Does the use of antibiotic spacer disrupt induced membrane function?

Treatment of large segmental bone defects has been a challenging and long process for both physicians and patients. At present, the induced membrane technique is one of the reconstruction techniques commonly utilized in treating large segmental bone defects. It consists of a two-step procedure. In the first one, after bone debridement, the defect is filled with bone cement. The aim at this stage is to support and protect the defective area with cement. A membrane is formed around the area where cement was inserted 4-6 weeks after the first surgical stage. This membrane secretes vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), as shown in the earliest studies. In the second step, the bone cement is removed, and the defect is filled with cancellous bone autograft. In the first stage, antibiotics can be added to the applied bone cement, depending on the infection. Still, the histological and micromolecular effects of the added antibiotic on the membrane are unknown.This study investigates the molecular and histological effects of antibiotics addition into bone cement on the induced membrane.In this study, conducted on 27 male New Zealand rabbits, the 2 cm long defects of a bone were created in the rabbit femurs. Three groups were formed by placing antibiotic-free, gentamicin, and vancomycin-containing cement in the defect area.These groups were followed for six weeks, and the membrane formed at the end of 6 weeks was examined histologically. As a result of this study, it found that the membrane quality markers (Von Willebrand factor (vwf), Interleukin 6-8 (IL), Transforming growth factor beta (TGF-β), Vascular endothelial growth factor (VEGF) were significantly higher in the antibiotic-free bone cement group. Our study has shown that antibiotics added to the cement have negative effects on the membrane. Based on the results we obtained, it would be a better choice to use antibiotic-free cement in aseptic nonunions. However, more data is needed to understand the effects of these changes on the cement on the membrane.

Proximal row carpectomy generates better mid- to long-term outcomes than four-corner arthrodesis for post-traumatic wrist arthritis: A meta-analysis

INTRODUCTION

In posttraumatic wrist arthritis of intermediate severity, two main palliative procedures are used to preserve some mobility in the wrist: proximal row carpectomy (PRC) and scaphoid excision followed by four corner arthrodesis (4CA). Despite satisfactory overall results, the debate continues about which one provides the best results and long-term outcomes, particularly prevention of arthritis progression. Recent comparative studies now provide us with information about mid- and long-term results. The aim of this study was to compare the clinical results, complications, conversion rate to total wrist arthrodesis and progression to osteoarthritis of PRC versus 4CA in the medium and long term.

HYPOTHESIS

The null hypothesis was that there is no significant difference between PRC and 4CA in the clinical results, complications, conversion to total wrist arthrodesis and arthritis progression.

MATERIALS AND METHODS

A systematic literature review was carried out by following the PRISMA guidelines. Included were studies comparing 4CA and PRC for the treatment of post-traumatic wrist arthritis secondary to scapholunate dissociation (SLAC) and scaphoid nonunion (SNAC) with a mean follow-up of 5 years. A search was performed of the MEDLINE, EMBASE and Cochrane databases that identified 831 articles. After removing 230 duplicates and excluding 595 articles based on their title and/or abstract, and then adding 1 article manually, 7 articles were included in our analysis. Parameters analyzed were range of motion (ROM), pain, grip strength, functional scores, complications, conversion to total wrist arthrodesis, and arthritis progression.

RESULTS

In the 7 articles, 1059 wrists - 582 PRC and 477 4CA - were analyzed with follow-up ranging from 5.2 to 18 years. PRC produced significantly better ROM in flexion (weighted mean difference [WMD]=10.0°; p<0.01) and in ulnar deviation (WMD=8.7°; p<0.01) along with significantly lower complication rates (OR=0.3; p<0.01) and reoperation rates (OR=0.1; p<0.01). There was no significant difference in the conversion rate, grip strength, extension, radial deviation, pain, DASH and PRWE scores. The progression of osteoarthritis could not be analyzed due to lack of data.

DISCUSSION

This meta-analysis was the first to include recently published mid- and long-term studies comparing PRC and 4CA. The main finding is that PRC is superior overall with better ROM and a lower complication rate. Another important finding was the absence of differences in grip strength and the conversion rate to total wrist arthrodesis. Unfortunately, the lack of systematic studies on arthritis progression leaves this question unanswered. Our findings must be interpreted cautiously because it was impossible to stratify the cases by etiology and osteoarthritis stage.

LEVEL OF EVIDENCE

III; systematic review and meta-analysis.

Impact of peritraumatic dissociation in hospitalized patients with COVID-19 pneumonia: A longitudinal study

OBJECTIVE

Psychiatric impact of COVID-19 is still explored and previous data suggest potential risks of anxiety, depression and PTSD related to COVID-19. We aimed to explore the predictive value of risk factors during hospitalization (T0) for COVID-19 for anxiety, depression and PTSD and at three months (T1) because they could differ over these two time points.

METHODS

We performed a screening of mental suffering in hospitalized patients for COVID-19, as well as specialized care and three months longitudinal follow-up. We evaluated at T0 and at T1 the prevalence of anxiety, depression and PTSD in survivors who benefited from early detection and treatment, and assessed possible risk factors in adults surviving COVID-19 between the 30th March and the 1^st of July 2020.

RESULTS

109 patients were screened at T0 and 61 of these were reassessed at T1. At T0, we found 44.9% pathological score on peritraumatic dissociation experiences questionnaire (PDEQ), 85.4% of post-traumatic stress disorder symptoms (PTSS), 14.6% of pathological rate of post-traumatic stress disorder scale 5 (PCL5) and at T1, 86.9% of PTSS, 10.6% of pathological rate of PCL5. Finally, PDEQ score at T0 during hospitalization was positively correlated to PCL-5 score at T1 (β = 0.26, p = 0.01) and that was confirmed in multivariate analysis (β = 0.04, p = 0.02 for the log of PCL-5 per point on the PDEQ).

CONCLUSION

Screening of psychiatric symptoms during hospitalization for COVID-19 should be systematic, especially peritraumatic dissociation to offer an early treatment and prevent PTSD, which seemed frequent for hospitalized patients for COVID-19 at three months.

Treatment of post-traumatic direct carotid-cavernous fistulas using flow diverting stents: Is it alone satisfactory?

BACKGROUND

Direct carotid cavernous fistula (CCF) occurs between the internal carotid artery (ICA) and the cavernous sinus. Carotid cavernous fistulas (CCFs) frequently present with chemosis, pulsatile proptosis, ocular bruit, vision loss, and occasionally intracerebral hemorrhage or seizure. In this article, we share our experience in endovascular treatment of six patients having this pathology with intracranial flow diverting stents with review of literatures.

CASE DESCRIPTION

All six patients had posttraumatic direct CCF, most of their signs and symptoms were visual disturbance, chemosis, orbital bruit, headache, paralysis of extraocular muscles. They were treated with flow diversion stents with or without coils or liquid embolizing material; transvenous and transarterial routes were used. Most of them underwent multiple sessions, and their conditions were improved dramatically.

CONCLUSION

The best and most effective method is to start the procedure by coiling to convert the high-flow fistula to an aneurysmal pouch with the smallest possible size in the cavernous sinus, and then close the defect site with one or two flow diversion devices (FDDs).

Intra-articular depletion of macrophages increases acute synovitis and alters macrophage polarity in the injured mouse knee

OBJECTIVE

Acute synovial inflammation following joint trauma is associated with posttraumatic arthritis. Synovial macrophages have been implicated in degenerative changes. In this study, we sought to elucidate the role of intra-articular macrophages in the acute inflammatory response to fracture in the mouse knee.

METHOD

A closed articular fracture was induced in two models of synovial macrophage depletion: genetically-modified MaFIA mice administered AP20187 to induce programmed macrophage apoptosis, and wild-type C57BL/6 mice administered clodronate liposomes, both via intra-articular injection. Synovial inflammation, bone morphology, and levels of F4/80+ macrophages, NOS2+ M1 macrophages, and CD206+ M2 macrophages were quantified 7 days after fracture using histology and micro-computed tomography.

RESULTS

Intra-articular macrophage depletion with joint injury did not reduce acute synovitis or the number of synovial macrophages 7 days after fracture in either macrophage-depleted MaFIA mice or in clodronate-treated C57BL/6 mice. In macrophage-depleted MaFIA mice, macrophage polarity shifted to a dominance of M1 macrophages and a reduction of M2 macrophages in the synovial stroma, indicating a shift in M1/M2 macrophage ratio in the joint following injury. Interestingly, MaFIA mice depleted 2 days prior to fracture demonstrated increased synovitis (P = 0.003), reduced bone mineral density (P = 0.0004), higher levels of M1 macrophages (P = 0.013), and lower levels of M2 macrophages (not statistically significant, P=0.084) compared to control-treated MaFIA mice.

CONCLUSION

Our findings indicate that macrophages play a critical immunomodulatory role in the acute inflammatory response surrounding joint injury and suggest that inhibition of macrophage function can have prominent effects on joint inflammation and bone homeostasis after joint trauma.

Transnasal Endoscopic Optic Nerve Decompression in Post Traumatic Optic Neuropathy

To quantify the successful outcome in patients following optic nerve decompression in post traumatic unilateral optic neuropathy in form of improvement in visual acuity. A prospective study was carried out over a period of 5 years (January 2011 to June 2016) at civil hospital Ahmedabad. Total 20 patients were selected with optic neuropathy including patients with direct and indirect trauma to unilateral optic nerve, not responding to conservative management, leading to optic neuropathy and subsequent impairment in vision and blindness. Decompression was done via Transnasal-Ethmo-sphenoidal route and outcome was assessed in form of post-operative visual acuity improvement at 1 month, 6 months and 1 year follow up. After surgical decompression complete recovery of visual acuity was achieved in 16 (80%) patients and partial recovery in 4 (20%). Endoscopic transnasal approach is beneficial in traumatic optic neuropathy not responding to steroid therapy and can prevent permanent disability if earlier intervention is done prior to irreversible damage to the nerve. Endoscopic optic nerve surgery can decompress the traumatic and oedematous optic nerve with proper exposure of orbital apex and optic canal without any major intracranial, intraorbital and transnasal complications.

Post traumatic inferior vena cava thrombosis: A case report and review of literature

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This serious post traumatic entity with high risk of pulmonary embolism is not well described and only few cases have been published.

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Bleeding risk due to the frequent association of anticoagulation and trauma is the main difficulty encountered by health care providers.

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Our manuscript tried to highlight diagnostic aspects, therapeutic options and outcome of post traumatic inferior vena cava thrombosis.

Introduction

Post traumatic inferior vena cava (IVC) thrombosis is a rare and not well described entity with nonspecific clinical presentation. It remains a therapeutic challenge in traumatic context because of haemorrhagic risk due to anticoagulation.

Presentation of case

We report a case of IVC thrombosis in an 18 year-old man who presented with liver injury following a traffic crash. The thrombosis was incidentally diagnosed on admission by computed tomography. The patient was managed conservatively without anticoagulation initially considering the increasing haemorrhagic risk. IVC filter placing was not possible because of the unusual localization of the thrombus. Unfractionated heparin was started on the third day after CT scan control showing stability of hepatic lesions with occurrence of a pulmonary embolism. The final outcome was good.

Discussion

The management of post traumatic IVC thrombosis is not well described. Medical approach consists in conservative management with anticoagulation which requires the absence of active bleeding lesions. Surgical treatment is commonly based on thrombectomy under extracorporeal circulation. Interventional vascular techniques have become an important alternative approach for the treatment of many vessel lesions. Their main advantages are the relative ease and speed with which they can be performed.

Conclusion

Post traumatic IVC thrombosis is a rare condition. Its management is not well defined. Early anticoagulation should be discussed on a case-by-case basis. Other alternatives such IVC filter or surgical thrombectomy may be used when the bleeding risk is increased. The most serious risk is pulmonary embolism. Outcome can be favorable even with non surgical approaches.

Manipulation under anesthesia for post traumatic stiff knee-pearls, pitfalls and risk factors for failure

BACKGROUND

Stiffness is common following fractures around knee. Manipulation under anesthesia (MUA) is the initial noninvasive procedure usually performed for such patients. Though MUA has been extensively evaluated for knee arthroplasty, there is paucity of literature regarding its benefits in trauma cases. The purpose of this study was to define the role of manipulation in post traumatic stiff knees.

METHODS

Hospital inpatient and outpatient records from January 2010 to June 2014 were retrospectively reviewed to identify patients undergoing MUA at our institution. Patients with more than one year follow up and adequate data were included. Clinical and radiographic parameters were analyzed to assess outcomes, complications, effect of timing on flexion gain as well as identify risk factors associated with failure.

RESULTS

Out of 45 patients undergoing manipulation, 41 patients with 48 knees (34 unilateral and 7 bilateral) met inclusion criteria. Thirty six manipulations were successful while 3 were abandoned due to tight tissues and 9 developed complications.Successful MUA resulted in immediate gain of 62.36° of flexion which decreased to 49.86° at 1year. There was statistically significant loss of flexion of 12.5° over a year (p value 0.0013). Arc of motion improved from 48.5° to 106.1° at 1year (p value <0.0001). Significant improvement was also seen in extension and fixed flexion deformity (p value <0.0001). No significant difference could be detected between early (<3 months) and late (>3 months) groups with respect to outcomes (p value 0.883)or complications (p value 0.3193). Failed group had significantly lower pre MUA flexion and pre MUA range of motion (p value 0.003). Univariate analysis showed that extensor mechanism ruptures during injury (p value <0.0001) and knees with Flexion <40° (p value 0.0022) or ROM<30° (p value 0.0002) were significantly associated with failures.

CONCLUSION

MUA is a suitable non invasive treatment option for post traumatic stiffness. There is no effect of timing on outcome and late manipulation also results in good outcome. Extensor mechanism rupture and pre manipulation ROM<30° or flexion <40° are associated with failure and such cases should be considered for alternative options for better outcome.

An unusual presentation of neurofibroma masquerading as a vascular hamartoma, post-iatrogenic intervention

Neurofibroma is a localized discrete mass of benign nerve sheath tumour in the peripheral nervous system. Mostly present as skin lesions. Solitary neurofibroma may occur in deep soft tissue or subcutaneous plane in rare cases associated with syndromes like NF1. The neurofibroma most commonly present as skin lesions as isolated soft papules or nodules arising in any cutaneous site. Present case depicts unusual presentation of a neurofibroma as a vascular hamartoma post an iatrogenic intervention.