Assessing the spreading potential of an undetected case of COVID-19 in orthopaedic surgery.

BACKGROUND: With the novel coronavirus-induced disease (COVID-19), there is the fear of nosocomial infections and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmissions to healthcare workers (HCW). We report the case of a 64-year-old male patient who underwent explantation of a shoulder prosthesis due to a periprosthetic infection. He was tested SARS-CoV-2 positive 7 days after admission to the orthopaedic department following strict infection control measures, routinely including screening all patients for multi-drug-resistant organism (MDRO) colonization upon admission. Aim of our study is to report on the spreading potential of SARS-CoV-2 in a healthcare setting if standard contact precautions and infection control measures have been established. METHODS: All HCW with exposure to the patient from day of admission until confirmed diagnosis of COVID-19 were identified and underwent oropharyngeal swab testing for SARS-CoV-2 by real-time RT-PCR. RESULTS: Sixty-six HCW were identified: nine orthopaedic surgeons, four anaesthesiologists, 25 orthopaedic nurses, five nurse anesthetists, eight scrub nurses, five nursing students, two medical assistants and seven service employees. Fourteen HCW (21%) showed clinical symptoms compatible with a SARS-CoV-2 infection: cough (n = 4), sore throat (n = 3), nasal congestion (n = 3), dyspnea (n = 2), fever (n = 1), headache and myalgia (n = 1). SARS-CoV-2 was not detected in any of the 66 HCW. CONCLUSION: Hygienic measures and contact precautions, aimed at preventing the spread of MRDO, may have helped to prevent a SARS-CoV-2 transmission to HCW-despite high-risk exposure during intubation, surgical treatment and general care. LEVEL OF EVIDENCE: IV, case series.

What is the Likelihood That Tumor Endoprostheses Will Experience a Second Complication After First Revision in Patients With Primary Malignant Bone Tumors And What Are Potential Risk Factors?

BACKGROUND: Endoprosthetic reconstruction of massive bone defects has become the reconstruction method of choice after limb-sparing resection of primary malignant tumors of the long bones. Given the improved survival rates of patients with extremity bone sarcomas, an increasing number of patients survive but have prosthetic complications over time. Several studies have reported on the outcome of first endoprosthetic complications. However, no comprehensive data, to our knowledge, are available on the likelihood of an additional complication and the associated risk factors, despite the impact of this issue on the affected patients. QUESTIONS/PURPOSES: (1) What are the types and timing of complications and the implant survivorship free from revision after the first complication? (2) Does survivorship free from repeat revision for a second complication differ by anatomic sites? (3) Is the type of first complication associated with the risk or the type of a second complication? (4) Are patient-, tumor-, and treatment-related factors associated with a higher likelihood of repeat revision? METHODS: Between 1993 and 2015, 817 patients underwent megaprosthetic reconstruction after resection of a tumor in the long bones with a single design of a megaprosthetic system. No other prosthetic system was used during the study period. Of those, 75% (616 of 817) had a bone sarcoma. Seventeen patients (3%) had a follow-up of less than 6 months, 4.5% (27 of 599) died with the implant intact before 6 months and 43% (260 of 599 patients) underwent revision. Forty-three percent of patients (260 of 599) experienced a first prosthetic complication during the follow-up period. Ten percent of patients (26 of 260) underwent amputation after the first complication and were excluded from further analysis. Second complications were classified using the classification of Henderson et al. to categorize surgical results. Briefly, this system categorizes complications as wound dehiscence (Type 1); aseptic loosening (Type 2); implant fractures or breakage and periprosthetic fracture (Type 3); infection (Type 4); and tumor progression (Type 5). Implant survival curves were calculated with the Kaplan-Meier method and compared using the log-rank test. Hazard ratios (HR) were estimated with their respective 95% CIs in multivariate Cox regression models. RESULTS: A second complication occurred in 49% of patients (115 of 234) after a median of 17 months (interquartile range [IQR] 5 to 48) after the surgery for the first complication. The time to complication did not differ between the first (median 16 months; IQR 5 to 57) and second complication (median 17 months; IQR 5 to 48; p = 0.976). The implant survivorship free from revision surgery for a second complication was 69% (95% CI 63 to 76) at 2 years and 46% (95% CI 38 to 53) at 5 years. The most common mode of second complication was infection 39% (45 of 115), followed by structural complications with 35% (40 of 115). Total bone and total knee reconstructions had a reduced survivorship free from revision surgery for a second complication at 5 years (HR 2.072 [95% CI 1.066 to 3.856]; p = 0.031) compared with single joint replacements. With the numbers we had, we could not show a difference between the survivorship free of revision for a second complication based on the type of the first complication (HR 0.74 [95% CI 0.215 to 2.546]; p = 0.535). We did not detect an association between total reconstruction length, patient BMI, and patient age and survivorship free from revision for a second complication. Patients had a higher risk of second complications after postoperative radiotherapy (HR 1.849 [95% CI 1.092 to 3.132]; p = 0.022) but not after preoperative radiotherapy (HR 1.174 [95% CI 0.505 to 2.728]; p = 0.709). Patients with diabetes at the time of initial surgery had a reduced survivorship free from revision for a second complication (HR 4.868 [95% CI 1.497 to 15.823]; p = 0.009). CONCLUSIONS: Patients who undergo revision to treat a first megaprosthetic complication must be counseled regarding the high risk of future complications. With second complications occurring relatively soon after the first revision, regular orthopaedic follow-up visits are advised. Preoperative rather than postoperative radiotherapy should be performed when possible. Future studies should evaluate the effectiveness of different approaches in treating complications considering implant survivorship free of revision for a second complication. LEVEL OF EVIDENCE: Level III, therapeutic study.

[Results of open arthrolysis for extrinsic elbow stiffness via radial access. Indications and limits of the procedure]. / Ergebnisse der offenen Arthrolyse bei extrinsischen Ellenbogensteifen über den radialen Zugang. Indikation und Grenzen des Verfahrens.

Open release of elbow stiffness via the lateral approach has proven to be a reliable option in the treatment of elbow stiffness over the last years. For evaluation of patient outcome after this procedure the current literature and studies were reviewed and analyzed with special reference to the increase in range of motion and patient satisfaction. It appears that particularly posttraumatic elbow stiffness with contracture of the capsule and minor alterations of the joint surface can achieve improvement in mobility and patient satisfaction. Therefore careful selection of patients is important for successful therapy.

Comparison of efficacy of supraspinatus tendon tears diagnostic tests: a prospective study on the "full-can," the "empty-can," and the "Whipple" tests.

PURPOSE: This study compares the clinical results of the Whipple, empty-can, and full-can tests to detect supraspinatus tendon tears. We determined the sensitivities, specificities, and positive and negative predictive values of each test with respect to the intraoperative supraspinatus tendon lesion confirmation. METHODS: We examined 61 patients (26 women, 35 men) presenting for arthroscopic surgery with functional disability or persisting shoulder pain. All the patients underwent Whipple, empty-can, and full-can testing. We correlated the clinical results of the tests with the confirmation of a supraspinatus tendon lesion by direct arthroscopic visualization. RESULTS: We examined 34 right and 27 left shoulders. For full and partial supraspinatus tendon tears, the Whipple test showed a sensitivity of 88.6% and a specificity of 29.4%, whereas the empty-can test and the full-can test had sensitivities of 88.6% and 75.0%, and specificities of 58.8% and 47.1%, respectively. CONCLUSIONS: Compared with the empty-can test and the full-can test, the Whipple test was less specific, while its sensitivity was equal to that of the empty-can test and higher than that for the full-can test. Because of its low specificity, the Whipple test has a high risk of false-positive results in comparison with the other tests.

Simultaneous removal of a locking plate and implantation of a reversed shoulder prosthesis in elderly patients suffering from fracture sequelae of the proximal humerus.

PURPOSE: Open reduction and internal fixation with a locking plate are performed frequently to treat fractures of the proximal humerus. Avascular necrosis and non-union or malunion are potential complications of this procedure, which lead to specific fracture sequelae. The aim of this study was to investigate the clinical and radiological results of patients treated by removal of a failed locking plate of the proximal humerus and simultaneous implantation of a reverse total shoulder prosthesis. METHODS: Twenty-one patients (f = 17, m = 4; mean age 70 years) out of 29 patients were available for follow-up after a mean period of 45 (30-65) months. At follow-up, all patients were assessed with the constant score and the ASES score as well as plain radiographs. RESULTS: In comparison with the preoperative values, abduction (31° vs. 115°; p < 0.001) and forward flexion (34° vs. 121°; p < 0.001) improved until follow-up, while the pain score on a visual analog scale decreased (6.7 vs. 0.9; p < 0.001). At follow-up, the mean ASES score rated 73 and the constant score rated 62. The radiologic findings included scapular notching (n = 7; 33%), radiolucency (n = 4; 19%), heterotopic ossifications (n = 3; 14%), and stress shielding (n = 4; 19%). CONCLUSION: Reverse total shoulder arthroplasty is a useful instrument for the treatment of failed locking plate osteosynthesis of the proximal humerus in elderly patients. The patients benefit from both pain relief and improved shoulder function. The rate of radiologic changes like scapular notching, radiolucency, stress-shielding and heterotopic ossifications at follow-up is notable.

Assessing impairment and disability for syndromes presenting with chronic fatigue.

Many disability claims are based on the subjective symptom of fatigue, which can be caused by a wide spectrum of diagnoses including fibromyalgia, chronic fatigue syndrome and cardiopulmonary diseases. Chronic pain is very often a compounding problem. It is vital for every insurer to have fair and objective criteria to distinguish between invalid claims and those with merit. This review article proposes objective tools and parameters to achieve this goal.

A comparative study of isoxicam and naproxen in rheumatoid arthritis.

A 4-week parallel-group, double-blind comparison of isoxicam 200 mg once daily and naproxen 250 mg 3 times daily was carried out on 30 patients with classic or definite rheumatoid arthritis. Fifteen patients were randomly assigned to each treatment group. The articular index, scoring on a pain scale and morning stiffness were significantly reduced after 2 and 4 weeks of treatment with both drugs. Grip strength was significantly increased after 4 weeks of naproxen treatment. The mean increase in grip strength was also comparable in isoxicam-treated patients, but did not reach statistical significance. Joint swelling and walking times showed improvement in both groups. One patient withdrew from isoxicam treatment with a pruritic rash considered to be drug-related and another stopped taking isoxicam because of dizziness, nausea and vomiting--also probably drug-related. Eight other patients, 4 treated with isoxicam and 4 with naproxen, reported adverse reactions associated with the digestive system. In this study isoxicam 200 mg taken once daily was similar in efficacy to and was associated with a similar incidence of adverse reactions as naproxen 250 mg taken 3 times daily. Both drugs were effective in the treatment of rheumatoid arthritis and were well tolerated.

Tenoxicam in soft-tissue rheumatism.

A randomized double-blind trial with tenoxicam 10 mg/d and 20 mg/d and placebo was carried out for 2 weeks in 90 patients suffering from various extra-articular inflammatory conditions. Statistical analysis revealed significant differences in favour of tenoxicam as regards improvement of all parameters with an intensity which was moderate or severe at baseline, e.g. tenderness, mobility pain, functional limitation. The efficacy of tenoxicam at both dosages was similar (no statistically significant difference). Tenoxicam was well tolerated but some mild adverse reactions were observed in all three treatment groups.

Osteoporosis in the rheumatoid hand--the effects of treatment with D-penicillamine and oral gold salts.

Osteoporosis is a common and important feature of rheumatoid disease which can be further influenced by the treatment administered. D-penicillamine, a lathyritic agent, can also theoretically hasten the osteoporotic process through its effect on collagen metabolism. In the present study the effects of the long-term second-line drugs D-penicillamine and oral gold (Auranofin) on bone density are presented. All the patients studied lost bone mineral over the 3-year period, but continuous D-penicillamine therapy for 1 year reversed this trend. Oral gold did not have the same effect. Measurements of bone density are an accurate indirect measurement of hand function, and there is a good correlation between hand function and the progress of osteoporosis. It is therefore suggested that treatment with D-penicillamine reverses the tendency to lose bone mineral improving synovitis, thus leading to improved hand function.

[Principles of treatment of gout and hyperuricemia]. / Die beginsels van die behandeling van jig en hiperurisemie.

Gout can be considered to be a group of diseases that are typified by acute arthritis, tophi and kidney stones. The acute attacks of arthritis should be treated with standard anti-inflammatory agents and the patient should receive maintenance therapy after the second acute attack. The dangers of asymptomatic hyperuricaemia are acute arthritis and uric acid kidney stones. Patients should be treated when the serum uric acid level is greater than 0,54 mmol/l or if the urinary uric acid excretion is greater than 4,2 mmol/l/24 h.

Diflunisal in rheumatoid arthritis. A controlled trial.

Diflunisal (Dolobid; Frosst-MSD) is an acetylsalicylic acid (ASA) derivative and has potential advantages over ASA, e.g. a longer half-life, higher potency and better tolerance. It has been shown to be effective as an analgesic in a variety of conditions. In a 12-week double-blind controlled trial diflunisal was compared with naproxen (Naprosyn; Syntex) in patients with rheumatoid arthritis. Suitable efficacy data were only available at week 4 owing to a number of withdrawals from the naproxen group. Both drugs, however, produced improvement in all the indices measured. At week 12 the initial improvement in the diflunisal group was maintained. Side-effects from diflunisal were mainly related to the gastro-intestinal tract but were not of serious nature; tinnitus and deafness did not occur. Diflunisal is an effective analgesic and also has anit-inflammatory action. It is a useful addition to the range of aspirin derivatives available for the treatment of rheumatoid arthritis.

Carprofen in soft-tissue rheumatism. A controlled trial.

A randomized double-blind clinical trial was carried out comparing carprofen (RO 20-5720) 300 mg/d and indomethacin 75 mg/d in patients with extra-articular inflammatory processes. The drugs were given for 7 days. In general carprofen appears to be well tolerated, and at the dosage used its efficacy was good and equal to that of indomethacin.

An oral gold formulation in rheumatoid arthritis. A 12-month follow-up report.

Oral gold(Auranofin; SKF) 6 mg/d has been used in an open study in 31 patients with active rheumatoid disease, 19 of whom have been on continuous treatment for 1 year. Four of these patients were considered to be in remission and 9 had a good clinical response to treatment. Four showed only minimal improvement and 2 did not improve at all. There were, however, no changes in the biochemical parameters of inflammation, e.g. haemoglobin concentration, erythrocyte sedimentation rate, platelet count and rheumatoid factor, or in renal and hepatic function. Of the 31 patients, 9 (29%) have discontinued treatment but only 3 (9.7%) because of side-effects. Minor side-effects have been fairly common, occurring in 19 patients (61%), and included skin rashes and pruritus, diarrhoea and loose stools, nausea, stomatitis and thrombocytopenia or leucopenia. Oral gold would seem to be a safer, less potent form of chrysotherapy than parenteral gold.

Penicillamine in rheumatoid arthritis: wound healing, skin thickness and osteoporosis.

D-Penicillamine alters the normal metabolism of collagen by inhibiting cross-linking and protein synthesis. This could affect wound healing, accelerate skin thinning and possibly exaggerate the osteoporosis of rheumatoid disease. The mean time to wound healing after 42 orthopaedic surgical operations in 21 patients treated with penicillamine was 19.8 (+/- 13.1) days. Compared with an earlier study, these results suggest that the drug has a comparable effect on would healing to corticosteroids given for three years. Skinfold thickness over the fourth metacarpal of the dominant hand was measured in 28 cases before and during penicillamine treatment. There was a significant decrease both in the first and second four-month periods of treatment (P less than 0.005 and P less than 0.01). Corticosteroids in constant dose did not have an additive effect. In view of the wound healing findings the significance of these results must await further sequential measurements. The normal progression of osteoporosis over three years was documented in 70 patients who had not received penicillamine. Penicillamine reversed this trend in 35 patients after one year of treatment (P less than 0.005). The results confirm that the osteoporosis is related to disease severity rather than drug therapy.

Gold therapy in rheumatoid arthritis.

Forty patients with active rheumatoid arthritis were treated with intramuscular injections of gold salts. A significant response was shown by 67,5% of the patients. Treatment was discontinued owing to side-effects in 35%. Dermatitis and proteinuria from renal damage were the commonest complications of treatment. The method of treatment and its side-effects are discussed.

Sporadic ulcero-osteolytic neuropathy in Blacks. A report of two cases.

The triad of a peripheral neuropathy, skin ulceration and destruction of bones and joints of the feet is called ulcero-osteolytic neuropathy, when other common causes of similar lesions have been excluded. Malnutrition, alcoholism and local trauma predispose to the development of the condition. It is to be differentiated from burnt-out leprosy, and is a chronic condition that eventually leads to characteristic deformities.

The radiographic appearance of the rheumatoid hand.

The early diagnosis of rheumatoid arthritis ensures a timeous prognosis and appropriate therapy for this chronic disease. The radiograph of the hand is a valuable aid in making this diagnosis, but accurate interpretation is difficult. An outline of the X-ray changes seen in the rheumatoid hand is presented, and the salient points in the differential diagnosis are outlined.

Septic polyarthritis due to Bacteroides fragilis in a patient with rheumatoid arthritis. A case report.

Gram-negative septic arthritis is an uncommon but serious complication of rheumatoid arthritis and is usually mono-articular. The present case is unusual in that a septic polyarthritis due to Bacteroides fragilis developed in nine joints. The organism was grown only in anaerobic synovial fluid and blood cultures. The patient recovered after treatment which included repeated needle aspirations of the joints under anaesthesia and oral metronidazole (Flagyl; Maybaker). Any patient with rheumatoid arthritis who develops an acute flare-up of disease in one or more joints should have these aspirated to exclude the possibility of septic arthritis. Both anaerobic and aerobic cultures of synovial fluid and blood should be done. Prompt antibiotic treatment and joint drainage are the cornerstones of treatment.

Indomethacin or sulindac at night in rheumatoid arthritis.

The effects of indomethacin and sulindac in relieving troublesome morning stiffness and nighttime pain were tested in a double-blind cross-over trial. Thirteen of the 17 patients who completed the trial preferred indomethacin which was found to be superior to sulindac in all the parameters tested. Sulindac did, however, have some beneficial effect and can be used as an alternative to indomethacin when this drug cannot be used as the agent of first choice.