Periprosthetic knee infection by Mycobacterium bovis and Candida guilliermondii in the context of a zoonosis: a case report and review of the literature.

INTRODUCTION: Periprosthetic joint infections are a major challenge for treating physicians. Musculoskeletal infections with Mycobacterium bovis are extremely rare, with an assumed incidence of 0.08-0.1%. Consequently, periprosthetic joint infections with Mycobacterium bovis are even less frequent. Fungal periprosthetic joint infections are very rare. No cases of Candida guilliermondii infection of implanted prostheses are described in the literature. CASE PRESENTATION: An 87-year-old Swiss man with German ethnic origin suffered from symptoms of osteoarthritis of the knee. We present the first described case of periprosthetic joint infection after total knee arthroplasty by both Mycobacterium bovis and Candida guilliermondii in the context of a zoonosis with 14 months of follow-up. The infection was presumed to originate more than 55 years earlier, when these infectious agents were still present in cattle in Switzerland. After diagnosis of the pathogens, our patient was successfully treated with tuberculostatic and mycocide medication, and a two-stage revision knee arthroplasty was performed. The medication was given for 1 year. The postoperative course was normal and he achieved ambulant musculoskeletal rehabilitation. After 14 months of follow-up no further complication emerged. At all routine consultations, there were no indications for joint inflammation, wound healing was normal, and the range of motion was flexion/extension 110/0/0°. CONCLUSIONS: We found no comparable cases in our literature search. Only a few joint infections by Mycobacterium bovis after intravesical instillation of Bacillus Calmette-Guérin are described. Primary infections without previous Bacillus Calmette-Guérin injection appear to be even less frequent. In cases where mycobacterial infection cannot be ruled out, we recommend cultivating mycobacteria cultures for weeks. In addition, a histological examination of the tissue should be carried out. After diagnosis, the concept of a two-stage reimplantation of total knee arthroplasty with mycostatic therapy for 1 year and antimycotic therapy appears to be effective.

Correction of knee deformity in patients with Ellis-van Creveld syndrome: A case report and review of the literature.

Ellis-van Creveld Syndrome (EVC) is a rare autosomal recessive disorder. In 1940 Richard W. Ellis and Simon van Creveld first reported on a rare skeletal dysplasia, which to emphasize the main clinical characteristics, was termed "chondro-ectodermal dysplasia". The ectodermal involvement includes the skin, hair and nails while the chondrodysplastic characteristics involve the cartilage and bones, primarily in the forearms and lower legs. For the orthopaedic surgeon progressive valgus knee deformity accompanied by patella dislocation is the main problem in EVC. This study reports a ten year follow-up after a primarily failed operative therapy of knee deformity due to incomplete correction and the surgical technique utilized to correct the residual external torsional deformity and dislocation of the patella in a 19 year old girl who presented with the typical clinical features of Ellis-van Creveld Syndrome.

Closed reduction and minimally invasive percutaneous fixation of proximal humerus fractures using the Humerusblock.

OBJECTIVE: To evaluate the results after closed reduction and percutaneous fixation of displaced fractures of the proximal humerus with the Humerusblock system. DESIGN: Prospective case series. SETTING: Level 1 trauma center. PATIENTS AND METHODS: Fifty-eight consecutive patients with displaced proximal humerus fractures were followed over a mean period of 15.2 (12-28) months. INTERVENTION: All patients were treated by closed reduction and percutaneous fixation using the Humerusblock. MAIN OUTCOME MEASUREMENTS: Intra- and postoperative complications, secondary fracture displacement, rate of avascular necrosis, range of motion, pain according to a visual analogue scale, and the Constant-Murley shoulder score. RESULTS: No intra-operative complications occurred. Implant removal was performed 6 to 8 weeks after the initial surgery. In 13 (22%) cases, secondary impaction of the humerus lead to perforation of k-wires through the articular surface requiring premature removal of the entire implant after an average time of 4.9 weeks. Five patients required revision surgery, including open reduction and fixation because of secondary fracture displacement. In five patients, k-wires loosened and backed out laterally, requiring revision surgery and retightening of the clamping screws in three cases and premature implant removal in two. Two patients showed radiologic signs of partial avascular necrosis at the final follow-up. The average range of motion of the operated shoulder was flexion 119.2 degrees, extension 33.5 degrees, internal rotation 64.2 degrees, external rotation 41.4 degrees. and abduction 107 degrees. The mean visual analogue scale pain score was 1.1 points, and the mean Constant-Murley score was 73.6 points, representing 88% of the mean Constant-Murley score of the unaffected shoulder. CONCLUSION: The Humerusblock system allows reliable minimally invasive fixation of selected displaced proximal humerus fractures, even in elderly patients with potentially reduced bone mass. In this study, postoperative rates of avascular necrosis were lower than that which has been reported after conservative treatment and open anatomic reduction and internal fixation. The overall unplanned re-operation rate of 40% was high, comparable with what has been reported for conventional percutaneous pinning. However, clinical outcome was good in 77% of the patients, and reduction could be held in 91% successfully, including elderly patients with potentially reduced bone mass.

Elastic stabilisation of proximal humeral fractures with a new percutaneous angular stable fixation device (ButtonFix(®)): a preliminary report.

INTRODUCTION: The ButtonFix(®) system represents a new angular stable percutaneous fixation device for stabilisation of fractures of the proximal humerus. The purpose of this study was to present a preliminary report of the radiological and clinical outcome after minimally invasive stabilisation of selected proximal humerus fractures with the ButtonFix(®). PATIENTS AND METHODS: Seventeen patients with fractures of the proximal humerus were treated in our department with the ButtonFix(®) system. The mean final follow-up was performed 19 months postoperatively. Follow-up included assessment of postoperative reposition, range of motion, the DASH score, the Constant-Murley score, and the Short Form 36 (SF36). RESULTS: Twelve patients showed anatomical head-to-shaft angles, four revealed minor valgus replacement, and one minor varus replacement. In one patient unplanned revision surgery was necessary due to early secondary fracture dislocation requiring ORIF with an angular stable form plate. Implant removal was performed after 6 weeks in all patients. At the final follow-up, mean range of motion was: flexion 135°, extension 45°, abduction 142°, internal rotation 51°, and external rotation 62°. The mean Constant-Murley score was 70. The mean DASH score was 26 points and the average SF36 score was 76 points. One patient showed radiological signs of avascular necrosis. CONCLUSION: The ButtonFix(®) system represents a valuable tool in the treatment of proximal humeral fractures with results indicating fewer complications compared to prior percutaneous fixation devices. Moreover, the ButtonFix(®) seems to be able to maintain reduction even in elderly patients with potentially reduced bone mass.

The PFNA proximal femur nail in treatment of unstable proximal femur fractures--3 cases of postoperative perforation of the helical blade into the hip joint.

The proximal femur nail antirotation represents a new generation of intramedullary nailing devices for fixation of stable and unstable trochanteric fractures of the proximal femur. We report 3 cases of postoperative perforation of the helical blade through the femoral head into the hip joint without any signs of rotational or varus displacement of the fracture.