Case: Cactus Knee
Reported by Myles Clough, Orthopaedic Surgeon, Kamloops, BC, Canada
A 14 year old boy presented 24th March 1999 with inability to straighten his left knee. 3 weeks previously while on holiday in Mexico he had fallen against a cactus which had punctured his knee in three places on the superolateral aspect. When asked if any spines had broken off, he was reasonably sure that none had. He was able to continue walking though his knee swelled and hurt. He attributed that to "poison" on the spines.
5 days before I saw him his knee locked. He was able to flex quite well and could still walk but couldn't straighten his knee less than 40 degrees. When I saw him he was afebrile, the puncture wounds had healed without inflammation, he had a significant effusion and wasting of the quads and painful locking with the pain being at the medial joint line. Xrays of the left knee were normal. I admitted him on suspicion of a medial meniscus injury having teased out of him the notion that perhaps he did twist his knee when he fell but didn't notice it due to the pleasure of the encounter with the cactus! As an afterthough I said to him and his parents that I would treat an infection if I found that the penetration of the spines had caused one. Honestly I didn't expect that; however, I did persuade the anaesthetist that the possibility of infection did exist and that we had better do him in the middle of the night.
I scoped his knee and found this gigantic broken off cactus spine. It was about 2 cms long and 2mm in diameter. It had broken off from the entry point in the suprapatellar region, floated round the knee then impaled itself into the medial meniscus. There was some blood stained slightly turbid fluid which I sent for culture. I retrieved the spine. There was none of the purulent exudate which you see in an infected knee, although there was some hyperaemia of the synovium. I placed suction/irrigation drains and ran 200cc saline /hour with 1 gram of Cefazolin per 3000cc through his knee for 24 hours. I also placed him on IV Cefazolin pending cultures.
In the lateral wall of the suprapatellar pouch I could distinguish the entry point of the spine. There was a small punture wound with a fibrinous clot hanging down from it. (Seen at 2 o'clock in the illustration at left) This illustration also shows the degree of hyperaemia of the synovium. The spine is shown just prior to removal below. It had been impaled into the meniscus seen to the left and had been withdrawn into the joint to free it up. A pituitary rongeur holding the blunt end on the spine is seen in the top of the picture.
Over the next 4 days he was afebrile and comfortable, taking no analgesics and wanting to go home. The drains were removed after 48 hours. On 29th March the infectious disease consultant told me they have cultured Aspergillus from the fluid. He advised against antifungal agents (Amphotericin) as he thought the patient would clear it up himself now that the contaminating spine was removed. I discharged him with review in 2 weeks at which time I am planning to aspirate the knee, if there is an effusion, and repeat the fungal culture.
2 weeks later I reviewed him in the orthopaedic clinic. He had 1 cm wasting of the quadriceps and a very small synovial effusion. There is full range flexion and about 5 degrees quads lag. He is non-tender. Considering the length of time he was symptomatic pre-op and the period of irrigation I felt his knee showed no signs of on-going infection or chronic synovitis. I did not repeat the aspiration. He is to undertake a physiotherapy rehabilitation programme.
At 3 month follow-up he was asymptomatic and had normal examination and function.
Editors Note: Many of these comments refer to thorn injuries or synovitis rather than aspergillosis per se.
From: Rick Strain <firstname.lastname@example.org>
Date: March 30, 1999 4:38 AM
I had a similar case a number of years ago. I believe that there is some old literature on "Thorn Arthritis" from areas in the world where dates (the fruit) are grown. These usually present in the subacute time frame and respond well to just removal of the foreign body. Do any of the members of the list in date growing areas have experience??
From: krishnan rajesh <email@example.com>
Date: March 30, 1999 11:24 AM
I remember hearing about cactus knee in one of the meetings in India(1991-92 ,can't remember exactly) presented by two orthopaedic consultants from the Middle east (I think) .They reported it in patients like the one you had,not immune compromised ones.I do not know whether it was a published report.I think one of the authors was Ramanathan (Ramnathan / swaminathan ?).Rajesh KrishnankuttyNair,FRCS,MS,DipNB VSpR (Ortho)South ManchesterUK
From: Sudhir Warrier <firstname.lastname@example.org>
Date: March 30, 1999 4:59 PM
Krishnan is right! I have heard at least three papers on "Date Palm Thorn Synovitis".These papers were from the Khoula Hospital, Muscat, Oman. One of the authors was Lewis, (Luis, Editor's note) who moved on to Australia, I believe. E.B.S.Ramanathan and Wahid-al-Kharusi were the other authors. The condition was noted in people who climbed date palms professionally. I will try and get more information on this.
Hand & Reconstructive Orthopedic Surgeon
Shushrusha Hospital & Laud Clinic
Res:B, Block, Hare Krishna Land, Juhu, Mumbai-400049 India
From: kklou <email@example.com>
Date: March 31, 1999 4:05 AM
In Malaysia, I have seen quite a number of oil palm plantation workers who had injuriesto various parts of their bodies by the oil palm thorns. They present typically with a very localised ,severe inflammatory reaction. Occasionally it leads to an abscess collection which is easily diagnosedand treated. Most of them however insist that the thorns have been removed, but the pain and stiffnesspersist and local examination reveals an area of mild to moderate induration only. X-ray normallydoes not pick up the foreign body, so most of the time, I proceed to explore the old injury and findthe foreign body. Not easy though! The ones with abscess usually come back as Staph. aureus onculture but I have never before taken tissue from the non-abscess wounds to check for infection.They all usually settle once the thorns are removed. However the incidence of knee injury by thorns is not so common here because the plantshere are above shoulder height and the common sites are hands and fingers (that would include thesmaller joints). IMHO, fungal infection may be common because the thorns are usually covered withspores and whatever pollen material that fly around in the air. Staph. aureus is the main organism in my area because the patients initially will try their best to dig out or pull out the thorns, that's whenthe puncture wounds get infected.
Penang Seventh Day Adventist Hospital
From: Jose M. Palomo Traver <firstname.lastname@example.org>
Date: March 31, 1999 3:03 PM
We ( North to Valencia, Eastern Spain ) have quite a large and all too similar experience with thorns of both palm and orange trees.
Jose M. Palomo, MD
Med. Adjunto ( Consultant Trauma & Orth. Surgeon )
Castello General Hospital
From: Myles Clough email@example.com
Date: April 1st 1999
A number of points emerged from the literature review
1. A large number of the cases present as a chronic synovitis. Often, especially with small children, the original injury had been forgotten. Some of the rheumatology papers say "Bear this possibility in mind when faced with a monoarthritis"
2. A number of papers suggest that complete synovectomy is required and that wash-out or simple removal of the thorn is not enough. I suspect this may be related to the chronicity of the cases and hope that in my (sub-acute) case it will not be necessary. Another of the pictures taken during my case shows the hyperaemia of the synovium and the presumed entry site of the cactus spine. Do people think this degree of synovitis will be a chronic problem?
3. The largest collection of cases published was 20 from India. However, some of the list members who corresponded suggest that the condition is quite common.
4. The bacteriology is very varied with no organism predominating. Dr Lou from Malaysia suggested that Staph aureus was common but only because most of the patients had tried to dig the thorn out themselves and got a secondary infection. I'm not sure if the consensus is that the synovitis is of microbial aetiology or is a hypersensitivity reaction to the foreign body.
5. CT scan was recommended where this diagnosis is suspected as it is much more likely to demonstrate the presence of an intraarticular thorn than plain xrays. There is one report of MR scanning showing up the object really well.
6. I found it amusing how many different people claim priority in the arthroscopic diagnosis and treatment of this condition.
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