Focused Extracorporeal Shock Wave Therapy in Calcifying Tendinitis of the Shoulder

Background:: The objective of this study is to assess the effectiveness of extracorporeal shock wave therapy in the management of calcifying tendinitis of the shoulder. Furthermore, a dose-response relationship was sought as a secondary confirmation of effectiveness. Hypothesis: Focused extracorporeal shock wave therapy has a high, dose-responsive effectiveness in the management of calcifying tendinitis of the shoulder. Study Design: Meta-analysis. Methods: Studies were identified from online databases (MEDLINE, EMBASE, and Cochrane Controlled Trials Register), manual searches, and personal communication with experts in the field. After assessment of heterogeneity, a random effects model was generated. The primary end points were identified as pain and function by using the visual analog scale and the Constant-Murley Score, respectively. These end points were pooled and the weighted mean differences and 95% confidence intervals were estimated. Odds ratios of the secondary end point deposit resorption were pooled. Results:: In 14 studies, shock wave therapy led to a significantly higher reduction of pain (weighted mean difference, −2.8 points; 95% confidence interval, −4.2 to −1.5 points) and improvement of function (weighted mean difference, 19.8 points; 95% confidence interval, 13.4-26.3 points), compared to other treatments and placebo. High-energy treatment produced significantly better results than low-energy treatment for pain reduction (weighted mean difference, 1.7 points; 95% confidence interval, 0.7-2.6 points) and improvement of function (weighted mean difference, 10.7 points; 95% confidence interval, 7.2-14.1 points). These results are consistent with a dose-response relationship supporting the effectiveness of shock wave therapy. Conclusion:: Shock wave therapy for calcifying tendinitis of the shoulder is effective in pain relief, function restoration, and deposit resorption; however, these conclusions are susceptible to bias arising from the limitations of the included studies

A retrospective analysis of the accuracy of radioactively labeled autologous leukocytes in patients with infected prosthetic joints

BACKGROUND: Labeled leukocyte scintigraphy (LS) is considered a valuable tool in preoperative diagnosis of prosthetic joint infections (PJI). The aim of this study was to determine the accuracy of LS combined with bone marrow scintigraphy (BMS), as well as inflammation markers CRP and WBC, in detecting infection in patients with prosthetic joints. MATERIAL AND METHODS: This study included patients suspected of having PJI between January and September 2013 at the Vienna General Hospital who underwent imaging with 99mTc-HMPAO labeled autologous leukocytes and subsequent BMS. Diagnostic accuracy was assessed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: A total of 48 patients were included. The most common joint investigated was knee (25), followed by hip (9), shoulder (2), and elbow (1). Other parts of the body investigated included the femur (6), tibia (2), leg (2), and foot (1). The pathogens most frequently isolated included Staphylococcus epidermidis and Candida albicans. The sensitivity of LS was 60%, specificity 97%, PPV 86% and NPV 90%. Overall accuracy was calculated to be 90%. CONCLUSIONS: This study was able to demonstrate that 99mTc-HMPAO labeled autologous leukocytes in patients presenting with symptoms of PJI is accurate. In contrast, however, inflammation markers CRP and WBC are not accurate pre-diagnostic markers for PJI

Wandel in der rheumatischen Hüftchirurgie

Der Trend zeigt bei Rheumapatienten tendenziell einen Rückgang an gelenkerhaltenden Operationen wie Synovektomie und Gelenkersatzoperationen mit Hüftprothesen. Dies ist v. a. auf die systemische Therapie mit den bDMARDS („biological disease-modifying antirheumatic drugs“) zurückzuführen. Die Ergebnisse der Operationen bei Rheumapatienten sind bis auf eine erhöhte Infektionsrate bei Prothesen durchaus mit Nicht-Rheumapatienten vergleichbar. Gerade in der Hüftchirurgie hat sich in den letzten Jahren einiges getan. Von der Hüftarthroskopie und „mini-open“ gelenkerhaltenden Hüftchirurgie bis zur minimalinvasiven Implantation von Hüftprothesen mit knochenerhaltenden oder Kurzschäften entwickelte sich ein neues breites Angebot an Operationsmethoden. Diese Methoden kommen bei entsprechender Pathologie durchaus auch den Rheumapatienten zugute, nicht zuletzt durch die Möglichkeit der schnelleren postoperativen Mobilisierung.There is a trend towards a reduction in joint-preserving hip surgery, such as synovectomy and total hip joint replacement in rheumatic patients. This is mostly due to the success of biological disease-modifying antirheumatic drugs (bDMARD) in systemic anti-rheumatic therapy. The results of hip surgery in rheumatic patients are comparable to those in non-rheumatic patients, except for prosthetic joint infections, which are higher in patients with rheumatoid arthritis. Especially in hip surgery there was a big evolution in the last few years including a broad range of minimally invasive surgical methods, such as hip arthroscopy, mini-open hip surgery and minimally invasive hip arthroplasty with bone preservation or short femoral shafts. These surgical methods also have an advantage in the treatment of typical rheumatoid pathologies and have the benefit of a rapid recovery.(VLID)361613

Der Orthopäde / Management von Protheseninfektionen

Protheseninfektionen mit biofilmbildenden Erregern sind eine der meistgefürchteten Komplikationen für Patienten und behandelnde Ärzte. Die Inzidenz ist niedrig, jedoch führen sie bei Auftreten zu verheerenden Einschränkungen in der Lebensqualität und Mobilität der Patienten sowie zu hohen Therapiekosten. Entscheidend für eine adäquate Behandlung einer Protheseninfektion ist in erster Linie eine umfangreiche Diagnostik, um eine aseptische Lockerung auszuschließen, und in zweiter Linie bei Vorliegen eines Infektes, den (die) biofilmbildenden Keim(e) zu ermitteln. In der Wahl der Therapie ist entscheidend, den Infekt richtig zu graduieren und in der Folge die entsprechende Therapie zu wählen. Diese muss sich sowohl in chirurgischer als auch mikrobiologischer Hinsicht an anerkannten Standards orientieren.Infections of prosthetic joints with biofilm-forming pathogens are one of the most devastating complications for patients and surgeons. Although the incidence is low they result in massive restrictions in the quality of life and mobility for patients as well as high costs for the treatment. Crucial for an adequate management of prosthetic joint infections are primarily comprehensive diagnostics to be able to exclude an aseptic loosening and secondarily in the presence of an infection to identify the pathogen responsible for forming the biofilm. The correct grading of the infection is crucial for selecting the appropriate form of infection management. Established standards in surgical treatment as well as in microbiology have be considered.(VLID)346206

Increased Temperature Enhances the Antimicrobial Effects of Daptomycin, Vancomycin, Tigecycline, Fosfomycin, and Cefamandole on Staphylococcal Biofilms▿

Implant-related infections are serious complications of trauma and orthopedic surgery and are most difficult to treat. The bacterial biofilms of 34 clinical Staphylococcus sp. isolates (Staphylococcus aureus, n = 14; coagulase-negative staphylococci, n = 19) were incubated with daptomycin (DAP; 5, 25, or 100 mg/liter), vancomycin (VAN; 5, 25, or 100 mg/liter), tigecycline (TGC; 1, 5, or 25 mg/liter), fosfomycin (FOM; 100, 250, or 1,000 mg/liter), and cefamandole (FAM; 50, 100, or 500 mg/liter) for 24 h at three different ambient temperatures: 35°C, 40°C, and 45°C. To quantify the reduction of the biomass, the optical density ratio (ODr) of stained biofilms and the number of growing bacteria were determined. Increasing the temperature to 45°C or to 40°C during incubation with FAM, FOM, TGC, VAN, or DAP led to a significant but differential reduction of the thickness of the staphylococcal biofilms compared to that at 35°C (P < 0.05). Growth reduction was enhanced for DAP at 100 mg/liter at 35°C, 40°C, and 45°C (log count reductions, 4, 3.6, and 3.3, respectively; P < 0.05). A growth reduction by 2 log counts was detected for FAM at a concentration of 500 mg/liter at 40°C and 45°C (P = 0.01). FOM at 1,000 mg/liter reduced the bacterial growth by 1.2 log counts (not significant). The antibacterial activity of antimicrobial agents is significantly but differentially enhanced by increasing the ambient temperature and using high concentrations. Adjuvant hyperthermia may be of value in the treatment of biofilm-associated implant-related infections

Reliability of the Radiographic Sagittal and Frontal Tibiotalar Alignment after Ankle Arthrodesis.

BACKGROUND:Accurate measurement of the tibiotalar alignment is important in radiographic outcome assessment of ankle arthrodesis (AA). In studies, various radiological methods have been used to measure the tibiotalar alignment leading to facultative misinterpretation of results. However, to our knowledge, no previous study has investigated the reliability of tibiotalar alignment measurement in AA. We aimed to investigate the reliability of four different methods of measurement of the frontal and sagittal tibiotalar alignment after AA, and to further clarify the most reliable method for determining the longitudinal axis of the tibia. METHODS:Thirty-eight weight bearing anterior to posterior and lateral ankle radiographs of thirty-seven patients who had undergone AA with a two screw fixation technique were selected. Three observers measured the frontal tibiotalar angle (FTTA) and the sagittal tibiotalar angle (STTA) using four different methods. The methods differed by the definition of the longitudinal tibial axis. Method A was defined by a line drawn along the lateral tibial border in anterior to posterior radiographs and along the posterior tibial border in lateral radiographs. Method B was defined by a line connecting two points in the middle of the proximal and the distal tibial shaft. Method C was drawn "freestyle"along the longitudinal axis of the tibia, and method D was defined by a line connecting the center of the tibial articular surface and a point in the middle of the proximal tibial shaft. Intra- and interobserver correlation coefficients (ICC) and repeated measurement ANOVA were calculated to assess measurement reliability and accuracy. RESULTS:All four methods showed excellent inter- and intraobserver reliability for the FTTA and the STTA. When the longitudinal tibial axis is defined by connecting two points in the middle of the proximal and the distal tibial shaft, the highest interobserver reliability for the FTTA (ICC: 0.980; CI 95%: 0.966-0.989) and for the STTA (ICC: 0.997; CI 95%: 0.996-0.999) is provided. Intergroup analysis for FTTA measurements revealed a statistically significant difference between the method in which the lateral border of the tibia was used to determine the longitudinal axis of the tibia, and the other methods in which the longitudinal axis was defined by bisecting the tibia. CONCLUSIONS:When the longitudinal axis of the tibia is defined by connecting two points in the middle of the proximal and the distal tibial shaft for measuring the FTTA and STTA, the most favorable interobserver reliability is provided. Therefore, this method can be recommended for evaluating the frontal and the sagittal alignment on anterior to posterior and lateral radiographs after ankle arthrodesis

Effects of Azithromycin in Combination with Vancomycin, Daptomycin, Fosfomycin, Tigecycline, and Ceftriaxone on Staphylococcus epidermidis Biofilms ▿

Staphylococcal biofilms on surgical implants are the underlying cause of a lack of response to antimicrobial treatment. We investigated the effects of vancomycin (VAN), daptomycin (DAP), fosfomycin (FOS), tigecycline (TGC), and ceftriaxone (CRX), alone and in combination with azithromycin (AZI), on established biofilms of Staphylococcus epidermidis. Biofilms were studied using the static microtiter plate model with established S. epidermidis biofilms, with an initial inoculum of 106/ml in 96-well polystyrene flat-bottom microtiter plates. Biofilms were inoculated with VAN, DAP, FOS, TGC, or CRX at two concentrations, alone or in combination with AZI (2, 512, or 1,024 mg/liter). To assess the reduction in biomass, the optical density ratio (ODr), calculated as (optical density [OD] of the treated biofilm)/(OD of the untreated biofilm, taken as 1), was used. For antibacterial efficacy, the viable bacterial count was used. Reductions in the biofilm ODr were observed for VAN (15 and 40 mg/liter) and FOS (200 mg/liter) only (ODr [mean ± standard deviation] for VAN at 15 and 40 mg/liter, 0.77 ± 0.32 and 0.8 ± 0.35, respectively; ODr for FOS at 200 mg/liter, 0.78 ± 0.26; P < 0.05), but not for DAP (2 and 5 mg/liter), TGC (0.2 and 2 mg/liter), or CRX (600 and 2,400 mg/liter). The addition of AZI had no further effect on the ODr, but a significant reduction of bacterial growth was achieved with high doses of AZI plus TGC or AZI plus CRX (a 3-log count reduction for AZI at 1,024 mg/liter plus CRX at 600 mg/liter and for AZI at 512 or 1,024 mg/liter plus CRX at 2,400 mg/liter; a 2-log count reduction for AZI at 512 or 1,024 mg/liter plus TGC at 2 mg/liter [P < 0.05]). No significant reduction in bacterial growth was observed for FOS (50 and 200 mg/liter), DAP (2 and 5 mg/liter), or TGC (0.2 mg/liter) in combination with AZI. None of the antibiotics at either concentration reduced the bacterial count of the biofilms when used alone. Thus, the use of a combination of AZI plus TGC, FOS, or CRX at high concentrations has little effect on biofilm density but significantly reduces bacterial growth

A comparative study of intraoperative frozen section and alpha defensin lateral flow test in the diagnosis of periprosthetic joint infection

Background and purpose — For decision-making (aseptic vs. septic), surgeons rely on intraoperatively available tests when a periprosthetic joint infection (PJI) cannot be confirmed or excluded preoperatively. We compared and evaluated the intraoperative performances of the frozen section and the alpha defensin lateral flow test in the diagnosis of PJI. Patients and methods — In this prospective study, consecutive patients with indicated revision surgery after arthroplasty were included. Patients were classified as having PJI using the MusculoSkeletal Infection criteria. The presence of alpha defensin was determined using the lateral flow test intraoperatively. During revision surgery, tissue samples were harvested for frozen and permanent section. Analysis of diagnostic accuracy was based on receiver-operating characteristics. Results — 101 patients (53 hips, 48 knees) were eligible for inclusion. Postoperatively, 29/101 patients were diagnosed with PJI, of which 8/29 cases were definitely classified as septic preoperatively. Of the remainder 21 septic cases, the intraoperative alpha defensin test and frozen section were positive in 13 and 17 patients, respectively. Sensitivities of the alpha defensin test and frozen section were 69% and 86%, respectively. The area under the curves of both tests showed a statistically significant difference (p = 0.006). Interpretation — The frozen section showed a significantly higher performance compared with the alpha defensin test and a near perfect concordance with the definitive histology, and therefore remains an appropriate intraoperative screening test in diagnosing PJI. Although the sensitivity of the alpha defensin test was lower compared with that of frozen section, this test is highly specific for confirming the diagnosis of PJI