Determination of diagnostic value (validity) leukocyte esterase (urine dipstick strip) in differentiating inflammatory arthritis from bacterial arthritis.

BACKGROUND: The current diagnostic cornerstone for septic arthritis contains gram stains, bacterial culture, and cell count with a differential of aspirated synovial fluid. Recently, a synovial leukocyte esterase (LE) test has been used for diagnosing septic arthritis. Since this test measures the esterase activity of leukocytes, there is always a dilemma for using this test in patients with inflammatory arthritis. METHODS: We collected the synovial fluid specimens as part of the general diagnostic protocol for patients suspected of Juvenile Idiopathic Arthritis (JIA) or Septic Arthritis (SA). Each group included 34 patients. We compared the result of the synovial LE test with the result of the culture of each patient. RESULTS: The mean ages of patients were 64.14 ± 31.27 and 50.88 ± 23.19 months in the JIA group and septic arthritis group, respectively. The LE test results were positive in 30 specimens, trace in 3 and negative in one in the first-time test and were positive in 31 specimens and trace in 3 in the second-time test, while it was negative in all patients with JIA. Hence, the sensitivity of the synovial LE test was 80.8%, the specificity, PPV, and NPV were 78.6, 70.0, 86.8% respectively based on a positive culture. CONCLUSION: The leukocyte esterase strip test can be used as a rapid, bedside method for diagnosing or excluding bacterial infections in different body fluids. The synovial LE test can be used as an accurate test to rapidly rule in or out an acute articular bacterial infection, even in patients with concurrent inflammatory arthritis.

Determination of diagnostic value (validity) leukocyte esterase (urine dipstick strip) in differentiating inflammatory arthritis from bacterial arthritis

Abstract Background: The current diagnostic cornerstone for septic arthritis contains gram stains, bacterial culture, and cell count with a differential of aspirated synovial fluid. Recently, a synovial leukocyte esterase (LE) test has been used for diagnosing septic arthritis. Since this test measures the esterase activity of leukocytes, there is always a dilemma for using this test in patients with inflammatory arthritis. Methods: We collected the synovial fluid specimens as part of the general diagnostic protocol for patients suspected of Juvenile Idiopathic Arthritis (JIA) or Septic Arthritis (SA). Each group included 34 patients. We compared the result of the synovial LE test with the result of the culture of each patient. Results: The mean ages of patients were 64.14 ± 31.27 and 50.88 ± 23.19 months in the JIA group and septic arthritis group, respectively. The LE test results were positive in 30 specimens, trace in 3 and negative in one in the first-time test and were positive in 31 specimens and trace in 3 in the second-time test, while it was negative in all patients with JIA. Hence, the sensitivity of the synovial LE test was 80.8%, the specificity, PPV, and NPV were 78.6, 70.0, 86.8% respectively based on a positive culture. Conclusion: The leukocyte esterase strip test can be used as a rapid, bedside method for diagnosing or excluding bacterial infections in different body fluids. The synovial LE test can be used as an accurate test to rapidly rule in or out an acute articular bacterial infection, even in patients with concurrent inflammatory arthritis.(AU)

Clinical Results of Percutaneous Fixation of Pelvic and Acetabular Fractures: A Minimally Invasive Internal Fixation Technique.

BACKGROUND: The pelvic ring fractures (PRF) and acetabular fractures (AF) are among the major orthopedic injuries associated with high rates of morbidity and mortality. Open surgical stabilization is the standard treatment for the majority of these complications. Percutaneous minimally invasive surgical stabilization of the fractures has become an accepted treatment method for the past several years. This study investigated the outcomes of percutaneous fixation of pelvic and acetabular fractures. METHODS: Totally, 143 patients with PRF or AF of whom 95 cases were males underwent percutaneous fixation between February 2015 and September 2016. All the operations were performed by a single surgeon in a supine position and under C-arm fluoroscopy visualization. The patients were followed up for one year. RESULTS: All the fractures healed in all of the patients within the first postoperative three months. The patients could bear weight completely on both lower limbs. Out of 143 patients, 133 cases could get back to their preoperative work (93%). The mean amount of intraoperative blood loss was 29±19 cc. Of the total patients, seven cases required oral analgesics because of moderate pain (4.9%). The means of operation time and length of incision were 32±8 min and 3.2±2.4 cm, respectively. There was one screw back out and one deep infection. No neurovascular injury was reported in this study. CONCLUSION: Closed reduction and percutaneous minimally invasive screw fixation for a pelvic ring or acetabular fractures is a useful surgical treatment option with low complication rates. LEVEL OF EVIDENCE: IV.

Diagnostic Value of Ischial Spine Sign in Patients with Acetabular Retroversion.

BACKGROUND: Acetabular Retroversion (AR) is a hip disorder and one of the causes of pain in this area. Evaluation of positive Cross Over Sign (COS) on AP X-Rays of the hip is currently the best method of diagnosis of AR. Several studies have measured co-existence of Ischial Spine Sign (ISS) in patients with AR. In this study we evaluated the diagnostic value of ISS in confirmation of AR and compared it with the diagnostic value of COS. METHODS: In this study, 4120 AP hip X-Rays from Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, were studied. Based on radiologic criteria, 1180 X-Rays were considered as standards and evaluated for ISS, COS and PWS (Posterior Wall Sign). Data analysis was done for correlation between ISS and COS. RESULTS: A total of 1180 out of 4120 X-Rays were considered as standard; among which, 86 were diagnosed with AR based on positive COS in presence of PWS. Both ISS and COS were positive concurrently in 69 X-Rays. ISS was positive in absence of COS in 11 X-rays. No significant difference in diagnostic value for diagnosis of acetabular retroversion was found between ISS and COS (P<0.05). CONCLUSION: According to our results, both ISS and COS signs can be employed for diagnosis of AR (acetabular retroversion). Considering the absence of a significant difference between these two signs in confirmation of AR, it can be perceived that the diagnostic value of ISS in confirmation of AR is equal to COS. Validation of the mentioned results requires further studies.

Serum D-Dimer Test Is Promising for the Diagnosis of Periprosthetic Joint Infection and Timing of Reimplantation.

BACKGROUND: Despite the availability of a battery of tests, the diagnosis of periprosthetic joint infection (PJI) continues to be challenging. Serum D-dimer assessment is a widely available test that detects fibrinolytic activities that occur during infection. We hypothesized that patients with PJI may have a high level of circulating D-dimer and that the presence of a high level of serum D-dimer may be a sign of persistent infection in patients awaiting reimplantation. METHODS: This prospective study was initiated to enroll patients undergoing primary and revision arthroplasty. Our cohort consisted of 245 patients undergoing primary arthroplasty (n = 23), revision for aseptic failure (n = 86), revision for PJI (n = 57), or reimplantation (n = 29) or who had infection in a site other than a joint (n = 50). PJI was defined using the Musculoskeletal Infection Society criteria. In all patients, serum D-dimer level, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level were measured preoperatively. RESULTS: The median D-dimer level was significantly higher (p < 0.0001) for the patients with PJI (1,110 ng/mL [range, 243 to 8,487 ng/mL]) than for the patients with aseptic failure (299 ng/mL [range, 106 to 2,571 ng/mL). Using the Youden index, 850 ng/mL was determined as the optimal threshold value for serum D-dimer for the diagnosis of PJI. Serum D-dimer outperformed both ESR and serum CRP, with a sensitivity of 89% and a specificity of 93%. ESR and CRP had a sensitivity of 73% and 79% and a specificity of 78% and 80%, respectively. The sensitivity and specificity of ESR and CRP combined was 84% (95% confidence interval [CI], 76% to 90%) and 47% (95% CI, 36% to 58%), respectively. CONCLUSIONS: It appears that serum D-dimer is a promising marker for the diagnosis of PJI. This test may also have a great utility for determining the optimal timing of reimplantation. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Association between iron status and febrile seizures in children.

OBJECTIVES: The aim of this study was to determine the association between iron status and febrile seizures in children aged 6 months to 5 years. METHODS: This prospective case-control study enrolled 300 children who presented with febrile seizures (case group) and 200 children who presented with a febrile illness without seizures (control group) from March 2007 to January 2009. Hemoglobin, mean corpuscular volume and serum ferritin concentration were compared in the two groups in relation to age, sex and use of iron supplementation. RESULTS: Patients with febrile seizures were more frequently iron deficient as defined by a serum ferritin level below 20 ng/dl (56.6% vs. 24.8%, P=0.0001). Mean hemoglobin concentration was 10.8 g/dl in the control group and 11.7 g/dl in the case group (P<0.05). The difference between groups in mean corpuscular volume was not statistically significant (75.5 fl vs. 74.4 fl, P<0.130). CONCLUSION: Low serum ferritin concentration and low iron status may be risk factors for the development of febrile seizures.

Comparing the efficacy of intra-articular application of morphine and tramadol on postoperative pain after arthroscopic knee surgery.

BACKGROUND: Intra-articular analgesia is a pain reliever that is frequently administered following arthroscopic knee surgery. OBJECTIVES: The purpose of this study was to compare the efficacy of intra-articular application of morphine and tramadol on postoperative pain after arthroscopic knee surgery. PATIENTS AND METHODS: For this randomized double blinded clinical trial, 132 patients undergoing minor arthroscopic knee surgery were randomly assigned to receive either; 5 mg morphine or 50 mg tramadol intra-articularly. Pain was evaluated by means of the verbal pain rating score (VRS) preoperatively (at rest and on movement of the knee joint) and postoperatively at 0, 1, 2, 3, 4, 6, 12 and 24 hours. Meanwhile, the time of the first analgesic request and need for supplemental analgesic were also recorded. RESULTS: There was no statistically significant difference in VRS scoring between the two groups during the preoperative period either at rest or on knee movement. Meanwhile, VRS scores did not differ significantly between the morphine and tramadol treated groups postoperatively, except for in the one-hour post-operative scores in which the tramadol-treated group experienced less pain (P < 0.007). Post-operative VRS scores at 6, 12, and 24 hours were significantly decreased when compared with previous scores in both morphine and tramadol prescribed subjects (P < 0.001), hence, both local analgesics can significantly reduce pain after minor knee surgery. CONCLUSIONS: We have found a postoperative analgesic effect of intra-articularly administered morphine and tramadol following minor arthroscopic knee surgeries with a maximum effect 6 hours post injection.

Modified retro-tubercle opening-wedge versus conventional high tibial osteotomy.

Despite the fact that common surgical techniques for the treatment of genu varum usually correct the malalignment in the affected knee, these methods have significant complications and cause problems in the long term. Retro-tubercle opening-wedge high tibial osteotomy is among the newer techniques for the treatment of genu varum. The goal of this study was to compare the results of retro-tubercle opening-wedge high tibial osteotomy with those of medial opening-wedge osteotomy. In a randomized, controlled trial, 72 patients with varus knees who were scheduled for surgery were assigned into either the retro-tubercle opening-wedge high tibial osteotomy (n=34) or medial opening-wedge osteotomy groups (n=38). Groups were matched for age and sex. The position of the patella was compared with respect to the tuberosity and the upper tibial slope pre- and postoperatively. Patients were followed for an average of 13 months (range, 10-21 months). In the retro-tubercle opening-wedge high tibial osteotomy group, the length of the patellar tendon did not significantly differ pre- and postoperatively (P≥.5); however, in the medial opening-wedge osteotomy group, a statistically significant shortening was noted in patellar tendon postoperatively (P≤.05). Similarly, the tibial plateau inclination showed a statistically significant difference postoperatively in the medial opening-wedge osteotomy group, while the difference in the retro-tubercle opening-wedge high tibial osteotomy group did not reach statistical significance.

Modified ilioinguinal approach to the acetabulum and pelvis from beneath the inguinal ligament: a subinguinal approach.

The ilioinguinal approach is favoured for fractures of the anterior part of the pelvis, but it is associated with some technical difficulties and it is not suitable for some complex fractures. In 2008, a modified ilioinguinal approach was introduced by Farid Yr which afforded visualisation of the inside and outside of the pelvis. The approach involves retroperitoneal access below the inguinal ligament to preserve the integrity of the inguinal canal and allows exposure of anterior and medial wall fractures as well as the anterior hip capsule. Despite the dimensions of the procedure, closure is anatomical because repair of the inguinal canal floor is not required. We report the use of this approach in 17 patients with T-type fractures of the acetabulum, transverse fractures of acetabulum, Tile C1 pelvic fractures, malunion of the pelvis and acetabular dysplasia. The approach is recommended in complex cases of acetabular surgery (including obese or muscular patients) and complicated or old fractures in which a better exposure is required. It is useful in visualisation of the anterior wall and labrum and intra articular structures, and in viewing the internal anatomy of the pelvis and acetabulum. It may be a suitable approach for periacetabular osteotomy.

Congenital dislocation of the knee in a 16-year-old girl.

Congenital dislocation of the knee ranges from hyperextension of the knee to translation of the femur on the tibia. Treatment options include bracing, splinting, manipulation and casting, and surgery. A 16-year-old girl presented with an inability to walk, stand upright, or bend her knees. She exhibited deformity of both lower extremities. She had deformed knees from birth, and they had been put in a cast for 2 months. No other therapeutic measures were taken. The patient walked on her abnormally hyperextended knees and could hyperextend the knees to 150 degrees recurvatum. She was diagnosed with a grade III congenital dislocation of the knee, and a flexion-shortening osteotomy at the distal femur above the trochlear level was performed on her knees in 2 sessions. Postoperatively, range of motion changed from hyperextention to 80 degrees flexion. A femoral supracondylar osteotomy was also performed 2 years later, and as a result, a 15 degrees flexion and 15 degrees valgus were added to the limb. The patient is now able to stand and walk without a knee brace and has 90 degrees passive and 80 degrees active knee flexion on both sides. Congenital dislocation of the knee is a rare congenital disorder. The results of treatment are favorable if started before age 3 months, or sometimes before age 2 years, but there is no effective treatment for older, neglected cases; therefore, we believe this case report demonstrates a novel surgical approach.

Sudden peroneal nerve palsy in a varus arthritic knee.

Peroneal nerve palsy has been reported in association with traumatic and nontraumatic causes. We encountered a 75-year-old man whose peroneal nerve palsy developed suddenly following varus deformity of the arthritic knee. A review of the literature found 1 other report describing a progressive peroneal nerve palsy associated with a varus deformity of the knee due to arthritis. Our patient had progressive intractable knee pain; 3-compartment, severe degenerative changes in the knees; varus knee malalignment and laxity; right peroneal nerve palsy; and decreased sensation to light touch and pinprick on the dorsum of the right foot. The preoperative WOMAC score was 36. Nerve conduction studies confirmed acute peroneal neuropathy with conduction block at the fibular neck and secondary axonal degeneration. Magnetic resonance imaging of the knee showed osteophytes and cysts surrounding the fibular neck. Although their compression could be responsible for the nerve palsy, the sudden process made this less possible. Thus, the patient underwent total knee arthroplasty of both knees without exploration of the nerve. At 5-month follow-up, the WOMAC score was 78. The patient walked with a cane with no varus thrust, and his right knee had no varus laxity in full extension. The peroneal nerve did not retain its function. Sensory examination and postoperative nerve conduction studies showed no improvement.