Neutrophil-to-lymphocyte ratio (NLR) distribution shows an advantage compared to C-reactive protein (CRP) for the early inflammation monitoring after total hip arthroplasty.

C-reactive protein (CRP) distribution has been used to monitor early inflammation after total hip arthroplasty (THA). Neutrophil to lymphocyte ratio (NLR) is a new and cheap inflammatory marker. This study aimed to verify whether Neutrophil to lymphocyte ratio (NLR) distribution has an advantage when compared to C-reactive protein (CRP) distribution for the inflammation monitoring after total hip arthroplasty (THA). 116 THA patients were retrospectively selected over a 2 years period. They all had available blood tests preoperatively and at postoperative days 2, 4 and 42. Median peak values were compared between CRP and NLR. The effect of demographics on CRP and NLR was tested. At days 4 and 42, 100% and 16.3% of patients had not reached normal CRP (< 10mg/L) while 56.8% and 6.8% of patients had not reached normal NLR (<5) respectively. There was no effect of demographics on NLR except for age. Older patients had higher NLR (p 0.037). NLR showed a quicker return to normal than CRP. Our results show that NLR seems to be a better marker to follow inflammation after THA than CRP.

Type II collagen peptide Coll2-1 is an actor of synovitis.

OBJECTIVE: We evaluated the ability of Coll2-1, a type II collagen peptide, to activate pro-inflammatory pathways in synovial cells and to induce arthritis in Lewis rats. METHOD: Human synoviocytes and chondrocytes from knee OA patients were cultured for 24 h with/without Coll2-1 and/or purified immunoglobulin G (AS0619) binding specifically this peptide, and/or CLI-095, a TLR-4 signaling inhibitor and/or apocynin and diphenyleneiodonium, Reactive oxygen species (ROS) production inhibitors. The Interleukin (IL)-8 and Vascular Endothelium Growth Factor (VEGF) expression, the IL-8 production, the IκB-α and p65 phosphorylation and ROS were evaluated. Coll2-1 peptide, bovine type II collagen (CIA), streptococcal cell wall (SCW) or saline solution were injected into Lewis rats. The Coll2-1 peptide was injected subcutaneously (SC; 20-200µg/100µl/animal) or intra-articularly (IA; 0.5-5µg/50µl/animal) and compared to CIA injected in SC (200µg/100µl/animal) and SCW in IA (5µg/50µl/animal). The animals were injected on day 0 and monitored for 28 days. Histological lesions assessment was performed using an arthritis score. RESULTS: Coll2-1 peptide significantly increased IL-8 gene expression and production by synoviocytes. AS0619 and CLI-095 significantly decreased IL-8 expression. Coll2-1 induced p65 and IκBα phosphorylation and oxidative stress inhibitors decreased it. In human chondrocytes culture, Coll2-1 significantly increased MMP-3 and VEGF gene expression. In Lewis rats, CIA, SCW or Coll2-1 injection triggered arthritis. Like CIA or SCW, Coll2-1 induced synovitis, loss of cartilage proteoglycans, cartilage structure lesion and subchondral bone remodeling. CONCLUSIONS: Coll2-1 activates synoviocytes to produce IL-8 and induces arthritis in rat. These findings suggest that neutralizing Coll2-1 could be a therapeutic approach of arthritis.

Can we assess healing of surgically treated long bone fractures on radiograph?

PURPOSE: To determine the frequency and causes for limitations in the radiographic evaluation of surgically treated long bone fractures. MATERIALS AND METHODS: Six readers separately scored 140 sets of antero-posterior (AP) and lateral radiographs of surgically treated long bone fractures, using a radiographic union score (RUS). We determined the rate of assessability of the fracture edges at each of the four cortical segments (n=560) seen tangentially on the two radiographs and the causes for non-assessability. The rate of feasibility of the RUS (more than two fracture edges assessable per fracture) was determined and compared according to different parameters. RESULTS: Fracture edges were visible in 71% to 81% of the 560 cortical segments. Metal hardware superimposition was the most frequent cause for non-assessability (79-95%). RUS values could be calculated in 58% to 75% of fractures. Scoring was statistically significantly less frequently calculable in plated (31-56%) than in nailed fractures (90-97%), in distal (47-61%) than in proximal (78-89%) bones and in upper (27-49%) than in lower (76-91%) limb bones (P≤0.01). CONCLUSIONS: The type of stabilization hardware is the main limiting factor in the radiographic assessment of surgically treated long bone fractures. Scoring was feasible in only 31% to 56% of plated fractures.

Early infection of hip joint prosthesis by Clostridium difficile in an HIV-1 infected patient.

Anaerobes are less frequently described as causative pathogen of prosthetic joint infection (PJI). We report the first case of early PJI after hip arthroplasty due to Clostridium difficile in a diabetic and HIV-1 infected patient with bacteremia. Our patient was successfully treated through surgical debridement and prosthesis retention combined with targeted antibiotic therapy.

Protective effect of a new biomaterial against the development of experimental osteoarthritis lesions in rabbit: a pilot study evaluating the intra-articular injection of alginate-chitosan beads dispersed in an hydrogel.

OBJECTIVE: This study aimed to evaluate the structural benefit of a new biomaterial composed of alginate-chitosan (AC) beads dispersed in a hydrogel (H) derived from chitosan on the development of osteoarthritis (OA) in rabbit. DESIGN: OA was induced by the surgical transection of the anterior cruciate ligament in rabbits. Animals received a single intra-articular injection (900 µl) of AC beads in H hydrogel, H hydrogel alone or saline a week after surgery. OA development was followed by X-rays. Blood samples were collected throughout the study to measure biological markers (Prostaglandins E2 - PGE2 and C reactive protein - CRP). Macroscopic observation and histological evaluation of articular cartilage and synovial membrane were performed 6 weeks after surgery. RESULTS: AC beads in H hydrogel prevented from the development of OA based on the reduction of the Kellgren & Lawrence (K&L) score. It also significantly reduced the histological score of cartilage lesion severity. This effect was homogenous on every joint compartment. It was due to a significant effect on cartilage structure and cellularity scores. The injection of AC beads in H hydrogel also tended to reduce the synovial membrane inflammation. No significant variation of biological markers was noted. CONCLUSIONS: The present pilot study provides interesting and promising results for the use of AC beads in H hydrogel in animal. It indeed prevented the development of OA cartilage lesions without inflammatory signs. The potencies of this biomaterial to protect OA joint should be further documented. It could then represent a new alternative for viscosupplementation in human OA management.

Low-molecular-weight heparin-induced skin necrosis: about 2 cases.

Heparin-induced skin necrosis is an infrequent condition, complicating unfractionated heparin and more rarely low-molecular-weight heparin administration. Like heparin-induced thrombocytopenia, it is associated with the presence of anti-PF4 antibodies. After reporting 2 observations, we briefly review the clinical features and management of this condition. Early recognition is of the utmost importance since heparin-induced skin necrosis can be associated with HIT, a potentially lethal disorder.

Multicentre, prospective, open study to evaluate the safety and efficacy of hylan G-F 20 in knee osteoarthritis subjects presenting with pain following arthroscopic meniscectomy.

The aim of the study was to evaluate the safety and efficacy of viscosupplementation with hylan G-F 20 in patients with mild to moderate osteoarthritis (OA) presenting with persistent knee pain 4-12 weeks after arthroscopic meniscectomy. A prospective, multi-centre, open study was carried out in patients with pain due to OA of the knee, not resolved by simple analgesics, 4-12 weeks after undergoing arthroscopic meniscectomy. To be eligible, patients had to score > or =50 mm and < or =90 mm on both walking pain and patient global assessment visual analogue scales (VAS; 0-100 mm) at baseline and be radiologically diagnosed pre-operatively with OA grade I or II on the Kellgren-Lawrence scale, with <50% joint space narrowing. Patients received three intra-articular, 2 ml injections of hylan G-F 20 in the target knee with an interval of 1 week between injections, and were followed for 52 weeks. The primary efficacy endpoint was the change from baseline in the walking pain VAS score at 26 weeks. Secondary outcome measures were the walking pain VAS scores at all other time points, the WOMAC Index at all time points, and patient and physician global assessment at all time points. The safety of the treatment was assessed using adverse event (AE) reports. A total of 62 patients (mean age 55.4 years, 52% male) were enrolled. The mean walking pain VAS score decreased by 36.8 mm from baseline at 26 weeks (P < 0.0001), and also showed statistically significant decreases (P < 0.0001) at all other time points. The change in WOMAC total and subscale scores from baseline were statistically significant (P < 0.0001) at all time points, as were the decreases in the physician and patient global assessment VAS scores. There were 18 target knee AEs (mostly pain and/or swelling and/or effusion) in 12 patients (19%) considered to be at least possibly related to treatment. The majority of these (78%) were mild or moderate in intensity. One patient (1.6%) experienced a serious adverse event (synovitis) in the target knee that was considered possibly related to study treatment. Hylan G-F 20 provides effective pain relief and improves stiffness and physical function in patients with mild to moderate OA presenting with persistent osteoarthritic pain 4-12 weeks after arthroscopic meniscectomy. Symptomatic efficacy was maximised at 12 weeks and maintained at 26 and 52 weeks. The type (pain and/or swelling and/or effusion) and the intensity (mostly mild/moderate) of AEs reported in this study are similar to those reported in other trials in different patient populations, but the incidence was higher (19%). The risk/benefit of hylan G-F 20 in this particular population of patients is favourable.

One-year follow-up of Coll2-1, Coll2-1NO2 and myeloperoxydase serum levels in osteoarthritis patients after hip or knee replacement.

OBJECTIVES: To determine Coll2-1, Coll2-1NO(2) and myeloperoxydase (MPO) levels in serum of patients with knee or hip osteoarthritis (OA) before the surgery, 3 months and 1 year after knee or hip replacement. METHODS: Coll2-1, Coll2-1NO(2) and MPO were measured in 103 patients with isolated symptomatic knee or hip OA candidates for joint replacement. Sera were taken the day before surgery, 3 months and 1 year after hip or knee replacement. Coll2-1 and Coll2-1NO(2) immunohistochemistry was performed on biopsies removed from cartilage lesions. RESULTS: Immunostainings revealed the extensive presence of Coll2-1 and Coll2-1NO(2) in the superficial layer of fibrillated cartilage and around some chondrocytes clusters. Three months after joint replacement, Coll2-1 and MPO serum levels were decreased and even reached the reference value for Coll2-1. By contrast, Coll2-1NO(2) levels remained elevated. At 1-year follow-up, Coll2-1 levels remained at the reference value, MPO levels were similar to those measured at 3 months, and Coll2-1NO(2) levels were unchanged and comparable to the pre-surgery values. However, in patients with pre-surgery values above the median (more than 0.42 nM), Coll2-1NO(2) levels significantly and progressively decreased post-operatively, but tended towards an increase in patients with pre-surgery Coll2-1NO(2) values below the median. CONCLUSIONS: The normalisation of Coll2-1 levels 3 months after surgery indicates that Coll2-1 is a disease-specific marker that is sensitive to the structural changes occurring in a single joint. Furthermore, the immunohistochemical findings are consistent with the concept that the major source of serum Coll2-1 is the damaged articular cartilage. Finally, serum MPO levels decreased after joint replacement indicating that neutrophil activation occurs in OA joints, even in the late stage of the disease.

Type II collagen peptides for measuring cartilage degradation.

This paper describes two new immunoassays for a peptide of the triple helix of type II collagen (Coll 2-1) and its nitrated form (Coll 2-1 NO(2)). In healthy subjects aged between 20 and 65 years old, Coll 2-1 and Coll 2-1 NO(2) levels in serum were in means 125.13+/-3.71 and 0.16+/-0.08 nmol/l, respectively. These levels did not significantly vary with age. However, up to 45 years of age, Coll 2-1 NO(2) levels in women were significantly higher than in men. In patients with knee osteoarthritis (OA), Coll 2-1 in serum was found to be elevated compared to healthy controls (267.45+/-26.42 nmol/l vs 126.78+/-6.61 nmol/l). Further, we have demonstrated that an increase of the urinary levels of Coll 2-1 or Coll 2-1 NO(2) over 1 year was predictive of joint space narrowing progression in OA patients. In conclusion, these preliminary results indicate that Coll 2-1 could be a predictive marker of knee OA progression.

[Elbow reconstruction with massive total osteoarticular allograft: early failure due to instability]. / Reconstruction du coude par allogreffe massive ostéo-articulaire totale: échec précoce par instabilité.

Total elbow allografts were implanted for the treatment of trauma-induced bone defects in three patients between 1986 and 1990. Six allografts were implanted and finally explanted. The longest follow-up for an implanted allograft was five years. Allografts had to be removed because of nonunion in one patient and gross instability in the others. A constrained elbow prosthesis was implanted in all three patients. This short series illustrates mid-term failure to be expected with total elbow allografts, mainly due to instability. Accordingly, we no longer recommend the use of total elbow allografts alone as a salvage procedure for bony defects. If an allograft is needed, it should be implanted with a prosthesis.

[Intra-articular myxofibrosarcoma of the hip in a 10-year-old child]. / Myxofibrosarcome intra-articulaire de la hanche chez un enfant de 10 ans.

We report a case of intra-articular myxofibrosarcoma with acetabular involvement observed in a 10-Year-old boy. Myxofibrosarcoma is a frequent soft tIssue sarcoma usually observed in elderly subjects. It is extremely rare in children and has not been reported previously before the age of 22 Years. Myxofibrosarcoma is a specific type of soft tIssue tumor. Discussion continues concerning its relation with the myxoid variant of malignant fibrous histiocytoma. The myxoid matrix harbors fibroblastic cells with a curvilinear vessel configuration. Prognosis is good after complete resection and careful surveillance. Local recurrence may occur generally with progression of the tumor stage and risk of later metastasis. This is the first report of an intra-articular localization. We discuss the therapeutic options.

[Mechanical complications of total shoulder inverted prosthesis]. / Complications mécaniques de la prothèse totale inversée de l'épaule.

Our series of inverted prosthesis included 5 patients with a mean age of 73 +/- 6 years. In 4 cases, the implant was performed as a surgical revision. The follow up was 81 +/- 15 months. Three shoulders were pain free whereas two caused a dull pain after a free interval due to mechanical complications. The mean active elevation was 72 degrees while external rotation was - 2 degrees. The adjusted Constant score passed from 32 to 60. In case of complications, the score dropped to 32. Mechanical complications were important with in one case, an unscrening of the glenosphere and in two cases, a loosening of the glenoid prosthesis. This last and major complication occurred 6 years after surgery and was promoted by the occurrence of a progressive bone erosion in the scapula. This gap represented an attempt to accomodate the medial part of the humeral prosthesis under the scapula when the arm is at rest or in adduction. The concept of an inverted prosthesis is attractive and this implant remains one of the options in cuff-tear arthropathy. Our results were not as good as those reported by others but most of ours patients had been already operated before. The occurrence of an osseous gap on pilar of scapula may lead to failure of this prosthesis. This gap remains a threath as it can progress and as such warrants a design alteration of the prosthesis.

Lesions of the menisci of the knee: value of MR imaging criteria for recognition of unstable lesions.

OBJECTIVE: This study aimed to determine the value of four MR imaging criteria for evaluating unstable meniscal lesions. MATERIALS AND METHODS: Criteria for unstable meniscal lesions were the presence of a displaced meniscal fragment, visibility on more than three 3-mm-thick coronal and two 4-mm-thick sagittal images, having more than one orientation plane or more than one pattern (contour irregularity, peripheral separation, tear), and having intrameniscal high signal intensity on T2-weighted spin-echo images. Sensitivity, specificity, and positive and negative predictive values for recognition of instability among all meniscal lesions were determined for the presence of each individual criterion and for the presence of at least one criterion in 50 consecutive patients (mean age, 46 years) who underwent MR imaging and subsequent arthroscopy. RESULTS: Sensitivities and specificities of these four criteria ranged between 18% and 54% and between 94% and 100%, respectively. Positive and negative predictive values ranged between 92% and 100% and between 39% and 52%, respectively. The presence of at least one criterion enabled recognition of unstable lesions with a sensitivity and specificity of 82% and with positive and negative predictive values of 90% and 70%, respectively. CONCLUSION: The four MR imaging criteria have high specificities and positive predictive values and low sensitivities and negative predictive values when evaluating unstable meniscal lesions.

Dual-detector spiral CT arthrography of the knee: accuracy for detection of meniscal abnormalities and unstable meniscal tears.

PURPOSE: To determine the sensitivity and specificity of dual-detector spiral computed tomographic (CT) arthrography of the knee in the detection of meniscal abnormalities and unstable meniscal tears. MATERIALS AND METHODS: The meniscal changes in 50 consecutive patients who underwent dual-detector spiral CT of the knee after intraarticular injection of iodinated contrast material (0.55-mm effective section thickness, 0.75 pitch value, 0.3-mm increment reconstruction, 0.43-mm in-plane resolution, 0.3-mm longitudinal resolution) were determined by two observers and were compared with arthroscopic findings. The sensitivity and specificity of CT arthrography for the detection of meniscal abnormalities and unstable meniscal tears and the kappa statistics for assessing interobserver reproducibility were determined. RESULTS: The sensitivity and specificity for the detection of meniscal abnormalities were 98% and 94%, respectively. The sensitivity and specificity for the detection of unstable meniscal tears were 97% and 90%, respectively. Interobserver agreement was excellent for the detection of meniscal abnormalities (kappa = 0.899) and of unstable meniscal tears (kappa = 0.885). CONCLUSION: Dual-detector spiral CT arthrography of the knee is an accurate and reproducible method for detecting meniscal abnormalities and unstable meniscal tears.

[Resection of the tip of the lateral malleolus by Ibister's method in the treatment of painful sequelae of calcaneus fractures]. / Résection de la pointe de la malléole externe selon Isbister dans le traitement des séquelles douloureuses des fractures du calcanéum.

Persistent pain below the tip of the lateral malleolus may occur after comminuted fractures of the calcaneus. The pain is the result of compression of the peroneal tendons or abutment between the calcaneus and the lateral malleolus. Computerized tomography clearly shows the etiology. In these cases, the excision of the tip of the lateral malleolus, procedure described by Isbister, was performed. The clinical results of fifteen procedures in thirteen patients who had persistent pain below the tip of the lateral malleolus after fracture of the calcaneus are reported. All the patients were completely relieved of lateral pain. Subjectively, for nine patients, the results were excellent (7) or good (2). 4 patients are not satisfied. In these cases, pain arising from the subtalar joint was the main complain.

[Papilloma of the choroid plexus of the lateral ventricle without generalized hydrocephalus]. / Papillome du plexus choroïde du ventricule latéral sans hydrocéphalie généralisée.

A benign papilloma of the choroid plexus of the left lateral ventricle is found in a five-month old infant. An important dilatation of the isolated occipital horn is observed, without generalized enlargement of the ventricles. The clinical signs are limited to a moderate macrocephaly with deviation of head and eyes to the left. The absence of global hydrocephalus is rather exceptional in such cases, where overproduction of cerebrospinal fluid, in an amount proportional to the tumoral mass, is generally admitted. Nevertheless, the literature offers no absolute proof of the role of oversecretion alone in the origin of hydrocephalus, whilst an eventual obstruction of the circulatory pathways and resorption areas of the C.S.F. must be kept in mind. The absence of hydrocephalus, in the present case, suggests that the subarachnoid spaces and arachnoid villi remained patent.