the possible role for serum and peritoneal concentrations of selected biomarkers, specifically presepsin, procalcitonin, monocyte chemoattractant protein-1 (MCP-1), high mobility group box 1 protein (HMGB-1) and interleukins (IL-6, -8, -10), in early prediction of sepsis and septic multiorgan failure for patients with secondary peritonitis. Methods We prospectively observed 32 selected patients with secondary peritonitis that underwent emergency surgery. Blood and peritoneal fluid samples were drawn at the time of surgery (T0), and after that, blood samples were taken at 24 (T1) and 48 (T2) hours postoperatively. Cytokines concentrations were determined using a sandwich enzyme-linked immunosorbent assay (ELISA), a non-competitive variant, both in peritoneal fluid and serum. For determining whole blood concentration of presepsin and procalcitonin, PATHFAST™ assays (Polymedco, Cortlandt, New York) were used, based on the principle of non-competitive chemiluminescent enzyme immune-assay (CLEIA). The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of University Emergency Hospital Bucharest (no. 40325/6 April 2023). Results We found significant elevations in the peritoneal concentrations of interleukins 6, 8, 10, HMGB-1, and MCP-1 in all patients with secondary peritonitis at the moment of surgery; however, no clear correlation could be made based on this data with patient evolution. With regards to blood concentrations of the aforementioned serum cytokines and presepsin, procalcitonin (as already established markers of sepsis), our results showed good predictive value of presepsin for developing sepsis and septic multiorgan failure from the first hours in this patient category. All other biomarkers, despite having higher concentrations than baseline, in particular at 24-48 hours after surgery, had unpredictable dynamics that couldn't be correlated with the severity of the disease. Conclusion Cytokine production is the mainstay in developing sepsis and septic multiorgan failure in patients with secondary peritonitis; therefore, studying the dynamics of said cytokines seems of interest in finding tools to predict the development of sepsis or sepsis-related mortality. However, at the time, there seemed to be no clear correlation between the values of these cytokines and the development of complications.

Restoring Anatomical Features in Primary Total Knee Arthroplasty

Today, the number of people affected by gonarthrosis symptoms is increasing proportionally. Total knee arthroplasty (TKA) is a successful intervention that aims to reduce pain and restore knee function. However, studies have shown that active young patients still have limitations in performing activities such as skiing, golfing, surfing, and dancing. Over the last few years, total knee arthroplasty has undergone significant changes. Most of the modern TKA implants are designed to reproduce the normal biomechanics of the knee joint, mimicking the physiological pattern with greater compliance in the medial compartment between the tibial insert and femoral condyle and less congruence on the lateral side. Unfortunately, functional outcomes are compromised in approximately half of TKA patients. This loss may be caused by the abnormal kinematics and inherent instability of many contemporary implants. The proper alignment of the femoral component during TKA is a crucial step that influences postoperative results. The position of the femoral component in the axial plane is responsible for flexion stability, knee joint kinematics, flexion alignment, and patellar tracking. The main goal when choosing a type of prosthesis is to achieve an adequate recovery that leads to an improvement in mobility and an increase in the efficiency of the quadriceps.

Cerebral Tuberculosis in a Patient Following Treatment With Infliximab for Ankylosing Spondylitis: A Case Report

Ankylosing spondylitis (AS) mainly belongs to the group of axial spondylitis. It is a chronic inflammatory disease that primarily affects the spine, but can also affect peripheral joints. It is characterized by inflammatory lower back pain and morning stiffness. Tuberculosis is still a cause of morbidity and mortality in developing countries. Management of patients with AS consists of patient education, spinal mobility exercises, non-steroidal anti-inflammatory drugs (NSAIDs), corticotherapy, and anti-tumor necrosis factor alpha (TNF-α) biological agents. Anti-TNF-α biological agents have changed the prognosis of patients with AS. They contain anti-TNF-α monoclonal antibodies (golimumab, infliximab, adalimumab, certolizumab) and the soluble TNF-α receptor (etanercept). Hip and knee involvement is common in patients with AS, as evidenced in radiographs as bone erosion and joint space narrowing. The patient may have severe pain, stiffness, and loss of mobility, and the treatment involves surgery for joint arthroplasty. We present the case of a 63-year-old patient with axial spondyloarthritis who was treated with infliximab and developed cerebral tuberculosis after three years of biological therapy. The purpose of the study is to determine the possibility of resuming biological therapy at the time of AS reactivation, given the long-term treatment and adverse reactions of cortisone therapy (aseptic necrosis of the femoral head).

A Narrative Review of Patellar Resurfacing Versus Non-resurfacing in Total Knee Arthroplasty

The number of individuals who experience the symptoms of gonarthrosis rises proportionally as life expectancy rises and the population becomes more active. The purpose of total knee arthroplasty (TKA) is to lessen pain and restore knee function, and it has a high success rate. The restoration of patellar tracking in addition to the proper alignment of the femoral and tibial components contributes to the success of the arthroplasty and the patient's happiness. Replacement of the knee is not an easy process. One of the major objectives of total knee replacement is to achieve the proper rotation of the femoral components. A critical step that affects postoperative outcomes in total knee arthroplasty is the correct alignment of the femoral component. The axial plane of the femoral component is to blame for flexion stability, knee joint kinematics, flexion alignment, and patellar tracking. The patella is the largest sesamoid bone in the human body, and its major role is to enhance the quadriceps' moment arm, which allows the knee to expand. The distribution of patellofemoral compressive pressures during knee flexion and the centralization of the quadriceps muscles' multidirectional pull during extension are both critical functions of the patella. After primary knee arthroplasty, there are 8% more cases of anterior knee discomfort than there were before. Whether or not the patella was resurfaced, patients with primary TKA experience anterior knee discomfort. Patella baja is caused by excessive joint line elevation, which causes persistent overload and discomfort. The design of the TKR might have an impact on postoperative patellofemoral problems. After TKR, patellofemoral maltracking and patellar dislocation are often caused by surgical mistakes.