Concomitant Septic Arthritis of the Hip in Patients with Osteonecrosis of the Femoral Head.

INTRODUCTION: Septic hip is a rare condition and is known to occur in immune-compromised patients. In general, surgeons are not concerned about the superimposed septic hip when they operate on patients with osteonecrosis of the femoral head (ONFH) if the patient is not immune compromised. We evaluated 1) the proportion of septic arthritis among patients with ONFH, 2) the clinical and laboratory features, and 3) the outcomes of two-stage THA in those patients. MATERIALS AND METHODS: We identified patients who were diagnosed as having concomitant septic arthritis of the hip among 1,226 patients who underwent THA due to ONFH from 2011 to 2018 at our institution. A diagnosis of septic arthritis was made by aspirated joint fluid; white blood cell (WBC) count >15,000/ml and neutrophils >75%, microbiological culture, and/or the findings of septic arthritis on magnetic resonance imaging (MRI) scan. Osteonecrotic patients with infection were treated with two-stage THA. RESULTS: Among the 1,226 osteonecrotic patients, 14 (1.1%) had concomitant septic arthritis of the hip. There were nine men and five women. None of them were immune compromised or had a remote septic focus. In the preoperative evaluation, all 14 patients had elevated serum erythrocyte sedimentation rate (ESR) (>20mm/hr) and/or C-reactive protein (CRP) (>0.5mg/dL), and three patients had a fever (>37.5°C). Findings of septic hip were seen in all 12 patients who had preoperative MRI. The neutrophil count in the high-power field was >5 in all 12 patients who had intraoperative frozen section histology. The 14 patients were followed for one to seven years after the arthroplasty, and no patient had evidence of infection at the final follow up. CONCLUSION: When a patient with ONFH has an unexplained elevation of ESR and/or CRP, concomitant septic arthritis of the hip should be suspected.

Loss of reduction and complications of coracoclavicular ligament reconstruction with autogenous tendon graft in acute acromioclavicular dislocations.

BACKGROUND: This study was conducted to report loss of reduction and complications after single-tunnel coracoclavicular (CC) ligament reconstruction with autogenous semitendinosus tendon graft for acute acromioclavicular (AC) joint dislocations. METHODS: This retrospective study included patients with acute, unstable AC dislocations (surgery within 6 weeks after trauma). We excluded patients with chronic injury and distal clavicle fractures with CC ligaments disruption. We measured the CC distance on anteroposterior radiographs of both clavicles, preoperatively, immediately postoperatively, and at the final follow-up visit. We evaluated clinical outcomes using the American Shoulder and Elbow Surgeons Shoulder Assessment and the University of California, Los Angeles Shoulder Rating Scale scores and perioperative complications. RESULTS: There were 30 patients (27 men and 3 women) with mean age of 41 years (range, 19-70 years). The mean follow-up period was 31 months (range, 12-186 months). Mean CC distance was 15.5 ± 3.7 mm (84% ± 14% of the contralateral shoulder) preoperatively, 8.9 ± 2.6 mm (9% ± 40%) immediately postoperatively (P < .001), and 10.6 ± 3.3 mm (24% ± 39%) at the final assessment (P < .001), showing an increase of the CC distance during the follow-up. Loss of reduction (defined as >25% increase of CC distance) developed in 14 patients (47%), and complications occurred in 6 patients (20%), including 3 distal clavicle fractures through the tunnel. Final clinical scores were significantly lower in patients with complications (27 vs. 33 of the University of California, Los Angeles assessment [P < .001] and 81 vs. 95 of the American Shoulder and Elbow Surgeons Shoulder assessment [P < .001]). CONCLUSION: In acute AC joint dislocation, single-tunnel CC ligament reconstruction using autogenous tendon graft resulted in loss of reduction rate of 47% and a complication rate of 20%. The development of complications adversely affected clinical outcomes.

Concomitant Syndesmotic Instability and Medial Ankle Instability Are Risk Factors for Unsatisfactory Outcomes in Patients With Chronic Ankle Instability.

PURPOSE: To determine whether concomitant chronic syndesmotic injury or chronic medial ankle instability is associated with unsatisfactory outcomes in patients with chronic lateral ankle instability (CAI). METHODS: We conducted a retrospective review of prospectively collected data from 276 male military patients with CAI who had undergone a modified Broström procedure between May 2007 and March 2010 and had been followed up for a mean of 26.7 months (range, 22 to 41 months). We evaluated clinical outcomes using American Orthopaedic Foot & Ankle Society ankle-hindfoot, visual analog scale, and ankle functional satisfactory scale scores. Possible associations with concomitant instability were reconstructed and investigated using the Pearson correlation coefficient and multivariate logistic regression analysis. RESULTS: Of the 236 patients with satisfactory outcomes, 19 (8%) had medial ankle instability and 13 (6%) had syndesmotic instability; in contrast, of the 40 patients with unsatisfactory outcomes, 14 (35%) had medial ankle instability and 12 (30%) had syndesmotic instability. The mean American Orthopaedic Foot & Ankle Society scores for patients with satisfactory and unsatisfactory outcomes increased from 68.1 to 92.8 (P < .001) and from 65.9 to 76.8 (P < .001), respectively. The mean visual analog scale scores for the groups with satisfactory and unsatisfactory outcomes decreased from 5.8 to 2.1 (P < .001) and from 6.2 to 4.8 (P < .001), respectively. The mean ankle satisfaction score was 27.8 for patients with satisfactory outcomes and 18.7 for those with unsatisfactory outcomes (P < .001). Multivariate logistic regression analysis showed a 4-fold higher risk of dissatisfaction (95% confidence interval [CI], 0.81 to 20.07; P = .0880) with CAI and syndesmotic instability, a 3.8-fold higher risk (95% CI, 0.96 to 15.07; P = .0576) with CAI and medial ankle instability, and an 11.7-fold higher risk (95% CI, 2.60 to 52.70; P = .0014) with CAI and both syndesmotic and medial ankle instability. CONCLUSIONS: Chronic syndesmotic instability and chronic medial ankle instability are significantly associated with unsatisfactory outcomes in patients with CAI. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Risk of Osteoporotic Fracture in Patients with Breast Cancer: Meta-Analysis.

BACKGROUND: The fracture risk induced by anti-estrogen therapy in patients with breast cancer remains controversial. The aim of this study was to perform a meta-analysis and systematic review to evaluate the risk of osteoporotic fracture in patients with breast cancer. METHODS: A systematic search was performed to identify studies that included any osteoporotic fracture (hip fracture and vertebral fracture) in patients breast cancer. Main outcome measures were occurrence and risk of osteoporotic fractures including hip and vertebral fractures in patients and controls. RESULTS: A systematic search yielded a total of 4 studies that included osteoporotic fracture outcomes in patients with breast cancer. Meta-analysis showed a higher risk of osteoporotic fracture in patients with breast cancer. Analysis of these 4 studies involving a total of 127,722 (23,821 cases and 103,901 controls) patients showed that the incidence of osteoporotic fractures was higher in the breast cancer group than in the control group. The pooled estimate of crude relative risk for osteoporotic fracture was 1.35 (95% confidence interval, 1.29-1.42; P<0.001). CONCLUSIONS: Although studies were limited by a small number, results suggested a possible association between anti-estrogen therapy and increased risk of osteoporotic fractures in patients with breast cancer.