Low-dose radiotherapy for greater trochanteric pain syndrome-a single-centre analysis.

PURPOSE: To determine predictive factors associated with a good response (GR) to and efficacy of low-dose radiotherapy (LDRT) in patients with greater trochanteric pain syndrome (GTPS). METHODS: Patients with GTPS were irradiated on a linear accelerator with 0.5-1.0 Gy per fraction to a total dose of 3.0-4.0 Gy per series. The endpoint was subjective good response (GR) to treatment 2 months after completion of the last LDRT series, defined as complete pain relief or marked improvement assessed using the von Pannewitz score. A positive response to steroid injection (SI) was defined as pain relief of at least 7 days. Patient and treatment-related characteristics were evaluated with respect to LDRT outcomes. RESULTS: Outcomes were assessed for 71 peritrochanteric spaces (PTSs; 65 patients, 48 females, with mean age of 63 [44-91] years). Prior SI had been given to 55 (77%) PTSs and 40 PTSs received two series of LDRT. Two months after completion of LDRT, GR was reported in 42 PTSs (59%). Two series of LDRT provided a significantly higher rate of GR than one series (72.5 vs. 42% PTSs, p = 0.015). Temporary pain relief after prior SI predicted GR to LDRT compared with PTSs which had not responded to SI (73 vs. 28% PTSs, p = 0.001). A regional structural abnormality, present in 34 PTSs (48%), was associated with a reduction of GR to LDRT (44 vs. 73% PTSs, p = 0.017). CONCLUSION: LDRT is an effective treatment for GTPS. Administration of two LDRT series, prior response to SI, and absence of structural abnormalities may predict significantly better treatment outcomes.

Focusing on individual morphological fracture characteristics of pelvic ring fractures in elderly patients can support clinical decision making.

INTRODUCTION: Pelvic ring fractures in the elderly are often caused by minor trauma. Treatment of these patients is currently based on fracture classification, clinical course, and ability to mobilize. Our aim was to identify morphological fracture characteristics with potential prognostic relevance and evaluate their association with clinical decision making and outcome, as well as their interobserver reliability. METHODS: Five fracture characteristics were investigated as potential variables: 1. Extent of the dorsal pelvic ring fracture (absent, unilateral, bilateral); 2. Extent of the ventral pelvic ring fracture (absent, unilateral, bilateral); 3. Presence of a horizontal sacral fracture; 4. Ventral dislocation; 5. Ventral comminution. These characteristics were assessed retrospectively in a series of 548 patients. The association of their presence with the decision to perform surgery, failure of conservative treatment and the length of hospital stay (LOS) was determined. Further, the inter-observer reliability for the specific characteristics was calculated and the relation with survival assessed. RESULTS: Four of the five evaluated characteristics showed an association with clinical decision making and patient management. In particular the extent of the dorsal fractures (absent vs. unilateral vs. bilateral) (OR = 7.0; p < 00.1) and the presence of ventral comminution/dislocation (OR = 2.4; p = 0.004) were independent factors for the decision to perform surgery. Both the extent of the dorsal fracture (OR = 1.8; p < 0.001) and the presence of ventral dislocation (OR = 1.7; p = 0.003) were independently associated with a prolonged overall LOS. The inter-observer agreement for the fracture characteristics ranged from moderate to substantial. A relevant association with increased mortality was shown for horizontal sacral and comminuted ventral fractures with hazard ratios (HR) of 1.7 (95% CI: 1.1, 2.5; p = 0.008) and HR = 1.5 (95% CI: 1.0, 2.2; p = 0.048). CONCLUSION: In the elderly, the extent of the dorsal fractures and the presence of ventral comminution/dislocation were associated to the decision to undergo surgery, failure of conservative treatment and length of stay. Survival was related to horizontal sacral fractures and ventrally comminuted fractures. These characteristics thus represent a simplified but highly informative approach for the evaluation of pelvic ring fractures in the elderly. This approach can support clinical decision making, promote patient-centred treatment algorithms and thus improve the outcome of individualized care.

Flouroscopic Control of Tibial Torsion After Intramedullary Nailing: A Technical Trick.

SUMMARY: After intramedullary nailing of tibia shaft fractures, torsional malalignment greater than 10 degrees occur in up to 41% of operated legs. The reason is the difficult clinical assessment of rotation intraoperatively, the large variation in absolute torsion of the tibia, and the absence of established reliable methods to fluoroscopically evaluate tibial rotation and compare with the contralateral side. We present here a fast and low-tech intraoperative method on how to achieve identical tibial torsion of the operated and noninjured side. The method can be used for tibia shaft and metaphyseal fractures and only requires a normal C-arm fluoroscope with 2 monitors. First, a true lateral image of the knee on the noninjured side with the femoral condyles aligned is obtained. Second, with the leg and the C-arm rotation and tilt fixed, the fluoroscope is moved parallel to the patient axis and a lateral ankle image is obtained and saved. The fibula position relative to the tibia at the level of the Volkmann tubercle on the lateral view defines the torsion of the tibia. The sequence described above is repeated on the operated side after implantation of the nail before proximal locking. On the operated side, the fibula position relative to the tibia should be identical to the noninjured side before proximal locking takes place. Otherwise, a rotational malalignment is present and must be corrected. The comparison between operated and noninjured side is easy on a fluoroscope with 2 monitors. The complete examination takes a few minutes and has minor additional radiation exposure. We performed the intraoperative torsion control in 10 patients and performed a postoperative low-dose Computer Tomography-control of the torsion of both legs and found the rotational deformity to be less than 10 degrees in all patients.

Scope and Limits of Teriparatide Use in Delayed and Nonunions: A Case Series.

Nonunion is known to occur in up to 10% of all bone fractures. Until recently, the treatment options considered in cases of delayed union and nonunion focused on revision surgery and improvement of local healing. Lately, teriparatide has been introduced as an osteoanabolic factor that induces fracture healing in cases with delayed or nonunions. We report on a series of five cases of delayed and nonunions treated with teriparatide: delayed unions of an atypical femoral fracture, of a multifragmentary clavicle fracture, and of a periprosthetic humeral fracture; nonunion of a tibial and fibular fracture; and infected nonunion of a tibial and fibular fracture. Based on this series, the indications and limits of application of teriparatide in cases of impaired fracture healing are discussed. Due to the "off-label" character of this application, informed consent, and cost coverage from the healthcare insurance must be obtained prior to treatment. In our experience and according to the limited existing literature, teriparatide is a safe feasible treatment in cases of delayed and nonunions with a reasonable need of resources. While adequate biomechanical stability remains the cornerstone of fracture healing, as well as healing of nonunions, teriparatide could help avoid repetitive surgeries, especially in atrophic delayed and nonunions, as well as in patients with impaired fracture healing undergoing bisphosphonate therapy. There is an urgent need for widely accepted definitions, standardized protocols, as well as further clinical trials in the field of impaired fracture healing.

[Periprosthetic Joint Infections - An Overview]. / Infekte in der Gelenkendoprothetik.

Periprosthetic Joint Infections - An Overview Abstract. Diagnostics and treatment of periprosthetic joint infections (PJI) is an interdisciplinary challenge. The key for success in the treatment of PJI is a rapid and adequate diagnostic and treatment in close cooperation between the general practitioner (GP), a specialised orthopaedic surgeon and an infectious disease specialist (ID). Acute PJI mostly occur peri- and early postoperative but can occur also lifelong due to haematogenous / lymphogenic seeding of the germs on the prosthesis. Both situations must be considered as an emergency scenario and patients should be transferred to the operating surgeon or even in a specialised centre for further diagnostics and treatment immediately. An acute infection (either < 4 weeks after implantation or < 3 weeks after the onset of symptoms with haematogenous / lymphogenic seeding) can frequently be cured by debridement, antibiotics and implant retention (DAIR) and should be the favoured approach in this scenario. In chronic PJI an interdisciplinary approach with complete exchange of the implant combined with an elaborated antibiotic therapy is always needed. Optimised and targeted diagnostic as well as an interdisciplinary planning of the treatment are mandatory for curing the infection, therefore patients with chronic PJI should be referred to a specialised centre. Surgery alone without adequate antibiotic therapy will mostly result in failure to cure PJI, same is true for exclusive antibiotic therapy without an adequate surgical procedure.

Direct transplantation of native pericytes from adipose tissue: A new perspective to stimulate healing in critical size bone defects.

BACKGROUND AIMS: Fractures with a critical size bone defect (e.g., open fracture with segmental bone loss) are associated with high rates of delayed union and non-union. The prevention and treatment of these complications remain a serious issue in trauma and orthopaedic surgery. Autologous cancellous bone grafting is a well-established and widely used technique. However, it has drawbacks related to availability, increased morbidity and insufficient efficacy. Mesenchymal stromal cells can potentially be used to improve fracture healing. In particular, human fat tissue has been identified as a good source of multilineage adipose-derived stem cells, which can be differentiated into osteoblasts. The main issue is that mesenchymal stromal cells are a heterogeneous population of progenitors and lineage-committed cells harboring a broad range of regenerative properties. This heterogeneity is also mirrored in the differentiation potential of these cells. In the present study, we sought to test the possibility to enrich defined subpopulations of stem/progenitor cells for direct therapeutic application without requiring an in vitro expansion. METHODS: We enriched a CD146+NG2+CD45- population of pericytes from freshly isolated stromal vascular fraction from mouse fat tissue and tested their osteogenic differentiation capacity in vitro and in vivo in a mouse model for critical size bone injury. RESULTS: Our results confirm the ability of enriched CD146+NG2+CD45- cells to efficiently generate osteoblasts in vitro, to colonize cancellous bone scaffolds and to successfully contribute to regeneration of large bone defects in vivo. CONCLUSIONS: This study represents proof of principle for the direct use of enriched populations of cells with stem/progenitor identity for therapeutic applications.

Characterization of indeterminate spleen lesions in primary CT after blunt abdominal trauma: potential role of MR imaging.

The purpose of this study was to determine the value of magnetic resonance imaging (MRI) for characterization of indeterminate spleen lesions in primary computed tomography (CT) of patients with blunt abdominal trauma. Twenty-five consecutive patients (8 female, 17 male, mean age 51.6 ± 22.4 years) with an indeterminate spleen lesion diagnosed at CT after blunt abdominal trauma underwent MRI with T2- and T1-weighted images pre- and post-contrast material administration. MRI studies were reviewed by two radiologists. Age, gender, injury mechanism, injury severity score (ISS), management of patients, time interval between CT and MRI, and length of hospital stay were included into the analysis. Patient history, clinical history, imaging, and 2-month clinical outcome including review of medical records and telephone interviews served as reference standard. From the 25 indeterminate spleen lesions in CT, 11 (44 %) were traumatic; nine (36 %) were non-traumatic (pseudocysts, n=5; hemangioma, n=4) and five proven to represent artifacts in CT. The ISS (P<0.001) and the length of hospital stay (P=0.03) were significantly higher in patients with spleen lesions as compared with those without. All other parameters were similar among groups (all, P>0.05). The MRI features ill-defined lesion borders, variable signal intensity on T1- and T2-weighted images depending on the age of the hematoma, focal contrast enhancement indicating traumatic pseudoaneurysm, perilesional contrast enhancement, and edema were most indicative for traumatic spleen lesions. As compared with CT (2/25), MRI (5/25) better depicted thin subcapsular hematomas as indicator of traumatic spleen injury. In conclusion, MRI shows value for characterizing indeterminate spleen lesions in primary CT after blunt abdominal trauma.

Influence of metal ions on human lymphocytes and the generation of titanium-specific T-lymphocytes.

BACKGROUND: There is mounting evidence to suggest the involvement of the immune system by means of activation by metal ions released via biocorrosion, in the pathophysiologic mechanisms of aseptic loosening of orthopedic implants. However, the detailed mechanisms of how metal ions become antigenic and are presented to T-lymphocytes, in addition to how the local inflammatory response is driven, remain to be investigated. METHODS: Human T-lymphocytes were cultured in the presence of a variety of metal ions before investigating functional and phenotypic changes using flow cytometric analysis. Additionally, human monocyte-derived dendritic cells (mDC) loaded with metal ions were used as antigen-presenting cells and incubated with naive T-lymphocytes with the aim of generating titanium-specific T-lymphocytes. RESULTS: Using an autologous in vitro model, with mDC treated with Titanium (IV), we were able to induce Titanium (IV)-specific T-lymphocytes. These T-lymphocytes responded in a dose-related manner to Titanium (IV), while they did not cross-react with Titanium (III) or other metal ions, indicating that the new antigenic peptide complexes formed by Titanium (IV) are highly specific. CONCLUSION: This study showed that mDC exposed to Titanium (IV) are able to induce the generation of Titanium (IV)-specific T-lymphocytes, demonstrating the strong and specific antigenicity of Titanium (IV) ions released by biocorrosion.

Health-related quality of life following spinal cordectomy for syringomyelia.

BACKGROUND: Spinal cordectomy has been described as an effective treatment option in paraplegic patients for the treatment of syringomyelia to manage spasticity, pain and ascending neurological dysfunction. The objective of this study was to investigate the long-term health-related quality of life (HRQoL) after cordectomy in patients with intractable symptoms caused by syringomyelia. METHODS: Seventeen patients underwent spinal cordectomy for syringomyelia between February 2000 and July 2009. The etiology of syringomyelia was traumatic in 16 patients and spinal ependymoma in one patient. The mean follow-up was 3.8 years (range, 0.9-10.3). The HRQoL was assessed pre- and postoperatively using the EuroQol (EQ; degree of discomfort: 1 = none, 2 = moderate and 3 = extreme) and the short-form SF-36 quality of life score (SF-36). All patients underwent a telephone interview. RESULTS: The mean pre- and postoperative EuroQol-levels for mobility were 1.8 and 1.5; for self-care, 1.9 and 1.5; for usual activities, 2.1 and 1.5; for pain/discomfort, 2.3 and 2.0; and for anxiety/depression, 1.7 and 1.5, respectively. The mean overall EQ visual analogue scale improved postoperatively from 42 points (range, 15-80) to 67 points (range, 10-95) (p = 0.006). The component summary measure for mental health (SF-36) significantly improved postoperatively (p = 0.01). A telephone interview revealed a high subjective patient satisfactory (94.1%) in terms of postoperative sequelae. Following the intervention, 58.8% of all patients were employed full or part-time. CONCLUSIONS: Spinal cordectomy may increase the quality of life and can be considered as an ultimo ratio therapy in a selective group of patients with intractable symptoms caused by syringomyelia.

Functional and proteomic analysis of serum and cerebrospinal fluid derived from patients with traumatic brain injury: a pilot study.

BACKGROUND: An enhanced fracture healing response has been reported in patients with traumatic brain injury (TBI). This has been attributed to circulating humoral factors that are thought to be proteins produced and released by the injured brain. However, these factors remain unknown. The aim of this study was to identify osteogenic factors in serum and cerebrospinal fluid (CSF) from TBI patients. This was carried out using in vitro proliferation assays with the human foetal osteoblastic 1.19 cell line (hFOB) combined with a novel proteomic approach. METHODS: Serum was collected from brain-injured (n = 12) and non-brain-injured (n = 9) patients with a comorbid femur shaft fracture. Similarly, CSF was obtained from TBI (n = 7) and non-TBI (n = 9) patients. The osteoinductive potential of these samples was determined by measuring the in vitro proliferation rate of hFOB cells. Highly osteogenic serum and CSF samples of TBI patients were chosen for protein analysis and were compared to those of non-brain-injured patients. A new hFOB cell-based method was used to enrich the proteins in these samples, which had a functional affinity for these osteoprogenitor cells. These enriched protein fractions were mapped using two-dimensional gel electrophoresis and protein imaging methods displaying serum and CSF proteins of brain-injured and control subjects that had an affinity for human osteoprogenitor cells. RESULTS: Serum and CSF derived from brain-injured patients demonstrated a greater osteoinductive potential (P < 0.05) than their non-brain-injured counterparts. Clear-cut differences in the pattern of proteins in two-dimensional gels were detected between TBI and control patients. Fourteen proteins were exclusively present in the serum of TBI patients, while other proteins were either up- or downregulated in samples collected from TBI patients (P < 0.05). CONCLUSION: Osteoinductive factors are present in the serum and CSF of brain-injured patients. These may include one or more of those proteins identified as having an affinity for osteoprogenitor cells that are either exclusively present or up- or downregulated in the serum and CSF of brain-injured patients.

Recurrent laryngeal nerve monitoring during esophagectomy and mediastinal lymph node dissection.

BACKGROUND: Patients who undergo surgery to the esophagus and lungs are in jeopardy of recurrent laryngeal nerve (RLN) damage during the procedure. This study was designed to investigate the feasibility of intraoperative monitoring of the RLN for single-lung ventilation esophagus and lung surgery. METHODS: Twelve consecutive patients booked for esophagus or lung surgery were included in this prospective, observational study. Six patients underwent transthoracic esophagectomy for carcinoma of the esophagogastric junction or lower esophagus, five had a lobectomy, and one underwent a pneumonectomy for lung carcinoma. Intraoperative, noninvasive RLN identification and monitoring was performed unilaterally (n = 8) or bilaterally (n = 4) using a handheld stimulator and a laryngeal surface electrode. The correct functioning of the nerve monitoring system was tested directly at the vagus nerve. Diagnosis of postoperative RLN paralysis was performed using indirect laryngoscopy. RESULTS: During the surgical procedures, we monitored a nerve signal in all 12 patients. In one patient with lower esophagus carcinoma, a nerve signal could be detected only on one side. Postoperative indirect laryngoscopy showed normal vocal cord movement in all patients. CONCLUSIONS: Intraoperative RLN identification and monitoring during single-lung ventilation surgery is technically feasible, easy, and reliable. The introduction of standardized RLN monitoring during this type of surgery may reduce the incidence of permanent RLN paralysis.

Web-based audiovisual patient information system--a study of preoperative patient information in a neurosurgical department.

BACKGROUND: In the current climate of increasing awareness, patients are demanding more knowledge about forthcoming operations. The patient information accounts for a considerable part of the physician's daily clinical routine. Unfortunately, only a small percentage of the information is understood by the patient after solely verbal elucidation. To optimise information delivery, different auxiliary materials are used. METHODS: In a prospective study, 52 consecutive stationary patients, scheduled for an elective lumbar disc operation were asked to use a web-based audiovisual patient information system. A combination of pictures, text, tone and video about the planned surgical intervention is installed on a tablet personal computer presented the day before surgery. All patients were asked to complete a questionnaire. RESULTS: Eighty-four percent of all participants found that the audiovisual patient information system lead to a better understanding of the forthcoming operation. Eighty-two percent found that the information system was a very helpful preparation before the pre-surgical interview with the surgeon. Ninety percent of all participants considered it meaningful to provide this kind of preoperative education also to patients planned to undergo other surgical interventions. Eighty-four percent were altogether "very content" with the audiovisual patient information system and 86% would recommend the system to others. CONCLUSIONS: This new approach of patient information had a positive impact on patient education as is evident from high satisfaction scores. Because patient satisfaction with the informed consent process and understanding of the presented information improved substantially, the audiovisual patient information system clearly benefits both surgeons and patients.

Serum after traumatic brain injury increases proliferation and supports expression of osteoblast markers in muscle cells.

BACKGROUND: Traumatic brain injury is associated with an increased rate of heterotopic ossification within skeletal muscle, possibly as a result of humoral factors. In this study, we investigated whether cells from skeletal muscle adopt an osteoblastic phenotype in response to serum from patients with traumatic brain injury. METHODS: Serum was collected from thirteen patients with severe traumatic brain injury, fourteen patients with a long-bone fracture, and ten control subjects. Primary cultures of skeletal muscle cells isolated from patients undergoing orthopaedic surgery were performed and characterized with use of immunofluorescence microscopy, reverse transcription-polymerase chain reaction, and Western blot analysis. Proliferation and osteoblastic differentiation were assessed with use of commercial cell assays, Western blot analysis (for Osterix protein), and the Villanueva bone stain. RESULTS: All serum-treated cell populations expressed the osteoblast marker Osterix after one week in culture. Cells treated with serum from all study groups in mineralization medium had increased alkaline phosphatase activity and mineralized nodules within the mesenchymal cell subpopulation after three weeks in culture. Serum from patients with traumatic brain injury induced a significant increase (p = 0.02) in the rate of proliferation of primary skeletal muscle cells (1.87 [95% confidence interval, 1.66 to 2.09]) compared with the rate induced by serum from patients with a fracture (1.42 [95% confidence interval, 1.21 to 1.58]) or by serum from controls (1.35 [95% confidence interval, 1.15 to 1.54]). CONCLUSIONS: Human serum supports the osteoblastic differentiation of cells derived from human skeletal muscle, and serum from patients with severe traumatic brain injury accelerates proliferation of these cells. These findings suggest the early presence of humoral factors following traumatic brain injury that stimulate the expansion of mesenchymal cells and osteoprogenitors within skeletal muscle.

[Aneurysmal subarachnoid hemorrhage - therapy and complications]. / Aneurysmatische Subarachnoidalblutung - Diagnostik und Therapie zerebraler und systemischer Komplikationen.

The management of patients with aneurysmal subarachnoid hemorrhage (SAH) requires a fundamental knowledge of the disease, its therapeutic options and possible complications. The preoperative goal is to prevent rebleeding by controlling blood pressure and treating pain and anxiety as well as stabilizing cardiopulmonary functions. An acute hydrocephalus has to be treated immediately. Microsurgical clipping or endovascular coiling are the therapeutic options available. The postoperative goal aims at securing cardiopulmonary functions as well as recognizing and treating cerebral (cerebral vasospasm, hydrocephalus, epilepsy) and systemic complications (electrolyte disorder, cardiac dysfunction). This article provides an overview about the pre-, peri- and postoperative management of patients with SAH.

Titanium uptake, induction of RANK-L expression, and enhanced proliferation of human T-lymphocytes.

There is increasing evidence that titanium ions are released from orthopedic implants by biocorrosion. The aim of this study was to investigate titanium uptake by human T-lymphocytes and its effects on phenotype and proliferation. Freshly isolated human nonadherent peripheral blood mononuclear cells (NA-PBMC), were exposed to TiCl4 [Ti(IV)]. Bioavailability and distribution of Ti(IV) in T-lymphocytes was determined by energy-filtered electron microscopy (EFTEM). The effects of Ti(IV) challenge on nonactivated and PHA-activated cells were assessed by flow cytometric analysis of surface markers, RANK-L production, and proliferation assays. EFTEM colocalized Ti(IV) with phosphorus in the nucleus, ribosomes, cytoplasmic membranes, and the surface membrane of T-lymphocytes. Ti(IV) increased significantly the expression of CD69, CCR4, and RANK-L in a concentration-dependent manner. Titanium enters T-lymphocytes through a currently unknown mechanism and binds to phosphorus-rich cell structures. Titanium influences phenotype and function of T-lymphocytes, resulting in activation of a CD69+ and CCR4+ T-lymphocyte population and secretion of RANK-L. These results strongly suggest the involvement of titanium ions challenged T-lymphocytes in the complex pathophysiological mechanisms of aseptic loosening of orthopedic implants.

Titanium induced production of chemokines CCL17/TARC and CCL22/MDC in human osteoclasts and osteoblasts.

There is increasing evidence that titanium (Ti(IV)) ions are released from orthopedic implants and play a role in aseptic loosening. This study aimed to investigate whether titanium induces expression of chemokines and cytokines that are important in osteoclastogenesis in human osteoclasts and osteoblasts. Incubation of those cells with 1 muM Ti(IV) significantly upregulated expression of CCL17/TARC and CCL22/MDC, RANK-L, M-CSF and pro-inflammatory cytokines as determined by quantitative real-time PCR and ELISA assays. Additionally, flow cytometry was used to show Ti(IV) related increased expression of CCR4, the cognate receptor for CCL17 and CCL22 in challenged osteoclast precursors. These results strongly suggest that Ti(IV) ions play a role in the recruitment of osteoclast precursors to the bone-implant interface by increasing CCL17 and CCL22 expression and by upregulating their cognate receptor. Moreover the increased expression of RANK-L and M-CSF by osteoblasts together with increased levels of pro-inflammatory cytokines may enhance osteoclast differentiation and activity, and subsequently contribute to the pathomechanism of aseptic loosening.

Metal is not inert: role of metal ions released by biocorrosion in aseptic loosening--current concepts.

Metal implants are essential therapeutic tools for the treatment of bone fractures and joint replacements. The metals and metal alloys used in contemporary orthopedic and trauma surgery are well tolerated by the majority of patients. However, complications resulting from inflammatory and immune reactions to metal implants have been well documented. This review briefly discusses the different mechanisms of metal implant corrosion in the human body, which lead to the release of significant levels of metal ions into the peri-implant tissues and the systemic blood circulation. Additionally, this article reviews the effects of the released ions on bone metabolism and the immune system and discusses their involvement in the pathophysiological mechanisms of aseptic loosening and metal hypersensitivity in patients with metal implants.

A life-threatening abscess in a patient treated with a tumour necrosis factor-alpha antagonist: a case report.

A 25-year-old man with a 3-year history of ankylosing spondylitis presented with a sudden onset of pain in his left thigh. His ankylosing spondylitis had been treated for 2 years with the tumour necrosis factor-alpha (TNF-alpha) antagonist infliximab. The initial diagnosis was a muscular tear, and non-steroidal anti-inflammatory drugs were prescribed. 40 days later, the patient had tender swelling with warmth and light redness on his left thigh. His knee function had decreased markedly. His C-reactive protein level was 320 mg/l and white cell count was 30.4 x10(9)/l, indicating severe infection. Magnetic resonance imaging revealed a loculated fluid collection in the quadriceps musculature measuring 30 cm. Hyperintensity seen on T1-weighted images was suggestive of infection. The infliximab therapy was stopped and repeated debridement and drainage performed, with about 2.5 litres of pus evacuated. Flucloxacillin was administered for 2 weeks. The wound was closed 9 days later. The patient was discharged 20 days after surgery. An alternative immunosuppressive therapy--abatacept--was introduced. At the 18-month follow-up, the patient reported only light discomfort in the thigh during exercise, with a mildly impaired range of knee movement. No infectious complications recurred.