Increased interleukin 1ß levels in the subacromial fluid in diabetic patients with rotator cuff lesions compared with nondiabetic patients.

BACKGROUND: Diabetic patients have a high prevalence of shoulder pain and stiffness. Interleukin (IL) 1ß was reportedly correlated with shoulder stiffness and decreased shoulder function. We retrospectively compared the expression of IL-1ß in the subacromial synovial fluid between diabetic and nondiabetic patients with rotator cuff tearing. MATERIALS AND METHODS: We enrolled 68 patients with rotator cuff tearing (23 diabetic patients and 45 nondiabetic patients). The preoperative sum of range-of-motion deficit (SROMD), Constant score, and visual analog scale (VAS) score were obtained. Intraoperatively, subacromial synovial fluid was collected for the IL-1ß level measurement. Comparisons of IL-1ß levels, Constant scores, SROMD, and VAS scores between diabetic and nondiabetic patients were analyzed with the Mann-Whitney U test. RESULT: Diabetic patients with rotator cuff tearing had significantly increased subacromial IL-1ß levels (P = .048), SROMD (P < .001) and VAS scores (P = .022) and lower Constant scores (P < .001) than nondiabetic patients. The IL-1ß levels in the subacromial fluid were significantly correlated with the Constant score (r = -0.477, P < .001), VAS score (r = 0.698, P < .001), and SROMD (r = 0.293, P = .015) in all patients. CONCLUSION: The elevated IL-1ß levels in the subacromial fluid of patients with diabetes may explain the likelihood of pain and shoulder stiffness developing in these patients. We suggest more aggressive treatment for rotator cuff lesions in diabetic patients.

Preoperative templating and computer-assisted total knee arthroplasty for arthritic valgus knee.

We reported the functional outcomes, component alignment and optimal thickness of the tibial inserts and joint line changes of 21 arthritic valgus knee deformities using preoperative templating and computer-assisted total knee arthroplasty(TKA). The osseous cut was modified using a novel preoperative templating technique. Soft tissue balance and component implantation were implemented with the aid of a computed tomography-free navigation system. The arthritic valgus knees had clinical, and functional improvement of the knee Society scores and Lysholm scores postoperatively, at an average of 37.8 ± 7.2 months. The mean anatomic axis (15.2° ± 4.5° vs. 6.1° ± 1.4°) and mechanical axis (8.3° ± 5.2° vs. 0.28° ± 1.6°) were also significantly improved postoperatively. The mean thickness of tibial inserts and joint line changes was 10.7 ± 1.46 mm and 0.1 ± 1.4 mm. This computer-assisted technique with preoperative radiographic templating is an alternative strategy to improve TKA results in arthritic valgus knees.

Long-term retrospective analysis of surgical treatment for irretrievable tuberculosis of the ankle.

BACKGROUND: Although antituberculosis medication is the first step in the management of skeletal tuberculosis (TB), surgical debridement, biopsy, synovectomy, or arthrodesis may be needed for the definitive diagnosis and treatment of the symptomatic ankle. METHODS: Twenty-nine patients with TB around the ankle joint were enrolled during a 23-year period and followed for 73.1 months (range, 30-260 months) after TB was controlled. Among 61 surgical procedures performed in 29 patients, complete resolution of ankle TB was seen in 28 patients. RESULTS: According to Martini and Ouahes classification, radiographic findings of localized osteoporosis were stage I in 4 patients, one or more erosions were stage II in 9 patients, destruction of the whole joint was stage III in 8 patients, and anatomic disorganization and subluxation were stage IV in 8 patients. Functional results were excellent in 6 patients and good in 16 patients, but with talar bone collapse or hindfoot malalignment, a fair result was noted in 6 patients. The diagnostic accuracy rates were 28.5% with aspiration of synovial fluid, 66.7% in histological analysis, and 44.4% in bacteriological analysis. Mixed infection with bacterial flora was noted in 8 patients (27.6%). CONCLUSIONS: Ankle TB is easily misdiagnosed and may ultimately involve the peritalar neighboring joints with talar height loss or hindfoot deformity. Successful treatment depends on the extent of disease at presentation, accurate staging, duration of adequate chemotherapy, and optimal surgical intervention. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Extracorporeal shockwave therapy shows time-dependent chondroprotective effects in osteoarthritis of the knee in rats.

BACKGROUND: Recent studies reported that extracorporeal shockwave therapy (ESWT) has a chondroprotective effect on the initiation and regression of osteoarthritis of the knee in rats. However, the time course effects of ESWT in the osteoarthritic knee are not fully understood. The purpose of this study was to evaluate the effects of ESWT over time on osteoarthritis of the knee in rats. METHODS: We used 72 8-week-old male Sprague-Dawley rats with body weights ranging from 245 to 265 g. We randomly divided the rats into three groups, with 24 rats in each group. The control group received neither surgery nor ESWT. The anterior cruciate ligament transected (ACLT) group underwent anterior cruciate ligament transection but received no ESWT. The ACLT plus ESWT group underwent ACL transection and received ESWT at 1 wk after surgery. The animals were killed at 2, 4, 8, and 12 wk, 6 rats from each group at each time course. Evaluation parameters included Mankin score, Safranin O stain, and collagen II for the articular cartilage; and vascular endothelial growth factor (VEGF), bone morphogenetic-2 (BMP-2), and osteocalcin for the subchondral bone using histopathological examination and immunohistochemical analysis. RESULTS: The ACLT group showed significant increases in Mankin score and Safranin O stain, and a decrease in collagen II in the articular cartilage, and significant decreases in VEGF, BMP-2, and osteocalcin in the subchondral bone compared with the control (P < .05). The ACLT + ESWT group showed significant decreases in Mankin score and Safranin O stain and an increase in collagen II in the articular cartilage, and significant increases in VEGF, BMP-2, and osteocalcin in the subchondral bone compared with the control group. The changes in the ACLT + ESWT group appeared to correlate with the time courses of treatment; the most beneficial effects were noticed 4 weeks after ESWT. CONCLUSION: Extracorporeal shockwave therapy is effective in preventing osteoarthritis of the knee in rats. The beneficial effects of ESWT appear to be time-dependent beginning at 4 weeks after treatment.

Effect of sodium hyaluronate treatment on rotator cuff lesions without complete tears: a randomized, double-blind, placebo-controlled study.

HYPOTHESIS: A randomized, double-blind, placebo-controlled study of sodium hyaluronate (ARTZ Dispo) treatment was performed in 51 patients with rotator cuff lesions without complete tears. We hypothesized that ARTZ Dispo would render better results than the placebo. MATERIALS AND METHODS: Twenty-five patients (ARTZ Dispo group) had injections of 25 mg/wk of sodium hyaluronate into the subacromial bursa for 5 consecutive weeks. Twenty-six patients (placebo group) were given 2.5 mL of normal saline solution with the same injection protocol as the ARTZ Dispo group. No significant difference in age, height, weight, gender, vocation, involved shoulder, duration of symptoms, baseline Constant score, or visual analog scale (VAS) score existed between the 2 groups. RESULTS: The 2 groups did not significantly differ with regard to Constant scores, VAS scores, or global improvement assessments 1 week after injections. The ARTZ Dispo group had a better Constant score (P = .0095) and VAS score (P = .0018) than the placebo group 6 weeks after treatment. Patients in the placebo group were given 5 sodium hyaluronate injections, rather than placebo, after disclosure of the blind list, if they wished. Forty-one patients who underwent hyaluronate injection exhibited a significantly improved Constant score, from 64.0 +/- 11.7 at baseline to 88.9 +/- 10.4 (P < .0001), and a significantly improved VAS score, from 6.4 +/- 1.3 to 1.5 +/- 1.6 (P < .0001), at a mean follow-up of 33.1 months. No significant adverse effect was noted. CONCLUSIONS: Subacromial injections of sodium hyaluronate are effective in treating rotator cuff lesions without complete tears.

Functional outcomes of arthroscopic posterior cruciate ligament reconstruction: comparison of anteromedial and anterolateral trans-tibia approach.

INTRODUCTION: The hypothesis of this study is that anterolateral (A-L) trans-tibia approach is better than anteromedial (A-M) technique in posterior cruciate ligament (PCL) reconstruction. The purpose of this prospective clinical study was to compare the functional outcomes of A-M and A-L trans-tibia approach in arthroscopic PCL reconstruction. MATERIALS AND METHODS: Between 1999 and 2003, 55 patients (55 knees) with an average age of 30 +/- 11 years (range 16-60 years) underwent arthroscopic single-bundle reconstruction for symptomatic isolated PCL tear. Patients were randomly divided into two groups with 28 patients (28 knees) undergoing A-M trans-tibia approach on odd-numbered days, and 27 patients (27 knees) with A-L trans-tibia approach on even-numbered days. Hamstring auto grafts were used in all cases. All patients received the same rehabilitation program postoperatively. The evaluation parameters included clinical assessment, functional outcome, ligament laxity and radiographic changes of the affected knee. RESULTS: Significant improvements in pain and function of the knee were observed at an average follow-up of 48 +/- 15.9 months for A-M and 45.0 +/- 13.7 months for A-L approach. However, the difference between the two techniques was statistically not significant. In IKDC for symptom-activity level, normal or nearly normal knees were noted in 68% of A-M and 67% of A-L approach, respectively, but no difference was noted between the two groups. In ligament laxity, approximately two-thirds of the knees showed normal posterior laxity with no difference between the two groups. Radiographs of the knee showed no discernible difference in the overall alignment and degenerative changes as well as the sizes of bone tunnel between the two groups. CONCLUSION: A-M and A-L trans-tibia arthroscopic PCL reconstructions produced comparable clinical results in short-term follow-up. Contrary to our initial hypothesis, the theoretical disadvantages of A-M technique including graft failure were not observed during the follow-up period. Long-term results are needed to confirm the adverse effects of A-M trans-tibia approach in PCL reconstruction.

Functional outcomes of bilateral hip necrosis: total hip arthroplasty versus extracorporeal shockwave.

INTRODUCTION: This study compared the functional outcomes of total hip (THA) in one and shockwave (ESWT) in the other in 17 patients with bilateral hip necrosis. METHOD: In THA side, only one type of prosthesis was used and all components were press fixed. In ESWT side, each hip received 6,000 impulses of shockwave at 28 kv. RESULTS: The evaluations included pain score and Harris hip score, radiographs and MR images. The magnitudes of improvement in pain and function favored the ESWT side. Thirteen patients rated ESWT better than THA; four patients reported comparable results between THA and ESWT, and none graded THA better than ESWT. Better functional outcomes were observed after ESWT for early hip necrosis than THA for late cases in patients with bilateral hip disease.

Acid-labile core cross-linked micelles for pH-triggered release of antitumor drugs.

Micelles of a model amphiphilic block copolymer, poly(hydroxyethyl acrylate)-block-poly(n-butyl acrylate) (PHEA-b-PBA), synthesized via the RAFT polymerization were cross-linked by copolymerization of a degradable cross-linker from the living RAFT-end groups of PBA chains, yielding a cross-linked core without affecting significantly the original micelle size. The cross-linker incorporation into the micelles was evidenced via physicochemical analysis of the copolymer unimers formed upon acidic cleavage of the cross-linked micelles. High doxorubicin loading capacities (60 wt %) were obtained. Hydrolysis of less than half of the cross-links in the core was found to be sufficient to release doxorubicin faster at acidic pH compared to neutral pH. The system represents the first example of core-cross-linked micelles that can be destabilized (potentially both above and below CMC) by the pH-dependent cleavage of the cross-links and the subsequent polarity change in the core to enable the release of hydrophobic drugs entrapped inside the micelle.

Navigation-assisted total knee arthroplasty for a knee with malunion of the distal femur.

Conventional total knee arthroplasty (TKA) has been developed for several decades. However, very few previous reports describe TKA with less invasive modality for extra-articular angular deformity. Herein, we report a case of navigation-assisted TKA for severe osteoarthritis associated with malunited distal femoral fracture. Fourteen months after navigation TKA surgery, satisfactory alignment, diminished length discrepancy, and improved range of motion were noted. Our report reveals that navigation system without intramedullary reaming is a feasible and less invasive alternative for TKA surgery for complex arthritic knee disorders.

Triple positioning of tibial tubercle osteotomy for patellofemoral disorders.

BACKGROUND AND PURPOSE: Patellofemoral disorders are often associated with patellofemoral malalignment. Tibial tubercle transfer is an effective method to correct the patellofemoral malalignment. This study evaluated the long-term results of triple positioning of tibial tubercle osteotomy for refractory patellofemoral disorders with 10-year follow-up. PATIENTS AND METHODS: Fifty-six patients with 62 knees underwent triple positioning of tibial tubercle osteotomy for refractory patellofemoral disorders. All patients received standard rehabilitation protocol postoperatively. The average length of follow-up was 128.5±9.8 months (range 116 to 149). The evaluations included pain score, Kujala patellofemoral score, Lysholm score and radiograph of the knee. RESULTS: The overall clinical results were excellent in 41.9%, good in 37%, fair in 12.9% and poor in 5% at 1 year; and 29% excellent, 41% good, 18.3% fair and 9.3% poor at 10 years. Satisfactory results were 78.9% and 70.9%, and unsatisfactory results 21.1% and 29.1% at 1 year and 10 years respectively. There was no correlation of clinical outcomes with age, sex, body weight and height and preoperative pain score. However, there was a positive correlation of clinical outcomes with the improvement of the congruence angle on postoperative X-rays of the knee, and a negative correlation of clinical outcome with the severity of articular cartilage damage assessed in arthroscopy. The complications included 1 non-union and 1 infection with non-union. CONCLUSION: Triple positioning of tibial tubercle osteotomy is effective and long lasting in patients with patellofemoral disorders with 70.9% satisfactory results at 10-year follow-up. LEVEL OF EVIDENCE: IV (refer to instructions for detailed description on the level of evidence).

Functional outcomes of uni-knee arthroplasty for medial compartment knee arthropathy in asian patients.

BACKGROUND: Uni-knee arthroplasty (UKA) has shown better knee kinematics and motion that may better suit the activities of daily living in Eastern countries. The purpose of this study was to evaluate the functional outcomes of UKA for medial compartment knee arthropathy in Asian patients. METHODS: The study cohort consisted of 48 patients with 51 UK A knees. Only one type of prosthesis was used and all components were cemented. Postoperative management included ambulation with weight bearing, range of motion, and muscle strengthening exercises as tolerated until full recovery. The average follow-up was 52.0 ± 24.0 (range 12-92) months. The evaluation included functional assessment, the Knee Society knee and functional scores, the International Knee Document Committee (IKDC) subjective and objective scores, and radiographs of the knee. RESULTS: The overall clinical outcomes of the knee showed the functional outcome of the knee to be normal in 51%, nearly normal in 37%, abnormal in 8%, and severely abnormal in 4%. The functional activities included stair climbing in 96%, squatting in 76%, jogging in 71% and kneeling in 47%. Three-quarters of the patients were able to kneel for daily activities. Approximately 98% of the patients were satisfied with the operation. The survivorship of the prosthesis was 98% with one revision pending. Radiographic evaluations revealed the components were centered in 82% and off-centered in 18%. Osteoarthritis was 22% preoperative and 27% postoperative for the patellofemoral compartment, and 0% before and 4% after surgery for the lateral compartment. The functional outcomes showed no difference between patients with and without patellofemoral arthritis. The complications included one component malposition and one knee pain of undetermined origin. CONCLUSIONS: UKA provides excellent pain relief and restoration of knee function including kneeling, squatting, and sit-to-stand activities that perfectly fit the oriental lifestyle and high patient satisfaction in Asian patients at medium-term follow-up. The complications were rare and the survival rate was 98% at medium-term follow-up.

A free vascularized tibia-fibular composite graft for the traumatic femoral bony defect of a 6-year-old boy with 10-year follow up: a case report.

INTRODUCTION: Free vascularized fibular grafts have been widely used for the reconstruction of long bone defects. However, the use of a vascularized tibial graft is precluded by its weight-bearing function and unacceptable donor site morbidity. CASE PRESENTATION: We present a rare case of using a vascularized tibia-fibular composite graft taken from a 6-year-old Chinese boy's ipsilateral lower leg to reconstruct a large bony defect of his traumatic femur. Hypertrophy of the tibial graft, good remodeling of the femoral shaft, and atrophy of the unloaded fibular graft were noted at the 10-year follow up. He was able to participate in outdoor activities such as basketball while wearing his prosthesis. CONCLUSIONS: The 10-year follow up demonstrates the feasibility of this salvage procedure for a floating knee injury with neurovascular compromise.

Long-term results of extracorporeal shockwave therapy and core decompression in osteonecrosis of the femoral head with eight- to nine-year follow-up.

BACKGROUND: This study analyzed the long-term outcomes of extracorporeal shockwave therapy (ESWT) and core decompression for early osteonecrosis of the femoral head (ONFH) with 8- to 9-year follow-up. METHODS: The study cohort consisted of 48 patients with 57 hips including 23 patients with 29 hips in the ESWT group and 25 patients with 28 hips in the surgical group. Patients in ESWT group received shockwave therapy to the affected hip. Patients in surgical group underwent core decompression and autogenous cancellous bone and allogenous fibular graft. The average length of follow-up was 103.5 ± 3.4 (ranged 93-106) months and 104.5 ± 4.3 (ranged 95-108) months for the ESWT and the surgical group, respectively. The evaluations included clinical assessment for pain and function, X-ray and MRI of the affected hips. RESULTS: The overall clinical results were 76% good or fair and 24% poor for the ESWT group; and 21% good or fair and 79% poor for the surgical group. THA was performed in 3% and 21% at one year, 10% and 32% at 2 years and 24% and 64% at 8-9 years for ESWT and the surgical group respectively. Significant differences in pain and Harris hip scores were observed at different time intervals favoring the ESWT group. There was a trend of decrease in the size of the lesion in the ESWT group when compared with the surgical group. CONCLUSION: ESWT appears to be more effective than core decompression and bone grafting for early ONFH with 8- to 9-year long-term follow-up.

Functional analysis on the treatment of torn discoid lateral meniscus.

The purpose of this study is to evaluate the functional outcome on the treatment of torn discoid lateral meniscus. Thirty-two torn discoid lateral meniscuses in 29 patients were retrospectively reviewed. There were 13 males and 16 females with a mean age of 31.3±17.0. The age distribution were 24% in pediatric age (< 11 years old), 38%in young adult under 25 years and 38% in 25 years and older. Subjective symptoms included pain in 63%, popping and snapping in 56%, locking in 41%, givingway in 17%; and objective signs included decreased knee motion in 16%. Partial lateral menisectomy and saucerization were performed in 18 knees (56%), meniscus repairs were done in eight knee (25% ) and subtotal lateral menisectomy in six knees (19%). At an average follow up of 52.5±25.9 months (24-96 months). The results showed 84% good to excellent, 16% fair, and none poor. No significant difference was noted on the outcomes of different treatment methods. The age of symptom onset and the time of operation correlated with the IKDC and Tenger score. (p<0.001). Our data showed symptomatic torn discoid lateral meniscus may manifest at any age from childhood to adult. The first manifestation of symptom before age 11 year old was observed in only 24%. Therefore, discoid lateral meniscus should not be considered a childhood disease.

Complications of hip fractures in children.

BACKGROUND: Hip fractures account for < 1% of all pediatric fractures. Most are caused by a high-energy mechanism. Complications occur at a high rate because the vascular and osseous anatomy of the child's proximal femur is vulnerable to injury. The purposes of this study were to evaluate whether osteonecrosis influences the functional results and to analyze the risk factors for the development of osteonecrosis. METHODS: We conducted a retrospective review of the complications of hip fractures (3 transepiphyseal fractures, 13 transcervical fractures, 6 cervico-trochanteric fractures, and 1 intertrochanteric fracture) in 23 patients (15 boys and 8 girls) between January 1988 and December 1997. Most injuries were caused by falling from a height or a motorcycle accident. The medical records and serial radiographs of all patients were reviewed. The function of the injured site was evaluated using Ratliff's criteria. RESULTS: The ages of these children at the time of injury ranged from 1.5 to 16 years (average 11.1 years). The mean follow-up was 4.91 years (range, 1 year to 12 years and 7 months). Overall, complications included osteonecrosis in 11 (48%) patients, premature physeal closure in 11 (48%), coxa vara in 3 (13%) and coxa valga in 2 (9%). There was no nonunion. Poor outcomes were related to the development of osteonecrosis. The time to surgery (≤ 12 hours) and the quality of reduction significantly influenced the occurrence of osteonecrosis. The occurrence and severity of femoral head osteonecrosis significantly influenced the functional results (p < 0.001, and p < 0.048, respectively). CONCLUSION: Osteonecrosis is the most severe complication after hip fractures in children and is associated with poor functional results. The time to surgery and the quality of reduction were the significant predictors in our study.

Woodward procedure improves shoulder function in Sprengel deformity.

BACKGROUND: Sprengel deformity is a congenital failure of descent of the scapula. Limited shoulder abduction and cosmetic appearance are the major concerns. Although the Woodward procedure reportedly affords satisfactory correction, the long-term functional outcome postoperatively has not been addressed. METHODS: Eight patients (9 shoulders) who underwent the Woodward procedure for Sprengel deformity were evaluated. The cosmetic appearance and functional results of the shoulders were evaluated using the Cavendish grading system and functional Constant scoring. Grading of the cosmetic appearance, range of motion of the shoulder, and radiographs were obtained for interpretation. RESULTS: After a mean follow-up of 113 ± 29 months, the cosmetic appearance had improved. The Cavendish cosmetic grade improved significantly (p = 0.000). The superior displacement ratio decreased from 0.5 ± 0.1 to 0.2 ± 0.1 (p = 0.004). The height-to-width ratio of the affected scapula increased from 1.3 ± 0.2 (range 1.1 to 1.7) to 1.6 ± 0.2 (range 1.4 to 2.0) (p = 0.001). The abduction of the shoulder improved from 122 ± 14 (range 100 to 140) degrees to 157 ± 20 (range 125 to 180) degrees (p = 0.008). The average abduction power of the involved shoulders was 21.8 ± 3.2 lbs, which was not significantly different from the uninvolved shoulders 23.1 ± 2.5 lb (p = 0.525). The average Constant score for the operated shoulders was 91.7 ± 4.2 (range 82 to 96) points. CONCLUSION: The Woodward procedure offers substantial improvement of shoulder function and cosmetic appearance for patients.

Increased Dickkopf-1 expression accelerates bone cell apoptosis in femoral head osteonecrosis.

Intensive bone cell apoptosis contributes to osteonecrosis of femoral head (ONFH). Dickkopf-1 (DKK1) reportedly mediates various types of skeletal disorders. This study investigated whether DKK1 was linked to the occurrence of ONFH. Thirty-nine patients with various stages of ONFH were recruited. Bone specimens were harvested from 34 ONFH patients underwent hip arthroplasty, and from 10 femoral neck fracture patients. Bad, Bcl2 TNFalpha, DKK1, Wnt3a, LRP5, and Axin1 expressions were analyzed by quantitative RT-PCR and ELISA. Apoptotic cells were assayed using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end-labelling (TUNEL). Primary bone-marrow mesenchymal cells were treated with DKK1 RNA interference and recombinant DKK1 protein. ONFH patients with the histories of being administrated corticosteroids and excessive alcohol consumption had significantly higher Bad and DKK1 mRNA expressions in bone tissue and DKK1 abundances in serum than femoral neck fracture patients. Bone cells adjacent to osteonecrotic bone displayed strong DKK1 immunoreactivity and TUNEL staining. Increased DKK1 expression in bone tissue and serum correlated with Bad expression and TUNEL staining. Serum DKK1 abundance correlated with the severity of ONFH. The DKK1 RNA interference and recombinant DKK1 protein regulated Bad expression and apoptosis of primary bone-marrow mesenchymal cells. Knock down of DKK1 reduced dexamethasone-induced apoptosis of mesenchymal cells. Taken together, promoted DKK1 expression was associated with bone cell apoptosis in the occurrence of ONFH patients with the histories of corticosteroid and alcohol intake and progression of ONFH. DKK1 expression in injured tissue provides new insight into ONFH pathogenesis.

Cocktail therapy for hip necrosis in SARS patients.

BACKGROUND: There are no treatment guidelines for hip necrosis in severe acute respiratory syndrome (SARS) patients. A new regimen of cocktail therapy that consists of extracorporeal shockwave therapy (ESWT), hyperbaric oxygen therapy (HBO) and oral alendronate was utilized in four patients with eight hips. This study evaluated the outcomes of cocktail therapy with a 4-year followup. METHODS: There were 3 women and 1 man with an average age of 26 +/- 3.8 years. Each hip was treated with 6000 impulses of ESWT at 0.62 mJ/mm2 energy flux density in a single session. Each patient received HBO treatment for 100 sessions and oral alendronate for one year. The evaluations included pain score and Harris hip score, radiographs and magnetic resonance imaging (MRI) of the affected hips. RESULTS: At the 4-year follow-up, significant improvements in pain score and Harris hip score were observed in all cases (p < 0.001). All patients returned to work as healthcare providers. None required surgical intervention including hip replacement. MRI showed a trend of reduction in bone marrow edema and the size of the lesion, but no changes in the stage of the lesion. CONCLUSION: Cocktail therapy seems promising in delaying the disease progression of SARS-associated femoral head necrosis in the short-term.

Epstein-Barr virus associated extranodal natural killer T cell lymphoma of nasal type mimicking pyogenic osteomyelitis of the proximal humerus.

Extranodal natural killer (NK) cell lymphoma/leukemia, nasal type, is rare but highly aggressive. These neoplasms are found to be associated with infection of the Epstein-barr virus (EBV). We report a male patient who suffered from EBV associated NK/T cell lymphoma of the proximal humerus but presented as pyogenic osteomyelitis with the clinical signs and symptoms of fever, local erythema, elevated erythrocyte sedimation rate and C-reactive protein. The patient was treated using antibiotic therapy but the clinical course did not improve until the initiation of systemic chemotherapy. The patient developed tumor recurrence and died due to pneumonia and respiratory failure 10 months after the initial diagnosis. The purpose of this case report was to emphasize the unusual presentation of a neoplasm mimicking osteomyelitis.