A case report of cutaneous mucormycosis of the hand after minor trauma in a patient with acute myeloid leukaemia.

BACKGROUND: Mucormycosis is a rare but life-threatening infection, caused by fungi of the Mucorales order, which can be found in soil, rotting leaves or on animals. Through characteristic angioinvasive growth, infections with mucor spores can occur as a pulmonary, rhinocerebral or cutaneous form. Infections mainly affect immunosuppressed patients with a history of uncontrolled diabetes or haematological malignancies, among others. Treatment is multimodal and requires an immediate combination of intravenous amphotericin B therapy and serial surgical debridements. Only a limited number of cases of cutaneous mucormycosis of the hand have been documented and described previously. CASE PRESENTATION: We report a cutaneous mucormycosis in an elderly patient with a therapy-resistant acute myeloid leukaemia after a minor trauma on his right hand, sustained whilst gardening. The fungal infection was treated with serial radical debridements, vacuum-assisted negative-pressure wound closure technique and intravenous antifungals. Despite successful eradication of the fungal infection, a palliative open wound care concept was implemented during the terminal course of the patient's leukaemia. CONCLUSIONS: Cutaneous mucormycosis is a rare but fulminant fungal infection mostly affecting immunosuppressed patients. Survival is possible when diagnosed and treated early, yet mortality rates remain high.

Synovitis as a concomitant disease in shoulder pathologies.

INTRODUCTION: Shoulder pathologies are often accompanied by rotator interval synovitis. This phenomenon is poorly described in the literature so far. The aim of the study was to analyze the occurrence of macroscopically visible synovial reaction in the rotator interval in patients with chronic shoulder pathologies and to perform a histopathological evaluation. MATERIALS AND METHODS: In this prospective cohort study, 167 consecutive patients undergoing arthroscopic shoulder surgery for chronic shoulder pathology were included (♀ = 45, ♂ = 122; [Formula: see text]54.5 years ± 12.8). Included patients were divided into subgroups according to the encountered chronic shoulder pathology: (1) impingement syndrome with or without bursal sided partial rotator cuff tear (RCT); (2) articular sided partial RCT; (3) full-thickness RCT; (4) RCT that involves at least two tendons; (5) shoulder instability; and (6) cartilage damage. Standardized soft tissue biopsies from the rotator interval were taken. The synovitis score of Krenn/Morawietz was used for histopathological examination. RESULTS: Extraarticular pathology (group 1) showed significantly decreased synovitis scores compared to all the other groups. Increased size of rotator cuff tears (group 4), as well as cartilage damage (group 6) showed significantly higher synovitis scores than group 3 (p < 0.05). Moreover, the synovitis score was significantly increased in patients with concomitant pathologies of the long head of the biceps (p = 0.001). CONCLUSIONS: This study suggests that chronic intra- and extraarticular shoulder diseases are very often accompanied by a histopathologically verifiable low-grade synovitis. Intraarticular pathologies seem to induce increased levels of synovitis. Furthermore, the increased size of rotator cuff tears is accompanied by a higher degree of synovitis. STUDY DESIGN: Cohort study, level of evidence, 2b.

The effect of autologous platelet rich plasma on tenocytes of the human rotator cuff.

BACKGROUND: Platelet rich plasma (PRP) is widely used in rotator cuff repairs but its effect on the healing process is unclear. Several cell culture studies on the effect of allogenic PRP have reported promising results but are not transferable to clinical practice. The aim of the present study is to assess the possible effect of autologous PRP on rotator cuff tendon cells. The amount of growth factors involved with tendon-bone healing (PDGF-AB, IGF-1, TGF-ß1, BMP-7 and -12) is quantified. METHODS: Rotator cuff tissue samples were obtained from (n = 24) patients grouped by age (>/< 65 years) and sex into four groups and cells were isolated and characterized. Later, autologous PRP preparations were obtained and the effect was analyzed by means of cell proliferation, collagen I synthesis and expression of collagen I and III. Furthermore, the PRPs were quantified for growth factor content by means of platelet-derived growth factor (PDGF-AB), insulin-like growth factor (IGF-1), transforming growth factor (TGF-ß1), as well as bone morphogenetic protein (BMP) -7 and - 12. RESULTS: Cell proliferation and absolute synthesis of collagen I were positively affected by PRP exposure compared to controls (p < 0.05), but expression and relative synthesis of collagen I (normalized to cell proliferation) were significantly reduced. PRP contained high amounts of IGF-1 and lower levels of TGF-ß1 and PDGF-AB. The amounts of BMP-7 and -12 were below the detection limits. CONCLUSIONS: PRP is a source of growth factors such involved with tendon-bone healing. PRP had an anabolic effect on the human rotator cuff tenocytes of the same individual in vitro by means of cell proliferation and absolute, but not relative collagen I synthesis. These results encourage further studies on clinical outcomes with more comparable standards in terms of preparation and application methods. LEVEL OF EVIDENCE: Controlled laboratory study.

Does Pure Platelet-Rich Plasma Affect Postoperative Clinical Outcomes After Arthroscopic Rotator Cuff Repair? A Randomized Controlled Trial.

BACKGROUND: The exact role of platelet-rich plasma (PRP) in rotator cuff tendon reconstruction remains unclear. PURPOSE/HYPOTHESIS: This study investigated whether an intraoperative pure PRP injection, compared with a local anesthetic injection, improves patient-reported outcomes at 3 and 6 months after arthroscopic rotator cuff repair. The hypothesis was that pure PRP improves patient-reported outcomes (Oxford Shoulder Score [OSS]) at 3 and 6 months after surgery and has the same pain-reducing effect compared with a postoperative subacromial local anesthetic (ropivacaine) injection. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Between January 2011 and November 2012, a total of 120 patients who underwent arthroscopic double-row repair of a supraspinatus tendon rupture were randomized to receive either pure PRP by an injection at the footprint (PRP group; n = 60) or ropivacaine injected in the subacromial region (control group; n = 60). Seventy-eight percent of patients had other concomitant tears. All patients, surgeons, and follow-up investigators were blinded. Clinical parameters and various outcome scores (Constant-Murley shoulder score; OSS; patient American Shoulder and Elbow Surgeons score; quick Disabilities of the Arm, Shoulder and Hand score; EuroQol 5 dimensions) were documented preoperatively and at 3, 6, and 24 months postoperatively. The repair integrity was assessed by magnetic resonance imaging or ultrasound at 24 months. Furthermore, a pain diary was completed within the first 10 postoperative days, and adverse events were recorded. Group outcome differences were analyzed using t tests, Fisher exact tests, and mixed models. RESULTS: The final follow-up rate was 91%. An associated tear of the subscapularis tendon was diagnosed in 23% of PRP-treated patients and 36% of control patients. Three months after surgery, the mean (±SD) OSS was 32.9 ± 8.6 in PRP-treated patients and 30.7 ± 10.0 in control patients (P = .221). No significant differences were noted for other outcome parameters as well as at 6 and 24 months postoperatively. Smoking was a significant effect modifier. Pain for both groups decreased from postoperative day 1 to 10 without any significant group difference (P = .864). Six (12.2%) and 11 (20.8%) patients were diagnosed with a recurrent supraspinatus tendon defect in the PRP and control groups, respectively (P = .295). Twenty-two (40.7%) and 18 (30.5%) PRP-treated and control patients, respectively, experienced a local adverse event within 24 months (P = .325). CONCLUSION: Patients treated with pure PRP showed no significantly improved function at 3, 6, and 24 months after arthroscopic repair compared with control patients receiving ropivacaine; however, a similar pain reduction was documented in both groups. The negative influence of smoking on the effect of pure PRP requires further investigation. REGISTRATION: NCT01266226 (ClinicalTrials.gov).

Serial MRI evaluation following arthroscopic rotator cuff repair in double-row technique.

INTRODUCTION: So far, recurrent rotator cuff defects are described to occur in the early postoperative period after arthroscopic repair. The aim of this study was to evaluate the musculotendinous structure of the supraspinatus, as well as bone marrow edema or osteolysis after arthroscopic double-row repair. Therefore, magnetic resonance (MR) images were performed at defined intervals up to 2 years postoperatively. STUDY DESIGN: Case series; Level of evidence, 3. MATERIALS AND METHODS: MR imaging was performed within 7 days, 3, 6, 12, 26, 52 and 108 weeks after surgery. All patients were operated using an arthroscopic modified suture bridge technique. Tendon integrity, tendon retraction ["foot-print-coverage" (FPC)], muscular atrophy and fatty infiltration (signal intensity analysis) were measured at all time points. Furthermore, postoperative bone marrow edema and signs of osteolysis were assessed. RESULTS: MR images of 13 non-consecutive patients (6f/7m, ∅ age 61.05 ± 7.7 years) could be evaluated at all time points until ∅ 108 weeks postoperatively. 5/6 patients with recurrent defect at final follow-up displayed a time of failure between 12 and 24 months after surgery. Predominant mode of failure was medial cuff failures in 4/6 cases. The initial FPC increased significantly up to 2 years follow-up (p = 0.004). Evaluations of muscular atrophy or fatty infiltration were not significant different comparing the results of all time points (p > 0.05). Postoperative bone marrow edema disappeared completely at 6 months after surgery, whereas signs of osteolysis appeared at 3 months follow-up and increased to final follow-up. CONCLUSIONS: Recurrent defects after arthroscopic reconstruction of supraspinatus tears in modified suture bridge technique seem to occur between 12 and 24 months after surgery. Serial MRI evaluation shows good muscle structure at all time points. Postoperative bone marrow edema disappears completely several months after surgery. Signs of osteolysis seem to appear caused by bio-absorbable anchor implantations.

Do patient age and sex influence tendon cell biology and clinical/radiographic outcomes after rotator cuff repair?

BACKGROUND: Many clinical and radiographic studies suggest that patient age and sex have an influence on rotator cuff (RC) repair outcomes. However, these findings result from retrospective statistical analyses and cannot provide a causal answer. PURPOSE: To analyze whether age and sex influence the biological potential at the time of RC repair or midterm clinical and radiographic outcomes. Also assessed was the effect of the biological potential on intraindividual clinical/radiographic results. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 40 patients underwent arthroscopic RC repair. At the time of surgery (t = 0), supraspinatus tendon biopsy specimens were obtained, cultivated, and assessed for their biological potential, particularly (1) cell growth and (2) collagen type I production. After a follow-up at 24 months (t = 1), all patients were assessed by clinical scores (Constant score, subjective shoulder value, American Shoulder and Elbow Surgeons [ASES] score, and Western Ontario Rotator Cuff Index [WORC] score) and underwent magnetic resonance imaging to determine RC integrity. The data were examined for age- and sex-related differences and to identify the correlation between biological potential (t = 0) and clinical/radiographic outcome (t = 1). RESULTS: The follow-up rate for the imaging and clinical evaluation was 100%. Age, but not sex, influenced the biological tendon cell parameters at t = 0. However, there was no effect of age or sex on the clinical and radiographic results at t = 1. Furthermore, no correlation was observed between the initial biological parameters and later clinical outcomes or radiographic RC integrity. Finally, there was no significant difference between intact and nonhealed repairs in terms of the respective clinical scores. CONCLUSION: Age, but not sex, was found to have a negative effect on RC tendon cell biology. However, neither sex nor, in particular, a higher age influenced repair outcomes after 24 months.