Aims

The current pandemic caused by COVID-19 is the biggest challenge for national health systems for a century. While most medical resources are allocated to treat COVID-19 patients, several non-COVID-19 medical emergencies still need to be treated, including vertebral fractures and spinal cord compression. The aim of this paper is to report the early experience and an organizational protocol for emergency spinal surgery currently being used in a large metropolitan area by an integrated team of orthopaedic surgeons and neurosurgeons.

Aims

Leucocyte esterase (LE) has been shown to be an accurate marker of prosthetic joint infection (PJI), and has been proposed as an alternative to frozen section (FS) histology for intraoperative diagnosis. In this study, the intraoperative assessment of LE was compared with FS histology for the diagnosis of prosthetic hip infection.

Leukocyte esterase (LE) has shown to be an accurate marker of prosthetic joint infections and has been proposed as an alternative to frozen section (FS) for intra-operative diagnosis. In this study, intra-operative determination of LE was compared with FS for the diagnosis of periprosthetic hip infections.

One hundred and nineteen patients undergoing hip revision surgery due to prosthetic joint failure from June 2015 to December 2017 were considered. Joint fluids were collected before the arthrotomy for determination of LE which was performed by using enzymatic colorimetric strips. Four to six samples were stained with hematoxylin eosin for FS and considered suggestive for infection when at least 5 polymorphonuclear leukocytes in 5 fields at high power fields were found.

Sensitivity and specificity of LE were 100% and 93.8 %, respectively. The positive predictive value was 79.3 %, while the negative predictive value was 100%. Time from collection to response was 20.1 ± 4.4 minutes.

Sensitivity and specificity of FS were 83.3 % and 92.1 %, respectively. The positive and negative predictive values were 84.6 % and 97.1%. Time from sample collection response was 27.2 ± 6.9 minutes.

LE showed a higher sensitivity and a slightly lower specificity and the same diagnostic accuracy of intraoperative FS. The faster turnaround time (about 20 minutes from receiving of sample by the laboratory), its ease of use and the low costs make this test a valuable alternative to frozen sections and is going to replace FS in our clinical practice.

Hydrogels have been widely used for articular tissue engineering application, due to their controllable biodegradability and high water content mimicking the biological extracellular matrix. However, they often lack the mechanical support and signaling cues needed to properly guide cells. Graphene and its derivatives have recently emerged as promising materials due to their unique mechanical, physical, chemical proprieties [1]. Although not yet widely used for medical applications, preliminary works suggest that both structural and functional properties of polymeric substrates may be enhanced when combined with graphene oxide (GO) [2]. In this work, reinforced 3D GO/alginate (Alg) hydrogels have been realized and the opportunity of tuning hydrogels mechanical properties in relation to the required physiological needs has been investigated.

After preparing GO nanosheets (Sigma Aldrich) aqueous suspension (1 mg/ml) by ultrasonic treatment, alginate (Manugel GMB, FMC Biopolymer) composite solutions were produced (0, 0.5, 2 wt% GO/Alg). Moulds of agarose (1% w/v in CaCl 0,1M) were prepared to allocate GO/Alg solutions and chemically cross-link gels via diffusion (2 hr. at 37 °C).

GO/Alg hydrogels were characterized through optical/ AFM and FTIR analysis. Biocompatibility tests were performed embedding 3T3 fibroblasts (8 millions/ml) in the GO/Alg hydrogels; cell viability was evaluated at different time points up to two weeks with Dead/alive kit.

Gels mechanical proprieties were assessed via Dynamic Mechanical- Analysis (DMA) up to 28 days of culture (with and w/o cells) at different time points. All tests were performed in triplicate and statistical analyisis carried out (Mann–Whitney U test, n=9, p<0,005).

3D composite GO/alginate hydrogels were successfully realized (3 mm height, 5 mm diameter). Cell viability tests showed that the presence of GO does not decrease cell viability, confirming absence of toxicity, at least up to 2% wt GO/Alg. For all time points cell viability was statistically higher in presence of GO, while there was no significant difference between 0.5 wt% and 2 wt% GO/Alg. Hydrogels functionalized with GO exhibit an Elastic modulus about 3 fold higher than the Alg control at T0. After an initial decreasing of the Young Modulus for the all GO/Alg samples, possibly due to a partial degradation of alginate, a drastic recovery was observed up to 28 days of culture only for GO functionalized samples. The mechanical features improvement was neither mediated nor triggered by cells activity.

We successfully realized a natural-based 3D hydrogel nano-functionalized with graphene, where both mechanical and biological properties were successfully improved. The delayed stabilization of GO/Alg mechanical proprieties may be due either to a chemical interplay between GO and alginate matrix or to GO self-assembling processes over time. Future developments will be carried out to decouple the chemical and topological role of GO on the results observed up to now. Moreover, functional tests will be performed to evaluate the GO effects on in vitro cell differentiation for possible articular clinical applications.

Culture examination is still considered the gold standard for diagnosis of bone and joint infections, including prosthetic ones, even if in up to 20–30% of cases, particularly prosthetic joint infections, it fails to yield microbial growth. To overcome this limitation, determination of markers of inflammation and or infection directly in joint fluid has been proposed.

Aim of this study was to evaluate the applicability of measurement of lecukocyte esterase (LE), C-reactive protein (CRP) and glucose in synovial fluid for diagnosis of bone and joint infections.

Synovial fluids from 80 patients were aseptically collected and sent to laboratory for microbiological cultures. After centrifugation at 3000 rpm for 10 minutes, pellet was used for cultures, while the surnatant was used for determination of LE, CRP and glucose. LE and glucose were evaluated by means of enzymatic colorimetric strips developed for urinanalysis. One drop of synovial fluid was placed on the LE and on the glucose pads and the results were read after about 120 seconds. A LE test graded + or ++, and a glucose test equal to trace or negative were considered suggestive for infection. CRP was measured by an automated turbidimetric method.

On the basis of clinical findings, microbiological, haematological and histological analyses patients were retrospectively divided into 2 groups. Group 1 comprised 19 infected patients (12 males, 7 females age: 70.6 ± 10.3 yrs, range: 47 – 88 yrs) while Group 2 included 61 aseptic patients (32 males and 29 females, age: 61.5 ± 16.3 yrs, range: 15 – 84). Sensitivity of the three tests was 89.5%. 84% and 73,7% for LE, CRP and glucose, respectively. Specificity was 98.4%, 88.5% and 70% for LE, CRP and glucose, respectively. Positive and negative predictive values were 94.4% and 96.8% for LE, 69.6% and 94.6% for CRP and 77.8% and 89.6% for glucose test. When LE was combined with CRP, sensitivity increased to 94.7%, while no differences were observed for LE combined with glucose.

Leukocyte esterase has proven to be a rapid, simple and inexpensive test to rule in or out bone and joint infections. Combination of its measurement with that of CRP increased sensitivity. In conclusion, the combination of leukocyte esterase and CRP may represent a simple and useful tool for diagnosis of bone and joint infections.