Septic arthritis following joint injections: a 17 years retrospective study in an Academic General Hospital.

BACKGROUND: Septic arthritis following intra-articular infiltrations is an uncommon devastating complication correlated  to high costs for the health service and often to poor outcomes. The purpose of this study is to assess a 17-years experience in a single academic multispecialist hospital managing this uncommon complication in Orthopaedic practice. METHODS: Patients with diagnosis of septic arthritis following joint injections treated in our hospital from January 2002 to December 2019 were included in the study. Clinical and demographic data, pathogens, injected agent, conservative/surgical treatments were reviewed. Patient were classified according to the ore operative Charlson Comorbidity Index (CCI) and the Cierny-Mader Classification(CMC). Furthermore follow-up outcome and time occurred to infection eradication were registered. RESULTS: We included in the study 11 patients with a median age of 74 years old (IQR= 61.5 - 79). The median CCI was 3  (IQR= 2 - 5) and the majority of patients belong to CMC = B class. Septic arthritis occurred mainly following corticosteroids injections and more frequently involving knees. The pathogen more often isolated was Staphylococcus aureus. Five (45%) patients referred an history of multiple intrarticular injections. 7 patients (64%) had a complete resolution following an arthroscopic debridement, 4 (36%) patients underwent to a 2-stage replacement and one of them hesitated in an arthrodesis because of a recurrent periprothesic joint infection and extensor apparatus insufficiency. CONCLUSION: The authors observed a potential increased risk of septic arthritis following joint injection in patients with history of multiple injections and poor health/immunological conditions. They recommend an early arthroscopic debridement as the treatment of choice especially in septic knees  performed in a multispecialist dedicated center.

SARS-CoV-2 in the knee joint: a cadaver study.

OBJECTIVES: Despite the considerable research efforts being made to learn more about COVID-19, little is known about the presence of SARS-CoV-2 genetic material in biological fluids other than respiratory droplets, blood, and feces. The aim of this post-mortem study was to assess the presence of SARS-CoV-2 RNA in the knee synovial fluid, synovial tissue, and bone tissue of COVID-19 patients in order to discover whether the joint is a possible route of transmission during orthopaedic surgical procedures, and clarify the possible role of SARS-CoV-2 as a directly arthritogenic virus. METHODS: Post-mortem synovial fluid, synovial tissue and bone tissue samples were collected from the knees of five patients who died of COVID-19 in our hospital between September and October 2020, and analysed for the presence of SARS-CoV-2 using a commercial real-time polymerase chain reaction (RT-PCR) panel. Quantitative RT-PCR was used to test post-mortem nasopharyngeal swabs of all of the patients. RESULTS: No SARS-CoV-2 RNA was detected in any of the knee samples, despite the positivity of the throat swab. CONCLUSIONS: Our findings indicate that SARS-CoV-2 was not detected in knee synovial fluid, synovial membrane or bone. This makes it unlikely that these are potential sources of contagion, and suggests that SARS-CoV-2 is not directly arthritogenic.

Postoperative outcomes in total hip arthroplasty following femoral head avascular necrosis in HIV-positive patients.

BACKGROUND: Few clinical studies have been published reporting the clinical outcomes of total hip replacement (THA) in HIV-positive patients affected by femoral head avascular necrosis (AVN) often with controversial results and often without any correlation with the immunological patient status. Our study aim is to retrospectively review the outcome of a HIV-positive patient series. MATERIAL AND METHODS: 24 THAs perfomed between 2007 and  2017 were assessed in the study. All patients have been classified with Charlson Comorbidity Index (CCI) and the CDC (Center for Disease Control and Prevention) HIV classification.  At the latest follow-up each patient have been evaluated using Harris Hip Score (HHS), WOMAC score, a numerical pain rating scale (NRS) and procedure-related complications were collected. RESULTS: At a mean mean follow up of 96,41 months the mean WOMAC score was 91,66  and the mean Harris Hip Score was 86,77 with  excellent results in 18 hips, good in 1 and poor in the 5. Post-operative complications were reported in 7 hips, 3 patients developed a periprosthetic joint infection (PJI) in patients with low CD4+ count and history of intravenous drug consumption. CONCLUSION: We registered a good outcome in HIV patient with femoral head AVN treated with Total Hip replacement. However, we reported a significant increase in complications and revision rate especially referred to PJI, in patient with history of intravenous drug consumption and low CD4+ count. The authors advocate further prospective multicentric studies with larger population in the future. (www.actabiomedica.it).

Case series of traumatic neglected Extensor Hallucis Longus lacerations: choice of surgical treatment based on injury type.

BACKGROUND AND AIM: Extensor Hallucis Longus (EHL) tendon rupture is a rare injury of the foot, representing only 1% of overall tendon rupture. Early diagnosis and surgical repair are recommended but there is still no consensus regarding the ideal treatment. The purpose of this study was to evaluate a case series of patients with neglected extensor hallucis longus (EHL) tendon rupture. METHODS: We report a case series of 3 patients affected by traumatic neglected EHL lacerations treated with reconstructive surgery using tissue scaffolds, between November 2019 and May 2020. Demographics data, mechanism of injury, zone of injury, tendon gap, time to surgery, type of surgical repair, preoperative and postoperative functional score were collected with a minimum follow-up of 8 months. RESULTS: The zone of injury (according to Al-Qattan classification) involved was in 1 case zone 2, in 1 case zone 4 and in the last case zone 5. The mean value of intraoperative tendon gap was of 3,4 cm. The elapsed time from injury to surgery was an average of 3,3 months. One tendon transfer surgery and two primary repairs with Krakow fashion were performed, all augmented with tissue scaffolds. The mean preoperative and postoperative American Orthopedic Foot and Ankle Society (AOFAS) scores were, respectively, 43 and 97. CONCLUSIONS: Our results highlight good functional result and satisfaction with active extension of the hallux restored in all patients. According to our experience, we recommend choosing reconstruction technique basing on the topographic zone of lesion and intraoperative tendon gap.

Humeral head necrosis associated to shaft non-union with massive bone loss: a case report.

Humeral non-union is a rare complication in shaft fractures, as well as humeral head necrosis is a possible complication in fracture involving the proximal third especially in four-part fractures. The presence of head osteonecrosis and diaphyseal non-union in the same arm represents a formidable challenge for an orthopaedic surgeon. We could not find any similar report in the literature dealing with this issue thus far. We present a case of a 65 years old woman referred to our hospital being affected by an atrophic humeral diaphyseal non-union with a massive bone loss (>10cm) associated to a humeral head osteonecrosis following a previous surgical procedures with a clear loosening of the hardware. At our institution,she was treated with hardware removal and insertion of a diaphyseal antibiotic spacer with Gentamycin for 2 months suspecting an active septic process at the union site despite negative cultural exams. Finally, she was treated with a cemented modular humeral megaprosthesis. At 20 months follow up, the patient, despite a reduced shoulder range of motion, referred to a pain-free recovery to an almost normal lifestyle, including car driving with no major disturbances. This case suggests that, in extreme selected cases following several failed treatments, megaprosthesis can represent a viable solution, especially in huge bone loss associated to joint degeneration, to ensure an acceptable return to a normal lifestyle.

Clinical outcome before and after COVID-19 quarantine in patients affect of knee and hip osteoarthritis.

BACKGROUND: The emergency caused by COVID-19 Pandemia has resulted in a complete suspension and consequent delay of common planned surgery such total hip replacement in patients affect by osteoarthritis. At the same time, the issue of the quarantine imposed changes to the normal lifestyle of these patients. The purpose of our study is to evaluate how the presence of these two factors affect the quality of live of patients living in the Italian red zone. METHODS: From outpatient pre-operative assessment we collect data about: demographic data, WOMAC score, NRS (Numeric rating scale 0-10), PCS SF12 and MCS SF12 score. Selected patients were therefore contacted by telephone call and re-assess using the same score. In addition, patients were asked if they intended to undergo the planned surgery again despite the current emergency Results:  14 patient have been recruited for the study. Male/female ration was 10/4, mean age was 70 years. Pre operative outpatient assessment mean WOMAC score was 44,86 (SD ± 8,52) , mean NRS was 8,07 (SD ± 1,33), PCS SF12 was  30,33 (SD ± 5,0) and MCS SF12 was 40,95 (SD ± 3,51).  At re-evalutation the mean WOMAC score was 32,86 (SD ± 17,88) , mean NRS was 5,79 (SD ± 3,66), PCS SF12 was  39,9 (SD ± 3,70) and MCS SF12 was 50,14 (SD ± 6,86) Conclusion:  The exceptionale pandemic from Covid-19 has profoundly changed our lifestyle, impacting normal daily activities but also on regular surgical activity in patients affected by osteoarthritis. Our study suggested that the lifestyle changes imposed by the situation led to an improvement of clinical score. This shows how an exceptional event can affect many aspects of daily life.

Intratendinous adipose-derived stromal vascular fraction (SVF) injection provides a safe, efficacious treatment for Achilles tendinopathy: results of a randomized controlled clinical trial at a 6-month follow-up.

PURPOSE: Although platelet-rich plasma (PRP) injection has shown controversial results for the treatment of Achilles tendinopathy, it remains the most used biological treatment. Recent findings seem to demonstrate that the stromal vascular fraction (SVF) within adipose tissue may counteract the impaired tendon homeostasis. The aim of this study was to prospectively compare the efficacy of PRP and SVF injection for the treatment of non-insertional Achilles tendinopathy. METHODS: Fourty-four patients were recruited in the study; 23 of them were assigned to the PRP group whereas 21 to the SVF group, treated unilaterally or bilaterally for a total of 28 tendons per group. All patients (age 18-55 years) were clinically assessed pre-operatively and at 15, 30, 60, 120 and 180 days from treatment, using the VAS pain scale, the VISA-A, the AOFAS Ankle-Hindfoot Score and the SF-36 form. The patients were also evaluated by ultrasound and magnetic resonance before treatment and after 4 (US only) and 6 months. RESULTS: Both treatments allowed for a significant improvement with respect to baseline. Comparing the two groups, VAS, AOFAS and VISA-A scored significantly better at 15 and 30 days in the SVF in comparison to PRP group (p < 0.05). At the following time points the scores were not significantly different between the two groups. No correlation has been found between clinical and radiological findings. CONCLUSIONS: Both PRP and SVF were safe, effective treatments for recalcitrant Achilles tendinopathy. The patients treated with SVF obtained faster results, thus suggesting that such a treatment should be taken into consideration for those patients who require an earlier return to daily activities or sport. LEVEL OF EVIDENCE: Randomized Controlled Clinical Trial, Level 1.

Magnetic resonance and ultrasound in achilles tendinopathy: Predictive role and response assessment to platelet-rich plasma and adipose-derived stromal vascular fraction injection.

OBJECTIVE: To assess the correlation between magnetic resonance and ultrasound findings and clinical outcome after intratendinous injection of leucocyte-rich platelet-rich plasma or adipose-derived stromal vascular fraction in patients with non-insertional Achilles tendinopathy. MATERIALS AND METHODS: Forty-three patients (age: 47.8±5.1, range 29-55) with unilateral or bilateral non-insertional Achilles tendinopathy (58 tendons overall) were randomly assigned to platelet-rich plasma (22 patients, 28 tendons) or adipose-derived stromal vascular fraction (21 patients, 30 tendons) injection group. All patients underwent magnetic resonance (tendon cross-sectional area, signal intensity, maximum anteroposterior thickness were measured), ultrasound (maximum anteroposterior thickness, power Doppler signal, ultrasound gray scale echotexture were measured), and visual analogue scale (VAS) pain evaluation at baseline and at six months from treatment. Wilcoxon, intraclass correlation coefficient, repeated measure ANOVA tests were used. RESULTS: There was a significant (P<0.001) decrease of mean VAS from pre-treatment (6.4±1.4) to six-month evaluation (1.8±1.7). Significant increase of tendon thickness measured using magnetic resonance (P=0.013) and ultrasound (P=0.012) and power Doppler signal (P=0.027) was seen. There was no significant difference between pre- and post-treatment cross sectional area, signal intensity, and echotexture (P>0.217). None of the pre-treatment parameters was a predictor of treatment outcome (P>0.104). There was an excellent agreement between tendon thickness measurement between magnetic resonance and ultrasound (intraclass correlation coefficient=0.986) CONCLUSIONS: Both treatments seem to allow for clinical benefit, associated to early slight increase of tendon size and power Doppler signal. Imaging cannot be used as a predictor of clinical outcome.

Bone-block arthrodesis procedure in failures of first metatarsophalangeal joint replacement.

BACKGROUND: The treatment for the failure of a first metatarsophalangeal joint (MTP1) prosthesis can be complex. There is no consensus regarding the ideal treatment. One of the main issues is the available bone stock after prosthesis removal. The aim of the study was to report the clinical and radiographic results for MTP1 arthrodesis with autologous calcaneus bone graft (bone-block fusion) as a revision procedure of a previous MTP1 implant failure. METHODS: This study included 12 patients diagnosed with failure of a MTP1 prosthesis. All patients were treated with MTP1 arthrodesis using ipsilateral calcaneal bone graft. Patients were evaluated with the Foot Ankle Disability Index (FADI), the visual analogue pain scale (VAS) and AOFAS Hallux Metatarsophalangeal Interphalangeal scoring system (AOFAS-HMI), weight-bearing radiograph of the foot, and a computed tomography scan. The 1-2 intermetatarsal angle, hallux valgus angle, and first ray length were measured before surgery and at final follow-up. RESULTS: Complications included 3 cases of arthrodesis nonunion, (1 symptomatic, 2 asymptomatic) with 2 of the 3 patients experiencing hardware failure and 1 superficial wound infection. The average FADI improved from 41.8 preoperatively to 84.6 at final follow-up (p<0.05); the average VAS improved from 8.5 preoperatively to 2 at final follow-up (p<0,05); the average AOFAS-HMI significantly improved from 50.7 preoperatively to 73.8 at final follow-up (p<0.05). The average length of the bone-block used was 14.3mm (range 11-19mm). The 1-2 intermetatarsal angle decreased from 9.5° preoperatively to 8.4° at final follow-up (p<0.05); hallux valgus angle improved from 19.7° preoperatively to 14.3° at final follow-up (p<0.05). CONCLUSIONS: The management of a failed first metatarsophalangeal joint prosthesis remains controversial. Bone-block arthrodesis using ipsilateral calcaneal autograft appears to be a viable option restoring the bone loss, and avoiding hallux shortening. Nonunion is the most frequent complication with 25% of patients affected, but only 1/3 of patients with nonunion were symptomatic and required revision.

Treatment of osteochondral lesions of the talus with autologous collagen-induced chondrogenesis: clinical and magnetic resonance evaluation at one-year follow-up.

PURPOSE: the aim of this study is to report the clinical and imaging results recorded by a series of patients in whom osteochondral lesions of the talus (OLTs) were repaired using the autologous collagen-induced chondrogenesis (ACIC) technique with a completely arthroscopic approach. METHODS: nine patients (mean age 37.4±10 years) affected by OLTs (lesion size 2.1±0.9 cm(2)) were treated with the ACIC technique. The patients were evaluated clinically both preoperatively and at 12 months after surgery using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and a visual analog scale (VAS). For morphological evaluation, the magnetic resonance observation of cartilage repair tissue (MOCART) score was used. RESULTS: the AOFAS score improved from 51.4±11.6 preoperatively to 71.8±20.6 postoperatively, while the VAS value decreased from 6.9±1.8 to 3.2±1.9. The mean MOCART score was 51.7±16.6 at 12 months of follow-up; these scores did not directly correlate with the clinical results. CONCLUSION: use of the ACIC technique for arthroscopic repair of OLTs allowed satisfactory clinical results to be obtained in most of the patients as soon as one year after surgery, with no major complications or delayed revision surgery. ACIC is a valid and low-invasive surgical technique for the treatment of chondral and osteochondral defects of the talus. LEVEL OF EVIDENCE: therapeutic case series, level IV.

All-Arthroscopic Autologous Matrix-Induced Chondrogenesis for the Treatment of Osteochondral Lesions of the Talus.

Several surgical techniques have been described for the treatment of talar chondral lesions. Among them, microfracture is well established. Autologous matrix-induced chondrogenesis (AMIC), using microfracture and biomaterials, has shown promising results for the treatment of knee osteochondral lesions and has been proposed for the ankle as an open technique. We describe an all-arthroscopic AMIC technique. The benefits of an all-arthroscopic procedure include smaller incisions with less soft-tissue dissection, better visualization of the joint, and a quicker recovery compared with open surgery. The use of matrix to support cartilage regeneration promotes good-quality cartilage tissue with satisfactory long-term outcomes. Our all-arthroscopic AMIC technique uses a type I-type III porcine collagen matrix (Chondro-Gide; Geistlich Pharma, Wolhusen, Switzerland) and is characterized by 2 different arthroscopic surgical phases. First, adequate exposure is achieved through use of a Hintermann spreader (Integra LifeSciences, Plainsboro, NJ) with sufficient joint distraction and wet lesion preparation. The second surgical step is performed dry, involving matrix placement and fixation. The all-arthroscopic AMIC technique for the treatment of osteochondral lesions of the talus allows a very precise reconstruction in the case of cartilage defects and avoids the need for a more invasive operation associated with higher morbidity and a longer surgical time.