Infection after spinal surgery and procedures

Postoperative infections after spinal surgery are a challenging issue, difficult to diagnose and treat, that requires prolonged medical therapy and even surgery. In this paper, we aim to review the current standards in the diagnosis and treatment of post-procedural Spondylodiscitis (SD). We performed a review of the available literature focusing on diagnostic and therapeutic standards of post-procedural SD, both after minimally invasive procedures and open surgery. Spinal infections can occur in less invasive procedures with an incidence ranging from 0.26% to 2.75%. Post-surgical spinal infections range from 2.1% to 8.5% for instrumented surgery, whereas these are less than 1% in open surgery without instrumentation. MRI is currently the most sensitive and specific technique to diagnose postoperative SD. CT guided aspiration culture should be performed in all patients with deep-seated infections with negative blood cultures. Early infections start with wound healing problems within a few weeks from surgery, and the occurrence of fever and an increase in serum markers of inflammation. Late infections often cause chronic pain, implant failure, non-union or wound dehiscence even a long time after surgery. The onset of the infection differentiates the specific treatment. Indeed, in the early postoperative period spinal fusion is not appropriate yet, and the stability of the fusion site only relies on the instrumentation. Therefore, even when suitable, implant removal may lead to undesirable consequences. In chronic infections, on the other hand, implant removal is unlikely to determine instability since the fusion has already been accomplished.

Hybrid hyaluronic acid versus high molecular weight hyaluronic acid for the treatment of osteoarthritis in obese patients

Osteoarthritis (OA) of the knee is one of the most relevant and debilitating health problems. Obesity represents one of the major risk factor for early development of OA. In the obese population, knee replacement should be delayed and eventually avoided and prefer conservative treatments including intrarticular hyaluronic acid (HA) viscosupplementation. In the present clinical randomized trial, we present a comparison between two groups of 24 obese patients which were randomized to be treated with two intrarticular injections of hybrid (low and high molecular weight) hyaluronic acid (Group A) or two injections of high molecular weight hyaluronic acid (Group B). Patients were followed-up through to 6 months and assessed though IKDC and KOOS scores, pain was evaluated with VAS. All patients reported a significant improvement when compared to baseline value in all outcome measures. At 3-month follow-up, IKDC had significantly improved in patients of Group A, compared to Group B (53.1±1.9 vs 51.4±2.4, p=0.0079) and the same for KOOS (52.1±2.0 vs 50.1±2.9, p=0.010). Furthermore, the difference in KOOS was persistently significant at 6-month follow-up (54.7±2.3 vs 51.7±4.9, p=0.014). The VAS reduced significantly more in Group A at 3 months (3.7±0.5 vs 5.2±0.7, p less than 0.001). In an obese population, where basal inflammatory pattern increases symptoms of OA and conservative treatment is recommended, HA viscosupplementation improved function and pain of the knee. The treatment with hybrid HA showed better outcomes than high molecular weight HA in obese patients. The combination of the anti-inflammatory action of low molecular weight HA on chondrocytes and the biomechanical role of high molecular weight HA might explain the different results.

Intrarticular injections of hyaluronic acid for trapezio-metacarpal osteoarthritis: a systematic review

Osteoarthritis (OA) of the base of the thumb, also known as Trapezio-Metacarpal (TM) OA, is a disabling condition, which mainly affects women and manual workers. When TM OA is not adequately treated, patients develop deformity and loss of function of the thumb. The surgical approach is a widespread strategy to treat this condition, but there is still no consensus on the most effective procedure. Therefore, several conservative strategies are commonly used, such as nonsteroidal anti-inflammatory drugs (NSAIDs) administration, thumb strengthening exercise, splinting, steroid (CS) and hyaluronic acid (HA) intrarticular injections. The present review of the literature aims to summarize the available scientific evidence on the treatment of TM OA with injections of HA. Thirteen studies were included: 7 randomized controlled trials, 5 case series and a case-control study. Among these, 5 studies compared HA versus CS injection. Results from most of them reported better outcomes with HA injections in terms of function (strength) and joint motion, while CS injections had greater effect on pain; moreover, CS action was faster but shorter, while HA required more time to obtain a therapeutic benefit and lasted longer. In non-comparative articles, this trend was also confirmed. Indeed, the authors reported an improvement in pain relief up to six months. Similarly, all studies indicated hand function improvement over time, measured though DASH score, pincher and grip strength tests. Available data from included studies show that there is no clear evidence to suggest a treatment with HA injections as the best advisable non-operative treatment for TM OA. However, promising potentials were shown by the randomized controlled trials, suggesting that there is some benefit and less comorbidities with the administration of HA. Further research, such as trials evaluating larger cohorts with validated scores for long-term follow-up, is still necessary.

The use of hyaluronic acid in the treatment of ankle osteoarthritis: a review of the evidence

Ankle osteoarthritis (OA) is a progressive degenerative joint disease that causes ankle pain and functional limitation especially during walking. It tends to involve younger people with high functional request and has often a post-traumatic origin. Symptoms control through conservative treatment is essential to procrastinate as long as possible the need for surgery. Although few data are present in literature about the use of local viscosupplementation in ankle OA, their potential use for ankle OA has been suggested. We systematically reviewed literature to evaluate the best evidence about short and long term effectiveness of intra-articular HA injections in the treatment of ankle OA. After having screened titles and abstracts from PubMed, Ovid, Cochrane Reviews, Google Scholar, we identified 14 full text articles and collected the outcome rates of intra-articular cycles of HA injections in patients with symptomatic ankle OA. Only 4 randomized control trials were included. Ankle Osteoarthritis Scales (AOS), American Orthopedic Foot, Ankle Society (AOFAS) clinical rating score, visual analog scales (VAS), Western Ontario and McMaster Universities (WOMAC) OA Index of Pain, Stiffness, and Physical Function Score were most frequently used to evaluate outcomes. Although randomized trials showed scores improvement also in placebo-treated patients, current evidence suggests that viscosupplementation for treatment of ankle OA is a safe and effective method. More randomized controlled trials with a large number of patients that compare not only the different types, dosages and frequency of HA injections, but also the effectiveness of HA versus corticosteroids infiltrations and HA versus other types of conservative treatment are still needed.

Biomechanical and neural changes evaluation induced by prolonged use of non-stable footwear: a systematic review

The aim of this review is to collect and discuss the current best evidence published in literature about the effect of the Masai Barefoot Technology(MBT) shoes on gait and muscle activation and try to draw conclusions on the possible benefits. We searched Medline, CINAHL, Embase and the Cochrane Central Registry of Controlled Trials. The reference lists of the previously selected articles were then examined by hand. Only studies comparing biomechanical and clinical outcomes were selected. Review, anatomical studies, letter to editor and instructional course were excluded. Finally, all the resulting articles were reviewed and discussed by all the authors to further confirm their suitability for this review: in the end, 22 articles were included. A total of 532 patients presenting a mean age of 34.3 years were studied. All patients evaluated were healthy or amateur sports except in two studies where only obese subjects and knee osteoarthritis patients were involved. Seven studies evaluated only male subjects, whereas four studies evaluated only female. Twelve of twenty-two studies performed electromyographic analyses. Weight was reported in 19 studies, whereas body mass index were reported only in a five studies. All studies reported kinematic analysis of shoe effects and compared the relationship between muscle recruitment and electromyographic activity. Unstable footwears were shown to immediately alter the stability in gait during daily-life activities. The center of body pressure is moved posteriorly with a consequent posterior displacement of the upper part of body in order to regain an appropriate body balance, and these postural changes are associated with an overall increase in the activity of lumbar erector spine muscles, as well as certain lower limb muscles. Current literature provides enough cues to conclude for a beneficial role of MBT shoes in the postural and proprioceptive recovery, but from the same literature cannot be drown clear and appropriate guidance to determine more in detail their indication for specific pathological conditions or for particular phases of the musculoskeletal recovery process.

Sarcopenia and its relationship with osteoarthritis: risk factor or direct consequence?

PURPOSE

The aim of this review is to evaluate the clinical role of sarcopenia in patients affected by osteoarthritis (OA) of major joints.

METHODS

An online database research was performed, in order to retrieve all articles investigating the relationship between sarcopenia and OA. No peer-reviewed journal was excluded. Papers in English, French, Spanish and Italian language were considered. After consulting the full-text article, five studies have been included in the review.

RESULTS

Of the five studies included, four are prospective studies and only one is a cross-sectional study which retrieved data retrospectively. A total of 4,231 patients, presenting a mean age of 62.0 years, were studied. Three studies evaluated only female subjects. Weight, height and body mass index were reported in all the articles. Knee OA has been assessed using the Kellgren-Lawrence grading system and the American college of rheumatology criteria. Alterations of the lean body mass on body weight ratio have been reported to be as a significant predictive parameter in two studies. Relationship between radiographic OA and an increase in the leg lean mass has been observed in one study.

CONCLUSIONS

We cannot support neither the thesis of a direct effect of sarcopenia on OA development nor the opposite relation, because the up-to-date literature lacks basic science studies concerning these topics. The absence of clinical studies regarding measurements and tools to compare sarcopenia and OA do not allow to definitely clarify this relationship.

Endothelial dysfunction and tendinopathy: how far have we come?

Symptomatic tendon tears are one of the most important causes of pain and joint dysfunction. Among the intrinsic causes, vascularization recently gained a major role. Endothelial function is indeed a key factor, as well as vascular tone and thrombotic factors, in the regulation of vascular homeostasis and the composition of vascular wall. In this review, we studied systematically whether there is a relationship between endothelial dysfunction and tendinopathy. A literature search was performed using the isolated or combined keywords endothelial dysfunction and tendon,' 'nitric oxide (NO) and tendinopathy,' and 'endothelial dysfunction in tendon healing.' We identified 21 published studies. Of the selected studies, 9 were in vivo studies, 2 focusing on animals and 7 on humans, while 12 reported about in vitro evaluations, where 7 were carried out on humans and 5 on animals. The evidence about a direct relationship between tendinopathy and endothelial dysfunction is still poor. As recent studies have shown, there is no significant improvement in clinical and functional assessments after treatment with NO in patients suffering from tendinopathy in different locations. No significant differences were identified in the outcomes reported for experiment group when compared with controls treated with conventional surgical procedures or rehabilitation programs. Nitric oxide could be a marker to quantify the response of the endothelium to mechanical stress or hypoxia indicating the final balance between vasodilatating and vasoconstricting factors and their effects, but more ad stronger evidence is still needed to fully support this practice.