ContextIn patients who present with an acutely painful and swollen joint, prompt identification and treatment of septic arthritis can substantially reduce morbidity and mortality.ObjectiveTo review the accuracy and precision of the clinical evaluation for the diagnosis of nongonococcal bacterial arthritis.Data SourcesStructured PubMed and EMBASE searches (1966 through January 2007), limited to human, English-language articles and using the following Medical Subject Headings terms: arthritis, infectious, physical examination, medical history taking, diagnostic tests, and sensitivity and specificity.Study SelectionStudies were included if they contained original data on the accuracy or precision of historical items, physical examination, serum, or synovial fluid laboratory data for diagnosing septic arthritis.Data ExtractionThree authors independently abstracted data from the included studies.Data SynthesisFourteen studies involving 6242 patients, of whom 653 met the gold standard for the diagnosis of septic arthritis, satisfied all inclusion criteria. Two studies examined risk factors and found that age, diabetes mellitus, rheumatoid arthritis, joint surgery, hip or knee prosthesis, skin infection, and human immunodeficiency virus type 1 infection significantly increase the probability of septic arthritis. Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%), a history of joint swelling (sensitivity, 78%; 95% CI, 71%-85%), and fever (sensitivity, 57%; 95% CI, 52%-62%) are the only findings that occur in more than 50% of patients. Sweats (sensitivity, 27%; 95% CI, 20%-34%) and rigors (sensitivity, 19%; 95% CI, 15%-24%) are less common findings in septic arthritis. Of all laboratory findings readily available to the clinician, the 2 most powerful were the synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells from arthrocentesis. The summary likelihood ratio (LR) increased as the synovial fluid WBC count increased (for counts 50 000/μL: LR, 7.7; 95% CI, 5.7-11.0; and for counts >100 000/μL: LR, 28.0; 95% CI, 12.0-66.0). On the same synovial fluid sample, a polymorphonuclear cell count of at least 90% suggests septic arthritis with an LR of 3.4 (95% CI, 2.8-4.2), while a polymorphonuclear cell count of less than 90% lowers the likelihood (LR, 0.34; 95% CI, 0.25-0.47).ConclusionsClinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis. However, the synovial WBC and percentage of polymorphonuclear cells from arthrocentesis are required to assess the likelihood of septic arthritis before the Gram stain and culture test results are known.

http://medical-mastermind-community.com/uploads/Septic-arthrits.pdf

Does this adult patient have septic arthritis

Intervertebral disc (IVD) degeneration is one of the major causes of low back pain, a problem with a heavy economic burden, which has been increasing in prevalence as populations age. Deeper knowledge of the complex spatial and temporal orchestration of cellular interactions and extracellular matrix remodelling is critical to improve current IVD therapies, which have so far proved unsatisfactory. Inflammation has been correlated with degenerative disc disease but its role in discogenic pain and hernia regression remains controversial. The inflammatory response may be involved in the onset of disease, but it is also crucial in maintaining tissue homeostasis. Furthermore, if properly balanced it may contribute to tissue repair/regeneration as has already been demonstrated in other tissues. In this review, we focus on how inflammation has been associated with IVD degeneration by describing observational and in vitro studies as well as in vivo animal models. Finally, we provide an overview of IVD regenerative therapies that target key inflammatory players.

https://royalsocietypublishing.org/doi/pdf/10.1098/rsif.2014.1191

Inflammation in intervertebral disc degeneration and regeneration

Heterotopic ossification (HO) is a benign condition of abnormal formation of bone in soft tissue. HO is frequently asymptomatic, though when it is more severe it typically manifests as decreased range of motion at a nearby joint. HO has been recognized to occur in three distinct contexts-trauma, neurologic injury, and genetic abnormalities. The etiology of HO is incompletely understood. A posited theory is that HO results from the presence of osteoprogenitor cells pathologically induced by an imbalance in local or systemic factors. Individuals at high risk for HO development frequently undergo prophylaxis to prevent HO formation. The two most commonly employed modalities for prophylaxis are nonsteroidal anti-inflammatory drugs and radiation therapy. This review discusses HO pathophysiology, clinical features, and the role of radiotherapy for prophylaxis.

Heterotopic ossification: Pathophysiology, clinical features, and the role of radiotherapy for prophylaxis

In this prospective study, a total of 134 prosthetic discs were replaced in 108 patients undergoing total disc replacement surgeries for degenerative disc disease. It was the aim of this study to correlate the clinical findings and the outcome of our patients treated with Prodisc II prostheses for various indications and to formulate indication criteria for disc replacement surgeries. The discs were implanted at L5/S1 in 61 patients, L5/L6 in 3 patients, L4/L5 in 31 patients, L3/L4 in 7 patients, and L2/L3 in 3 patients. There were 12 patients with two-level implants: from L4 to S1 in 11 of them and from L2 to L5 in the remaining one. Two patients also had three-level implants, from L3 to S1. Follow-up evaluation included plain radiographs, physical evaluation, and subjective evaluation by the patient using the Oswestry scale, the visual analog pain scale, and the SF-36V2 well-being questionnaire. The evaluation exercise showed that 90.8% of patients had excellent results, 7.4% had good results and 1.8% had fair results, with no poor results seen. Postoperatively, the average vertebral motion was increased in all patients at the operated level. Progression of disc degeneration at the adjacent levels was noted in ten patients. The average time to resuming activities of daily living unaided was 2.3 weeks. No implant failures or complications due to surgery were encountered in this study. Total prosthesis disc replacement for degenerative disc disease was found to be a good treatment modality, provided proper patient selection and criteria are adhered to. We were able to formulate indication criteria based on this.

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Indications for full prosthetic disc arthroplasty: a correlation of clinical outcome against a variety of indications

CPPD disease (also called pseudogout) is common, especially among persons older than 60 years of age, but it is underrecognized and undertreated. This review summarizes the diagnosis and treatment of the acute and chronic forms of this crystal-induced arthritis.

/pdf/calcium-pyrophosphate-deposition-disease-owt6jypyna.pdf

Calcium Pyrophosphate Deposition Disease

In two rare cases with avulsion of the hamstring muscles from the ischial tuberosity without fracture of the ischium, the clinical features were: (1) sudden onset of pain in the buttock; (2) difficulty on standing after trauma; (3) a palpable defect and tenderness on the area distal from the ischial tuberosity; and (4) weakness of flexion of the knee with a loss of normal outline of the hamstring muscles on the dorsal aspect of the knee. There was no roentgenologic evidence of fracture of the ischium. Surgical repair with reattachment of avulsed muscles to the ischium and proximal tendinous sheaths of the muscles restored function or corrected deformity.

Avulsion of the hamstring muscles from the ischial tuberosity. A report of two cases.

Fifty patients (15 men and 35 women; average age, 70.8 years) with pseudogout were studied. Arthroscopic biopsy was useful for diagnosis in one case with no light microscopic evidence of crystals in the synovial fluid. Attacks affected 93 sites in 50 patients. Attacks in ten patients occurred after mild trauma, long distance walks, total knee arthroplasty, or intraarticular injection of microcrystalline glucocorticoid. Twenty-five patients had fevers averaging 38 degrees. In five patients the fever was associated with mental confusion. Fourteen patients were initially suspected or misdiagnosed as having septic arthritis. Six patients were treated surgically under this misdiagnosis, with synovectomy complicated by limitation of motion of both knees in one patient. The involvement of more than one joint was noted in 21 patients. Polyarthritis could be an important clue to the diagnosis performed early; the combination of arthrocentesis and injection of microcrystalline glucocorticoid provided excellent therapy.

Clinical features of pseudogout attack. A survey of 50 cases.

The articular cartilage, synovial membrane, and meniscus from ten patients who had calcium pyrophosphate dihydrate (CPPD) crystal deposition disease showed strong immunoreactivity for dermatan sulfate proteoglycan, Type I collagen, and S-100 protein in hypertrophic chondrocytes around the crystals, their pericellular matrix, and deposits of the crystals. Electron microscopy revealed that small crystals were formed around the hypertrophic chondrocytes, especially in the degenerated matrix containing electron-dense granular materials and cellular debris. Chondrocytes of this kind were never observed in the articular tissue from ten patients who had osteoarthrosis. These hypertrophic chondrocytes with several unique immunohistochemical characteristics may initiate the formation of CPPD crystals.

A histologic and immunohistochemical study of calcium pyrophosphate dihydrate crystal deposition disease.

Hydroxyapatite crystal deposition in the articular cartilage of the proximal femoral head was examined by using light and electron microscopy and electron probe microanalysis. The hydroxyapatite deposition was significantly more frequent in patients with osteoarthritis (40.7%, 22 of 54) than in control subjects (6.0%, 3 of 50) (P less than 0.001). Initial deposition of needle-like crystals was always seen on or within the electron-dense, amorphous material around the degenerating hypertrophic chondrocytes. Matrix vesicles were rarely seen in the calcifying areas.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.1780300608

Koichiro Ishikawa

Papers

Avulsion of the hamstring muscles from the ischial tuberosity. A report of two cases.

Clinical features of pseudogout attack. A survey of 50 cases.

A histologic and immunohistochemical study of calcium pyrophosphate dihydrate crystal deposition disease.

Hydroxyapatite deposition in osteoarthritic articular cartilage of the proximal femoral head.

Chondrocytes that accumulate proteoglycans and inorganic pyrophosphate in the pathogenesis of chondrocalcinosis.