Introduction: Cutibacterium acnes is a slow-growing, aerotolerant anaerobic, gram-positive organism most often discussed in shoulder surgery and implant-associated infection. Native elbow septic arthritis due to C. acnes is rare and can be missed when cultures are not held long enough.
Case Presentation: An 18-year-old right-hand dominant male landscaper presented with six weeks of atraumatic left elbow pain, swelling, stiffness, and night sweats after failing a one-week course of oral sulfamethoxazole/trimethoprim and cephalexin. White blood cell count was normal at 9,000/microliter, whereas ESR was 59 mm/hr and CRP was 8.9 mg/dL. Radiographs showed elbow effusion without osseous abnormality, and MRI demonstrated a complex loculated effusion with surrounding soft tissue inflammation. Initial arthrocentesis was nondiagnostic because less than 2 mL of bloody fluid was obtained, leaving insufficient fluid for analysis or culture. Because symptoms persisted despite empiric inpatient intravenous antibiotics, the patient underwent open irrigation and debridement through a posterior triceps-split approach. Purulent material was encountered, multiple intraoperative specimens were deliberately sent for prolonged incubation, and at least two separate intraoperative cultures grew C. acnes on postoperative days 9 and 11. Formal antimicrobial susceptibility results were not available in the source record. The patient was discharged on oral ciprofloxacin and linezolid for two weeks until outpatient follow-up under the treating clinical team. At two-week follow-up, he had no early wound complication and range of motion improved to 5 to 120 degrees.
Discussion: This case illustrates an indolent native-joint infection with normal peripheral leukocyte count, elevated inflammatory markers, initially nondiagnostic aspiration, and delayed culture positivity after extended incubation. Antibiotic exposure before operative sampling and the absence of susceptibility data limit interpretation.
Conclusion: C. acnes should be considered in chronic atraumatic monoarthritis of the elbow. Multiple operative specimens and prolonged culture incubation are important when routine evaluation is nondiagnostic.
Cheng Bing Heng Adam, Nicholas Jiajie Leong, T Jegathesan
Introduction: Calcific tendinopathy most commonly affects the rotator cuff and typically presents as small, focal deposits. Involvement of the hamstring tendons is rare, and long-segment intratendinous calcifications have not been well described to our knowledge.
Case Presentation: We report the case of a 47-year-old male Masters athlete who presented with posterior thigh pain following a fall during a sprinting activity. Imaging revealed an unusually extensive 9.66 cm linear calcification within the proximal semimembranosus tendon. Initial conservative management (such as rest and icing) failed to provide symptomatic relief. The patient subsequently underwent a course of focused extracorporeal shockwave therapy (ESWT). Pain scores decreased from a visual analogue scale (VAS) of 3 to 1 at one month, with corresponding improvements in functional outcomes (LEFS, EQ-5D-5L, and Roles and Maudsley score). At six months, the patient achieved complete symptom resolution (VAS 0) and returned to full competitive activity.
Discussion: This case represents a rare presentation of long-segment semimembranosus calcific tendinopathy with a morphology distinct from the focal deposits typically described in the literature. The favourable clinical response to ESWT suggests that treatment principles established for rotator cuff calcific tendinopathy may be applicable to atypical anatomical locations. It also expands the spectrum of imaging appearances and clinical presentations of calcific tendinopathy affecting the hamstring tendons.
Conclusion: Long-segment calcific tendinopathy of the semimembranosus tendon is an uncommon entity that should be considered in patients with persistent posterior thigh pain. Focused ESWT may provide an effective non-operative treatment option, resulting in significant symptom improvement and successful return to sport.
Victor Fontes Pacheco, Giulia Haendchen Fornasari:, Nilza Alveellos Fernandes Neta, Rafael da Costa Serafim, Gabriela Sarturi Barbiero, Diego Cassol Dozza
Background: High-intensity peripheral magnetic stimulation (PMS), delivered as repetitive peripheral magnetic stimulation (rPMS) or functional magnetic stimulation (FMS), is increasingly used in rehabilitation, but interpretation is limited by unstable terminology, heterogeneous protocols, and frequent conflation with low-intensity electromagnetic field therapies.
Scope: This narrative review synthesizes peer-reviewed orthopedic, rehabilitation, pain, and translational literature on high-intensity PMS for musculoskeletal pain, including randomized trials, meta-analyses, mechanistic studies, feasibility studies, and adjacent evidence. Low-intensity exposure studies, non-musculoskeletal applications, commercial booklets, and non-indexed reports are discussed only to clarify scope, safety, or evidentiary boundaries.
Findings: The evidence base comprises several meta-analyses and a set of controlled, mechanistic, pilot, and feasibility studies. In low back pain, pooled estimates suggest short-term pain reduction (SMD -1.16, 95% CI -1.56 to -0.76; very-low GRADE certainty; VAS MD -1.89, 95% CI -3.32 to -0.47; very-low-to-low GRADE certainty) and disability gains (ODI MD -6.55 to -8.39; very-low-to-low GRADE certainty), with partial primary-trial overlap between pooled syntheses. Myofascial trials show short-term analgesic signals at low certainty. Mechanistic studies using fNIRS and TMS suggest cortical reweighting beyond peripheral afferent recruitment and segmental modulation at very-low certainty. Pilot evidence in radicular pain and knee osteoarthritis is promising but not definitive, especially when PMS is tested as an adjunct rather than standalone therapy.
Conclusion: High-intensity PMS is a biologically plausible, noninvasive adjunct for selected musculoskeletal pain presentations when paired with rehabilitation that converts transient analgesia into movement and function. Its clinical role depends on adequately powered sham-controlled trials with standardized dose reporting, validated outcomes, durable follow-up, and embedded mechanistic endpoints
Victor Fontes Pacheco, Giulia Haendchen Fornasari, Rafael da Costa Serafim, Nilza Alveellos Fernandes Neta, Gabriela Sarturi Barbiero, Fernando Borges Ribeiro
Background: Platelet-rich plasma (PRP) is used across musculoskeletal medicine, but clinical translation is limited by inconsistent preparation reporting, variable platelet dose, and limited access to proprietary systems. Acid citrate dextrose (ACD) yellow-cap tube workflows offer a practical low-cost platform for manual PRP preparation, but their centrifugation variables and product options require clearer synthesis.
Scope: This narrative review summarizes ACD and ACD-formulation tube studies relevant to manual PRP preparation for orthopedic and musculoskeletal practice. The review emphasizes centrifugation force and time, tube geometry, platelet recovery, dose implications, buffy-coat handling, platelet-poor plasma (PPP) use, and reporting standards.
Findings: Double-spin protocols outperform single-spin methods in ACD-based preparation. The strongest internally controlled dataset supports 600 × g for five minutes followed by 900 × g for 15 minutes as the highest-yield open protocol, whereas the closed Turn Down-Turn Up protocol reached 4.17-fold enrichment with 73.6% platelet recovery. Dose literature in knee osteoarthritis suggests that total deliverable platelets, not fold increase alone, should guide interpretation; multiple ACD tubes or repeated processing may therefore be required for high-dose clinical targets. Manual ACD workflows also permit phenotype customization by including or excluding the buffy coat and by using PPP as a separate biologic resource, including plasma gel or PRP matrix applications.
Conclusion: Manual ACD-tube PRP is best framed as an accessible, customizable preparation platform rather than a single protocol. Its value depends on transparent reporting of tube specifications, centrifugation physics, aspiration strategy, final dose, leukocyte profile, PPP use, and cost.
Introduction: Fungal periprosthetic joint infection (PJI) complicates 1–4% of all PJI and disproportionately affects immunosuppressed hosts. Non-albicans Candida species, particularly Candida glabrata, increasingly exhibit echinocandin resistance through FKS1 and FKS2 hot-spot mutations, but the orthopedic literature on resistant non-albicans Candida hip PJI remains small, and the 2019 International Consensus Meeting (ICM) does not stratify guidance by resistance phenotype.
Case Presentation: A woman in her late sixties with seropositive rheumatoid arthritis on prednisone and methotrexate presented 22 months after primary right cementless total hip arthroplasty (THA) with a six-month history of progressive right groin pain and a draining lateral sinus. An earlier outside-facility aspiration and debridement had been uninformative. Three of five intraoperative tissue samples and sonicate fluid grew Candida glabrata on Sabouraud dextrose agar; FKS2 sequencing identified a p.Phe659del mutation conferring pan-echinocandin resistance. Two-stage revision used a conventional-dose amphotericin-B-loaded cement spacer (200 mg per 40 g) with intravenous liposomal amphotericin B and oral flucytosine, later transitioned to oral posaconazole. A secondary extended-spectrum β-lactamase–producing Escherichia coli wound infection required repeat debridement. Stage II reimplantation with a cementless revision stem, a multi-hole uncemented acetabular shell, and a dual-mobility bearing was performed at five months, achieving Harris Hip Score 78 at one year. Reactivation at 20 months mandated salvage Girdlestone resection arthroplasty, underscoring that even a technically sound two-stage revision may not eradicate resistant non-albicans Candida PJI.
Discussion: This case highlights three lessons: the diagnostic findings that should prompt extended-incubation fungal culture and molecular susceptibility testing; the elution-driven limitations of conventional amphotericin-B-loaded cement spacers, which favour a liposomal formulation; and the realistic medium-term prognosis, with two-stage recurrence rates near 48% in contemporary non-albicans Candida PJI series.
Conclusion: Glabrata-complex PJI isolates should undergo echinocandin minimum inhibitory concentration testing and FKS1/FKS2 sequencing at speciation. Patients should be counselled pre-operatively about a meaningful probability of eventual joint salvage.
Introduction: Acute exertional compartment syndrome (AECS) of the forearm is rare, and bilateral cases are reported only sporadically. In sport climbers, the far more familiar entity is chronic exertional compartment syndrome (CECS) of the forearm, for which fasciotomy is elective. That mismatch in expected time pressure, paired with sparse upper-extremity AECS literature, drives delayed diagnosis and avoidable functional loss.
Case Presentation: A previously healthy man in his early thirties presented with bilateral forearm tightness, swelling, median and ulnar paresthesia, and inability to make a fist after a single high-volume climbing day combining outdoor multi-pitch effort with extended hangboard and campus-board training. Examination showed bilateral volar swelling, cyanotic discoloration, and reduced two-point discrimination with intact distal pulses. Serum creatine kinase peaked at 31,420 units/L, and forearm magnetic resonance imaging demonstrated diffuse volar compartment T2 hyperintensity. Right-sided compartment pressures (volar 58 and 62 mmHg, dorsal 38 mmHg, mobile wad 42 mmHg) prompted emergent two-incision fasciotomy. The contralateral forearm progressed clinically and was decompressed on hospital day 2. Both wounds underwent delayed primary closure. At six months the QuickDASH score was 14, and at three years the patient had returned to recreational climbing near his pre-injury level.
Discussion: Forearm AECS in athletes is uncommon and easily mistaken for chronic exertional compartment syndrome in the climbing population. The constellation of hours-acute symptom onset, marked rhabdomyolysis, and progressing neurologic deficit distinguished AECS from CECS in our patient and triggered emergent compartmental pressure measurement. Bilateral cases can present asynchronously; contralateral surveillance was the practical refinement that permitted timely staged decompression.
Conclusion: Bilateral forearm AECS in a sport climber is easily anchored to CECS. Recognition rests on the constellation of hours-acute onset, marked rhabdomyolysis, and progressing neurologic deficit, with contralateral surveillance for asynchronous bilateral progression. Decompression within the six-hour window can preserve near-baseline function.
