Streptococcus bovis - Gundersen Lutheran Health System

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Authors: Robert E. Ryan, MA, ATC Troy E. Ward, MA, ATC Steven R. Murray, DA Mesa State College Grand Junction, Colorado Mitchell T. Copeland, DO Western Orthopedics and Sports Medicine Grand Junction, Colorado Brian E. Udermann, PhD, ATC, FACSM University of Wisconsin–La Crossse La Crosse, Wisconsin Robert W. Pettitt, PhD, ATC Minnesota State University –Mankato Mankato, Minnesota Address for correspondence: Brian E. Udermann, PhD, ATC, FACSM 149 Mitchell Hall 1725 State Street University of Wisconsin–La Crossse La Crosse, WI 54601 Telephone: (608) 785-8181 email: udermann.bria@uwlax.edu I n a d 175, the ancient Greek physician Galen used a resorbable gut suture—the first recorded use of a bioabsorbable implant. 1 In the mid 1960s, bioabsorbable technology was introduced for clinical applications, since which time its use has increased dramatically. 2 Today some 40 different bioabsorbable polymers are being used for surgical procedures. 1,3 Advantages have been noted for the use of bioabsorbable implants in orthopedics. First, they are readily absorbed by the body, thus reducing the need for surgical revisions and the overall cost of treatment. 4 Second, they prevent radiographic obscurities typically found with metallic implants. 4 Third, in that they soften over time, bioabsorbable implants provide an incremental transfer of stress to the affected bone, thus providing a load-sharing effect that enhances healing. 1 While they have notable advantages, bioabsorbable implants have drawbacks, as well. Compared with their metallic counterparts, bioabsorbable implants are weaker and less stiff, have limited shelflife, and are initially more costly. 1 They also can cause exaggerated inflammatory reactions, such as synovitis, osteolysis, and, more rarely, giant-cell reactions. 5,6 We report a case of a foreign-body giant-cell reaction to a bioabsorbable implant. This case exemplifies an iatrogenic etiology that should be considered when treating patients who are unresponsive to rehabilitative exercise for surgical repair. Giant-Cell Reaction to a Bioabsorbable Implant AbStrACt A 51-year-old woman had shoulder pain and dysfunction 14 months following the surgical repair of her supraspinatus muscle via a bioabsorbable implant. Diagnostic testing revealed a giant-cell reaction at the location of the implant. The patient underwent a second surgery to burr, irrigate, and fill the lytic lesion that resulted from the giant-cell reaction, and the supraspinatus muscle was sutured to the greater tuberosity of the humerus. The patient completed a standard rehabilitation protocol for 8 weeks, and at 6 months she had no further complications with normal daily activities. CASe report A 51-year-old woman had pain in her right shoulder. Examination of the shoulder revealed an impingement syndrome, acromioclavicular arthrosis, and a tear in the supraspinatus muscle. Initial conservative treatment with range-of-motion and strengthening exercises and subacromial injections of steroids (ie, 3 mg of betamethasone and 6 mg of 0.25% bupivicaine) was ineffective. The patient was counseled and scheduled for surgery. Surgery included a 2-step acromioplasty and an 8-mm resection of the distal clavicle. The supraspinatus muscle was repaired using a bioabsorbable implant (Arthrex Bio-Corkscrew), with 4 sutures placed in a figure-of-8 fashion through the greater tuberosity of the of the humerus. The patient progressed without complications for 12 weeks until marked pain returned to the shoulder area. Conservative treatment, including modest range-of-motion and strengthening exercises, ensued resulting in a return to normal daily activities, Fourteen months after surgery, a palpable lesion deficit was found in the area of the of the implant. Radiographs revealed a 4- to 6-mm circular lytic lesion consistent with the site of placement of the bioabsorbable implant in the greater tuberosity (Figure 1). Given the findings and the patient’s course postoperatively, she was scheduled for shoulder arthroscopy with possible supraspinatus muscle repair and placement of a bone graft in the area of erosion. Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009 21
figure 1. Radiograph depicting a 4- to 6-mm lytic lesion consistent with the placement of the bioabsorbable implant. During the second surgery, no sign of a re-tear of the supraspinatus muscle was present. Pathological findings suggested that the lytic lesion was caused by a giant-cell reaction to the bioabsorbable implant used in the first repair of the supraspinatus muscle (Figure 2). The lesion was burred, irrigated, and filled with 0.75 cc of Allomatrix. To avoid any further reaction, the supraspinatus muscle was sutured using #2 FiberWire through holes in the greater tuberosity. Two weeks after surgery the patient had less pain and was improving with passive range-of-motion exercises. Four weeks after surgery she was instructed to begin active-assisted exercise. Eight weeks after surgery, the patient was neurovascularly stable, had improved range of motion, and had no signs of impingement. The patient was instructed to continue range-of-motion exercises for another 4 weeks and at 3 months to begin strengthening exercises. At 6 months the patient had no further complaints regarding shoulder discomfort on the right side and returned to normal daily activities. diSCuSSion Our case is an example of an exaggerated inflammatory reaction to a bioabsorbable implant, stressing the need for both awareness and precaution when using implants for pain. Our patient developed a giant-cell reaction to a bioabsorbable screw that was used as an anchor for the sutures in a supraspinatus muscle repair. A giant-cell reaction is manifested by individual macrophages adhering to form a large, multinucleated cell that engulfs the foreign body. The presence of giant cells interferes with healing at the surgical site of the implant and can lead to a breakdown of healthy tissue in the surrounding area. 7 As in our case, this often necessitates a second surgery to correct the defect. The initial phase of implant degradation is hydrolysis. As the implant absorbs water, it begins to degrade. The more porous the implant, the more quickly it absorbs water. 8 Any remaining fragments are removed by normal phagocytic response; however, the rapid degradation of these implants, 4 coupled with excessive stress being placed on the implant, 9 has been postulated to be the cause of marked foreign-body reaction, as occurred in our patient. Various factors, including the metabolic activity of the living cells, figure 2. Multinucleated giant-cell reaction (hematoxalin and eosin stain under 25X magnification with partial polarized light showing biorefringent particulate material). 22 Gundersen Lutheran Medical Journal • Volume 6, Number 1, June 2009
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Streptococcus bovis - Gundersen Lutheran Health System

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