Surgical treatment of an aseptic fistulized acromioclavicular joint cyst: a case report and review of the literature

An acromioclavicular joint cyst is an uncommonly reported condition, which seems to result from a massive rotator cuff tear and degenerative osteoarthritis of the acromioclavicular joint. We present the case of an 81-year-old man affected by an acromioclavicular joint cyst, associated to a massive rotator cuff tear, proximal migration of the humeral head and osteoarthritis of the gleno-humeral joint. The mass was 7 × 2.5 cm in size and the overlying skin presented a fistula that drained clear synovial-like fluid. Plain X-ray examination of the left shoulder showed proximal migration of the humeral head migration and osteoarthritis of the gleno-humeral joint, and further MRI evaluation confirmed the clinical diagnosis of a complete rotator cuff tear and observed a large subcutaneous cyst in communication with the degenerative acromioclavicular joint. The patient underwent surgical excision of the cyst and lateral resection of the clavicle to prevent disease recurrence. To the best of our knowledge, this is the first reported case of an acromioclavicular joint cyst complicated by an aseptic fistula resulting from multiple aspirations

Approach and treatment of the adult acquired flatfoot deformity

Abstract Adult acquired flatfoot deformity (AAFD), embraces a wide spectrum of deformities. AAFD is a complex pathology consisting both of posterior tibial tendon insufficiency and failure of the capsular and ligamentous structures of the foot. Each patient presents with characteristic deformities across the involved joints, requiring individualized treatment. Early stages may respond well to aggressive conservative management, yet more severe AAFD necessitates prompt surgical therapy to halt the progression of the disease to stages requiring more complex procedures. We present the most current diagnostic and therapeutic approaches to AAFD, based on the most pertinent literature and our own experience and investigations

CD40 activation of BCP-ALL cells generates IL-10-producing, IL-12-defective APCs that induce allogeneic T-cell anergy

The use of leukemia cells as antigenpresenting cells (APCs) in immunotherapy is critically dependent on their capacity to initiate and sustain an antitumor-specific immune response. Previous studies suggested that pediatric B-cell precursor acute lymphoblastic leukemia (BCP-ALL) cells could be manipulated in vitro through the CD40-CD40L pathway to increase their immunostimulatory capacity. We extended the APC characterization of CD40L-activated BCP-ALL for their potential use in immunotherapy in a series of 19 patients. Engaging CD40 induced the up-regulation of CCR7 in 7 of 11 patients and then the migration to CCL19 in 2 of 5 patients. As accessory cells, CD40Lactivated BCP-ALL induced a strong proliferation response of naive T lymphocytes. Leukemia cells, however, were unable to sustain proliferation over time, and T cells eventually became anergic. After CD40-activation, BCP-ALL cells released substantial amounts of interleukin-10 (IL-10) but were unable to produce bioactive IL-12 or to polarize TH1 effectors. Interestingly, adding exogenous IL-12 induced the generation of interferon- (IFN- )–secreting TH1 effectors and reverted the anergic profile in a secondary response. Therefore, engaging CD40 on BCP-ALL cells is insufficient for the acquisition of full functional properties of immunostimulatory APCs. These results suggest caution against the potential use of CD40L-activated BCP-ALL cells as agents for immunotherapy unless additional stimuli, such as IL-12, are provided.Fil: D'Amico, Giovanna. Università Milano Bicocca; ItaliaFil: Vulcano, Marisa. Universidad de Buenos Aires. Facultad de Medicina; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay; ArgentinaFil: Bugarin, Cristina. Università Milano Bicocca; ItaliaFil: Bianchi, Giancarlo. Università Milano Bicocca; ItaliaFil: Pirovano, Gisella. Università Milano Bicocca; ItaliaFil: Bonamino, Martin. Università Milano Bicocca; ItaliaFil: Marin, Virna. Università Milano Bicocca; ItaliaFil: Allavena, Paola. Università Milano Bicocca; ItaliaFil: Biagi, Ettore. Università Milano Bicocca; ItaliaFil: Biondi, Andrea. Università Milano Bicocca; Itali

Impact of COVID-19 Pandemic on Patients\u27 Perceptions of Safety and Need for Elective Foot and Ankle Surgery in the United States

Background: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the United States to divert health care resources and limit exposure. Little is known about the impact of COVID-19 on patient\u27s willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision. Methods: Patients across 6 US orthopedic institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient\u27s decisions. Results: A total of 150 patients participated in this study. Twenty-one (14%) opted not to proceed with surgery once restrictions were lifted. Forty-three percent (n = 9) listed concern for COVID infection as the reason; however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs 14%) and lower increase in pain medication used (5% vs 12%). Conclusion: COVID-19 has made a significant impact on the health care system. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic. Level of Evidence: Level III

Safety and Effectiveness of Talus Subchondroplasty® and Bone Marrow Aspirate Concentrate for Treatment of Osteochondral Defects of the Talus

Category: Arthroscopy Introduction/Purpose: Subchondroplasty® is a relatively new technique used to treat multiple conditions associated with bone marrow edema. Asymptomatic talus osteochondral defects (OCD) typically present with no bone marrow edema on MRI. Therefore the aim of this retrospective study is to assess the safety and effectiveness of an arthroscopic-percutaneous procedure for the treatment of painful OCDs using subchondral highly porous injectable calcium phosphate – to address the marrow edema - and intra-articular bone marrow aspirate concentrate (BMAC) – to address joint inflammation. Methods: From September 2016 to November 2016 9 consecutive patients with an isolated symptomatic osteochondral defect were included in the study. The Foot and Ankle Orthopaedic Score (FAOS) and the visual analogue scale (VAS) for pain were administered preoperatively and at the 1 year postoperative mark. At 52 weeks patients were asked if they would have the procedure again. The procedure was performed by debriding only unstable cartilage and joint synovitic tissue. No microfracture was performed to prevent spilling of calcium paste into the joint. At the end of the procedure 8 cc of BMAC were injected into the joint. Patients were allowed to weight bear as tolerated in a sneaker postoperatively. Return to sports was also indicated as tolerated. Results: Mean OCD size as measured on preoperative MRI was 1.3 x 1.4 cm (range, 1 x 0.8 cm to 2 x 2.3 cm). Mean 1.7 cc (range, 1.5 to 2 cc) of calcium paste were injected in the subchondral bone at the level of the OCD, under arthroscopic visualization to debride any calcium paste leakage. All outcome measures demonstrated marked improvement from baseline to final follow-up: The mean weight bearing VAS pain score improved from mean 7.8 (range 6 to 9) to 0.5 (range, 0 to 1); the mean total FAOS improved from mean 67.1 (range, 55 to 79) to mean 90.6 (range, 87 to 95). At the 1-year postoperative visit all patients declared that they would have the procedure again. Conclusion: Despite the short follow up and the limited number of patients, subchondroplasty and BMAC injection offered good pain relief in all patients. The procedure is not technically challenging, it allows for immediate postoperative weight bearing, and does not compromise future treatments in case of recurrence of symptoms. Further high-quality studies are needed to confirm these results and to assess the long-term outcomes of the procedure

The painful total ankle replacement

Category: Ankle Arthritis Introduction/Purpose: The last decade has seen a considerable increase in the use of in total ankle arthroplasty (TAA) to treat patients with end-stage arthritis of the knee. However, the longevity of the implants is still far from that of total knee and hip arthroplasties Methods: To introduce a systematic approach to the painful TAA based on the literature and on the senior author’s experience Results: See algorithm attached Conclusion: This new diagnostic and treatment algorithm may be useful to guide less experienced surgeons navigate through the possible causes and treatments of a painful TA

Bilateral iliopsoas intramuscular bleeding following anticoagulant therapy with heparin: a case report.

6Iliopsoas haematoma is an uncommon complication that may arise during anticoagulant therapy, especially with heparin and warfarin. Besides determining patient distress secondary to femoral nerve compression, this event may progress to life-threatening complications and require expensive treatments. We describe the case of a 70-year-old healthy man complaining of severe bilateral groin, lumbar and thigh pain, and paralytic ileus after therapy with heparin. The angio-computed tomography scan observed bilateral iliopsoas haematomas. In view of the clinical and radiological scenarios, we ordered a diagnostic and therapeutic angiography of the bleeding vessels by trans-catheter arterial embolization of the fourth right lumbar artery trunk. The treatment proved to be beneficial from a clinical, radiological and laboratory point of view. To the best of our knowledge, this is the first reported case of bilateral iliopsoas haematoma occurring in a male treated with therapeutic levels of heparin alone.openL. Murena;E. Vulcano;E. Salvato;M. Marano;F. D'Angelo;P. CherubinoMurena, Luigi; E., Vulcano; E., Salvato; M., Marano; D'Angelo, Fabio; Cherubino, Paol

Hallux rigidus: How do I approach it?

Hallux rigidus is a degenerative disease of the first metatarsalphalangeal (MTP) joint and affects 2.5% of people over age 50. Dorsal osteophytes and narrowed joint space leads to debilitating pain and limited range of motion. Altered gait mechanics often ensued as 119% of the body force transmit through the 1st MTP joint during gait cycle. Precise etiology remains under debate with trauma being often cited in the literature. Hallux valgus interphalangeus, female gender, inflammatory and metabolic conditions have all been identified as associative factors. Clinical symptoms, physical exam and radiographic evidence are important in assessing and grading the disease. Non-operative managements including nonsteroidal antiinflammatory drugs, intraarticular injections, shoe modification, activity modification and physical therapy, should always be attempted for all hallux rigidus patients. The goal of surgery is to relieve pain, maintain stability of the first MTP joint, and improve function and quality of life. Operative treatments can be divided into joint-sparing versus joint-sacrificing. Cheilectomy and moberg osteotomy are examples of joint-sparing techniques that have demonstrated great success in early stages of hallux rigidus. Arthrodesis is a joint-sacrificing procedure that has been the gold standard for advanced hallux rigidus. Other newer procedures such as implant arthro\uadplasty, interpositional arthroplasty and arthroscopy, have demonstrated promising early patient outcomes. However, future studies are still needed to validate its long-term efficacy and safety. The choice of procedure should be based on the condition of the joint, patient\u2019s goal and expectations, and surgeon\u2019s experience with the technique