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Rheumatology and Therapy Oct 2022Acquired von Willebrand syndrome (AVWS) is a rare, non-hereditary bleeding disorder related to heterogeneous medical conditions such as hematological malignancies and...
Acquired von Willebrand syndrome (AVWS) is a rare, non-hereditary bleeding disorder related to heterogeneous medical conditions such as hematological malignancies and cardiovascular and autoimmune diseases. We describe the clinical course of a 62-year-old man with polycythemia vera who experienced post-traumatic knee and leg swelling due to hemarthrosis. He was treated at another center with low molecular weight heparin due to misdiagnosed deep vein thrombosis further exacerbating the ongoing bleeding. At our center, he was diagnosed with AVWS with reduced von Willebrand factor (VWF):GPIbR plasma activity and loss of high molecular weight multimers (HMWM). He was treated with compressive bandages with resolution. Five months later, on clinical recurrence of knee and leg swelling, knee ultrasound scan showed the presence of chronic synovitis and a hemorrhagic Baker's cyst with signs of rupture. The treatment consisted of chemical synovectomy with rifampicin and steroids preceded by systemic replacement therapy using plasma-derived factor VIII-VWF concentrate. At the end of the treatment cycle, our patient reported complete resolution of knee pain and restoration of joint range of motion and function. Ultrasound evaluation confirmed complete resolution of knee capsule distension and Baker's cyst. Hemarthrosis is an anecdotal presentation of AVWS and chemical synovectomy was successful in treating this complication. A multidisciplinary approach allowed an effective management of this rare complication.
PubMed: 35947268
DOI: 10.1007/s40744-022-00477-2 -
Medicina (Kaunas, Lithuania) Jan 2024Peroneal disorders are a common cause of ankle pain and lateral instability and have been described in as much as 77% of patients with lateral ankle instability....
Peroneal disorders are a common cause of ankle pain and lateral instability and have been described in as much as 77% of patients with lateral ankle instability. Clicking, swelling, pain, and tenderness in the peroneal tendons track are frequent symptoms, but they can be confused with other causes of lateral ankle pain. The management of peroneal disorders can be conservative or surgical. When the conservative treatment fails, surgery is indicated, and open or tendoscopic synovectomy, tubularization, tenodesis or tendon transfers can be performed. The authors present a surgical technique of tendoscopy associated to minimally invasive tenodesis for the treatment of peroneal tendon tears, as well as the preliminary results of patients submitted to this procedure. Four patients with chronic lateral ankle pain who were diagnosed with peroneal brevis pathology were treated between 2020 and 2022 with tendoscopic-assisted minimally invasive synovectomy and tenodesis. Using a 2.7 mm 30° arthroscope and a 3.0 mm shaver blade, the entire length of the peroneus brevis tendon and most parts of the peroneus longus tendon can be assessed within Sammarco's zones 1 and 2. After the inspection and synovectomy, a minimally invasive tenodesis is performed. All patients were evaluated at least six months after surgery. All of them reported improvement in daily activities and in the Foot Function Index (FFI) questionnaire (pre-surgery mean FFI = 23.86%; post-surgery mean FFI = 6.15%), with no soft tissue complications or sural nerve complaints. The tendoscopy of the peroneal tendons allows the surgeon to assess their integrity, confirm the extent of the lesion, perform synovectomy, prepare the tendon for tenodesis, and perform it in a safe and minimally invasive way, reducing the risks inherent to the open procedure.
Topics: Humans; Tenodesis; Orthopedic Procedures; Tendons; Leg; Arthralgia; Chronic Pain
PubMed: 38256365
DOI: 10.3390/medicina60010104 -
Trauma Case Reports Aug 2021Respiratory pathogens such as may activate osteoclast cells, thereby inducing bone resorption and joint inflammation. Herein is a case report of a young man with...
Respiratory pathogens such as may activate osteoclast cells, thereby inducing bone resorption and joint inflammation. Herein is a case report of a young man with misdiagnosed persistent wrist pain without any major trauma. Investigation of the patient's medical history confirmed a recent systemic infection. Preoperative X-ray and magnetic resonance imaging (MRI) showed a substantial decrease in cancellous lunate bone compactness. A stepwise approach was undertaken considering the rapid onset of bone devascularisation and the clinical presentation. Wrist arthroscopy confirmed extensive joint inflammation associated with decreased osteochondral lunate solidity. Microbiological examination excluded joint infection. Histological analysis showed a diffuse inflammatory infiltration. Temporary mediocarpal K-wire stabilization and synovectomy were performed. Postoperative MRI confirmed lunate bone revascularization. At 6 and 12 months' follow-up the young man was pain-free and had good recovery of range of motion. In vitro and in vivo studies demonstrate that inflammatory conditions may promote osteoclast cell activity and induce bone resorption. Moreover, infection with could activate specific "osteoporotic" bone pathways. To the authors' knowledge, this is the first published case report of specific lunate bone loss induced by systemic infection. The authors proposed an etiologic explanation, and a stepwise approach was associated with good outcome.
PubMed: 34307820
DOI: 10.1016/j.tcr.2021.100431 -
Journal of Immunology Research 2019Iguratimod, a novel disease-modifying anti-rheumatic drug for the treatment of rheumatoid arthritis, has been approved in China and Japan. Here, we aimed to find whether...
OBJECTIVE
Iguratimod, a novel disease-modifying anti-rheumatic drug for the treatment of rheumatoid arthritis, has been approved in China and Japan. Here, we aimed to find whether iguratimod can inhibit the aggressive behavior and promote apoptosis of rheumatoid fibroblast-like synoviocytes (RA-FLSs).
METHODS
The proliferation of RA-FLSs was assessed by 5-ethynyl-2'-deoxyuridine test and Cell Counting Kit-8. Migration and invasion were determined by the wound test and a transwell assay. Apoptosis was tested by flow cytometry. The mRNA expression of matrix metalloproteinases (MMPs) and proinflammatory cytokines in RA-FLSs were measured by quantitative PCR and ELISA. To gain insight into the molecular signaling mechanisms, we determined the effect of iguratimod on the activation of mitogen-activated protein kinases (MAPK) signaling pathways by the cellular thermal shift assay (CETSA) and western blot.
RESULTS
Iguratimod treatment significantly reduced the proliferation, migration, and invasive capacities of RA-FLSs in a dose-dependent manner . MMP-1, MMP-3, MMP-9, Interleukin-6 (IL-6), and monocyte chemoattractant protein-1 mRNA and protein levels were all decreased after treatment with iguratimod. Furthermore, tumor necrosis factor-alpha- (TNF--) induced expression of phosphorylated c-Jun N-terminal kinases (JNK) and P38 MAPK were inhibited by iguratimod. Additionally, iguratimod promoted the apoptosis of RA-FLSs. Most importantly, iguratimod was shown to directly interact with JNK and P38 protein by CETSA assay. Moreover, activating transcription factor 2 (ATF-2), a substrate of both JNK and P38, was suppressed by iguratimod.
CONCLUSIONS
Our findings suggested that the therapeutic effects of iguratimod on RA might be, in part, due to targeting the aggressive behavior and apoptosis of RA-FLSs.
Topics: Antirheumatic Agents; Apoptosis; Arthritis, Rheumatoid; Cell Movement; Cell Proliferation; Chemokine CCL2; Chromones; Female; Fibroblasts; Gene Expression Regulation; Humans; Immunosuppressive Agents; Interleukin-6; JNK Mitogen-Activated Protein Kinases; Matrix Metalloproteinase 1; Matrix Metalloproteinase 3; Matrix Metalloproteinase 9; Primary Cell Culture; Signal Transduction; Sulfonamides; Synovectomy; Synovial Membrane; Synoviocytes; Tumor Necrosis Factor-alpha; p38 Mitogen-Activated Protein Kinases
PubMed: 31828173
DOI: 10.1155/2019/6929286 -
Frontiers in Surgery 2021The aim was to report 4 patients with intra-articular knee synovial haemangioma (KSH) and to perform a systematic review to describe the patient characteristics,...
The aim was to report 4 patients with intra-articular knee synovial haemangioma (KSH) and to perform a systematic review to describe the patient characteristics, patterns of tumor location, clinical presentation, usefulness of imaging examinations, pros and cons of arthroscopic vs. open resection, and follow-up in the literature. From 1996 to 2016, four patients with KSH were retrospectively reviewed. A literature search was conducted in PubMed from 2000/01 to 2020/06 using the search terms "synovial haemangioma" and "knee." Fifty full-text articles that included a total of 92 patients were included for further discussion. Four adults (20-40 years) were diagnosed with KSH. Three lesions located in the suprapatellar pouch, two eroding the patella and one the supratrochlear bone, and one in the posterior compartment. Persistent anterior knee pain was the main complain. MRI revealed a benign tumor mass in all cases except one. Open excisional biopsy and regional synovectomy were performed in three patients, and by arthroscopy of the posterior compartment in the fourth. Histological type was arteriovenous in three cases and capillary in one. A pain-free knee without recurrence was achieve in all cases except one, which was successfully reoperated. Average follow-up time was 3.5 years. A literature review showed that KSH appears most frequently in children and teenagers (64.6%) and does not differ by gender. The suprapatellar and patella-femoral joint compartment was the most frequent location (47.9%). The bony tissue of the knee was rarely affected (13.5%). Pain, swelling and haemarthrosis were frequently reported (88.2, 66.7, and 47.1%). MRI was the most commonly used imaging test (98%). Treatment consisted of regional synovectomy by open surgery or arthroscopy in 66.7 and 15.6% of cases, respectively. KSH should be considered in the differential diagnosis of adult patients with chronic low-intensity knee pain. MRI is the most useful exam because it establishes the location, extent and benign characteristics of the tumor. Definitive diagnosis requires histological examination. We believe excisional biopsy and regional synovectomy by arthroscopy should be the treatments of choice for intra-articular tumors, but we recommend open surgery when the lesion extends to the tendons, muscle or bone.
PubMed: 34950698
DOI: 10.3389/fsurg.2021.792380 -
Blood Advances Dec 2022Many people with hemophilia A (PwHA) undergo surgery in their lifetime, often because of complications of their disease. Emicizumab is the first bispecific monoclonal...
Many people with hemophilia A (PwHA) undergo surgery in their lifetime, often because of complications of their disease. Emicizumab is the first bispecific monoclonal antibody prophylactic therapy for PwHA, and its efficacy and safety have been previously demonstrated; however, there is a need to build an evidence base on the management of PwHA on emicizumab undergoing surgery. Data from the HAVEN 1-4 phase 3 clinical trials were pooled to provide a summary of all minor and major surgeries in PwHA with or without factor VIII (FVIII) inhibitors who were receiving emicizumab prophylaxis. Overall, 233 surgeries were carried out during the HAVEN 1-4 trials: 215 minor surgeries (including minor dental and joint procedures, central venous access device placement or removal, and endoscopies) in 115 PwHA (64 with FVIII inhibitors) and 18 major surgeries (including arthroplasty and synovectomy) in 18 PwHA (10 with FVIII inhibitors). Perioperative hemostatic support was at the discretion of the treating physician. Overall, the median (interquartile range [IQR]) age was 33.5 (13.0-49.0) years and the median (IQR) emicizumab exposure time before surgery was 278.0 (177.0-431.0) days. Among the 215 minor surgeries, 141 (65.6%) were managed without additional prophylactic factor concentrate, and of those, 121 (85.8%) were not associated with a postoperative bleed. The majority (15 of 18 [83.3%]) of major surgeries were managed with additional prophylactic factor concentrate. Twelve (80.0%) of these 15 surgeries were associated with no intraoperative or postoperative bleeds. The data demonstrate that minor and major surgeries can be performed safely in PwHA receiving emicizumab prophylaxis. These trials are registered at www.clinicaltrials.gov as #NCT02622321, #NCT02795767, #NCT02847637, and #NCT03020160.
Topics: Adult; Humans; Middle Aged; Factor VIII; Hemophilia A; Hemorrhage; Treatment Outcome; Clinical Trials, Phase III as Topic
PubMed: 35939785
DOI: 10.1182/bloodadvances.2022007458 -
Journal of Clinical Medicine May 2023Juvenile idiopathic arthritis is the most common chronic rheumatic disease encountered in children under the age of sixteen and causes significant impairments in daily...
Juvenile idiopathic arthritis is the most common chronic rheumatic disease encountered in children under the age of sixteen and causes significant impairments in daily life. Over the last two decades, the introduction of new drug treatments (including disease-modifying antirheumatic drugs and biologics) has changed the course of this disease, thus reducing the indication for surgery. However, some patients fail to respond to drug therapy and thus require personalized surgical management, e.g., the local reduction of joint effusion or a synovial pannus (via intra-articular corticosteroid injections, synovectomy, or soft tissue release), and management of the sequelae of arthritis (such as growth disorders and joint degeneration). Here, we provide an overview of the surgical indications and outcomes of the following interventions: intra-articular corticosteroid injections, synovectomy, soft tissue release, surgery for growth disorders, and arthroplasty.
PubMed: 37240508
DOI: 10.3390/jcm12103402 -
Case Reports in Orthopedics 2022Tenosynovial giant cell tumors are a benign but rare condition with potentially aggressive tumor-like traits which should be considered in young patients with...
BACKGROUND
Tenosynovial giant cell tumors are a benign but rare condition with potentially aggressive tumor-like traits which should be considered in young patients with monoarticular joint involvement. . This report presents a 31-year-old otherwise healthy woman with a right hip pain. Clinical and histopathological investigations revealed the diagnosis of diffuse-type tenosynovial giant cell tumor of the hip (the diffuse intra-articular form of PVNS). Open synovectomy and tumor resection and surgical dislocation of the hip were performed. She was free of symptoms and recurrence within a 9-year-follow-up period.
CONCLUSION
Open synovectomy and tumor resection through surgical dislocation of the hip without adjutant radiotherapy could be a reliable choice for the localization of the hip.
PubMed: 35154840
DOI: 10.1155/2022/1797218 -
JBJS Essential Surgical Techniques 2021Stiffness following total knee arthroplasty is a challenging complication for both the patient and surgeon, with an incidence that ranges from 1% to 13%. There are...
UNLABELLED
Stiffness following total knee arthroplasty is a challenging complication for both the patient and surgeon, with an incidence that ranges from 1% to 13%. There are several correctable mechanical causes for stiffness including malposition, malalignment, overstuffing, aseptic loosening, patella baja, and heterotopic ossification. Idiopathic stiffness is often termed arthrofibrosis and is more difficult to treat. Once patients have exhausted nonoperative options, including physical therapy and manipulation under anesthesia, revision surgery may be considered. Rotating hinge revision total knee arthroplasty has been shown to be an effective surgical treatment for severe arthrofibrosis.
DESCRIPTION
First, remove all soft-tissue and osseous sources of stiffness and adequately expose the knee, then remove all previous components. Create a stable and balanced extension gap, and, conversely, a relatively loose flexion gap, which allows for a substantial increase in range of motion. Then, in order to prevent instability in flexion, a rotating hinge prosthesis is utilized, which allows for appropriate kinematic motion despite gap imbalance. Additional steps to regain flexion include medial and lateral distal femoral partial condylectomies, as well as patellar component revision.
ALTERNATIVES
The first line of treatment for stiffness following total knee arthroplasty is nonoperative and is mainly focused on physical therapy. Manipulation under anesthesia can also be performed within the first 12 weeks postoperatively. Surgical treatments can include arthroscopic debridement as well as open debridement with possible polyethylene liner exchange. If there is a mechanical cause for stiffness, then this should also be addressed surgically. For cases of arthrofibrosis without a clear mechanical etiology or for cases in which the above treatment has failed, complete revision of the femoral and tibial components should be considered. An alternative option to the technique proposed here is to utilize a varus-valgus constrained implant.
RATIONALE
Revision with a hinged implant allows for a more aggressive approach to regaining motion, as compared with all other surgical alternatives. By revising all components, the surgeon is able to remove all sources of stiffness and reconstruct the knee until as much range of motion as possible is achieved. Unfortunately, even with balanced extension and flexion gaps, refractory stiffness is common. A solution for this residual stiffness is to unbalance the gaps and create a loose flexion gap. By doing so, the surgeon is advised to switch to a hinged implant to create a kinematically balanced knee. Any other revision implant, such as a varus-valgus constrained implant, would risk flexion instability.
EXPECTED OUTCOMES
Several studies have examined the use of revision total knee arthroplasty with a hinged implant for arthrofibrosis and have showed substantial improvements in knee range of motion. Bingham et al. showed that the rotating hinge group had a 20° improvement in range of motion (p = 0.048). Hermans et al. found a 35.8° flexion gain in the hinge group compared with a 14.2° flexion gain in the varus-valgus constrained group (p = 0.0002). van Rensch et al. found a median gain of 45° of range of motion. Patients should be aware that this procedure involving the use of a hinged implant has similar risks to other revision total knee arthroplasty procedures; specifically, there is a risk of recurrent arthrofibrosis as well as mechanical complications.
IMPORTANT TIPS
Achieve adequate exposure with a quadriceps snip.Perform a thorough synovectomy and debridement.Create a balanced extension gap with a relatively loose flexion gap.Distalize the joint line by resecting additional proximal tibia in cases of patella baja.Beware of refractory stiffness as a result of a scarred extensor mechanism.Consider revising the patellar component.Consider performing a partial condylectomy at the medial and lateral distal aspects of the femur.
ACRONYMS AND ABBREVIATIONS
TKA = total knee arthroplastyAP = anteroposteriorCT = computed tomographyMRI = magnetic resonance imagingRHK = rotating hinge kneeNSAIDs = nonsteroidal anti-inflammatory drugs.
PubMed: 35693134
DOI: 10.2106/JBJS.ST.21.00009 -
BMC Musculoskeletal Disorders Jan 2020In highly active older individuals, end-stage ankle osteoarthritis has traditionally been treated using tibiotalar arthrodesis, which provides considerable pain relief....
BACKGROUND
In highly active older individuals, end-stage ankle osteoarthritis has traditionally been treated using tibiotalar arthrodesis, which provides considerable pain relief. However, there is a loss of ankle joint movement and a risk of future arthrosis in the adjacent joints. Distraction arthroplasty is a simple method that allows joint cartilage repair; however, the results are currently mixed, with some reports showing improved pain scores and others showing no improvement. Distal tibial osteotomy (DTO) without fibular osteotomy is a type of joint preservation surgery that has garnered attention in recent years. However, to our knowledge, there are no reports on DTO with joint distraction using a circular external fixator. Therefore, the purpose of this study was to examine the effect of DTO with joint distraction using a circular external fixator for treating ankle osteoarthritis.
METHODS
A total of 21 patients with medial ankle arthritis were examined. Arthroscopic synovectomy and a microfracture procedure were performed, followed by angled osteotomy and correction of the distal tibia; the ankle joint was then stabilized after its condition improved. An external fixator was used in all patients, and joint distraction of approximately 5.8 mm was performed. All patients were allowed full weight-bearing walking immediately after surgery.
RESULTS
The anteroposterior and lateral mortise angle during weight-bearing, talar tilt angle, and anterior translation of the talus on ankle stress radiography were improved significantly (P < 0.05). Signal changes on magnetic resonance imaging also improved in all patients. Visual analog scale and American Orthopedic Foot & Ankle Society scores improved significantly (P < 0.05), and no severe complications were observed.
CONCLUSION
DTO with joint distraction may be useful as a joint-preserving surgery for medial ankle osteoarthritis in older patients with high levels of physical activity.
LEVEL OF EVIDENCE
Level IV, retrospective case series.
Topics: Aged; Aged, 80 and over; Ankle Joint; Arthritis, Rheumatoid; Arthroplasty; Arthroscopy; Exercise; External Fixators; Female; Humans; Male; Middle Aged; Osteoarthritis; Osteotomy; Postoperative Complications; Recovery of Function; Severity of Illness Index; Synovectomy; Visual Analog Scale; Weight-Bearing
PubMed: 31937287
DOI: 10.1186/s12891-020-3061-7