Delay in diagnosis of femoral hematogenous osteomyelitis in adults: an elusive disease with poor outcome.

BACKGROUND: Hematogenous osteomyelitis of long bone is rare in adults, especially in the immune competent host. Only a few cases have been described to date. OBJECTIVES: To present a case series of femoral hematogenous osteomyelitis in adults, a rare condition that is difficult to diagnose and may cause major morbidity and mortality. METHODS: We reviewed three cases of femoral hematogenous osteomyelitis that occurred between 2007 and 2009. The course of the disease, physical findings, imaging modalities, laboratory analysis, culture results and functional outcomes were recorded. RESULTS: In all cases the diagnosis was delayed after symptoms were first attributed to radicular-like pain or lateral thigh pain due to an inflammatory non-infectious source. In all cases infection was caused by an unusual or fastidious bacterium. The pathogen was Haemophilus aphrophilus in one case, and Streptococcus specimens were found in the other two. Pathological fracture occurred in two of the cases despite culture-specific antibiotic treatment and a non-weight bearing treatment protocol. It took five surgical interventions on average to reach full recovery from infection, but residual disability was still noted at the last follow-up. CONCLUSIONS: Clinicians should be aware that although femoral hematogenous osteomyelitis is a rare condition in adults, its ability to mimic other pathologies can result in delayed diagnosis and major morbidity. In our series the pathogen was different in each case and was cultured only from the infected site. Pathological fracture is a devastating complication but we do not recommend prophylactic stabilization at this point.

[Chronic exertional compartment syndrome].

Chronic exertional compartment syndrome is an uncommon phenomenon first reported in the mid 50's. This condition is characterized by sharp pain during physical activity, causing reduction in activity frequency or intensity and even abstention. This syndrome is caused by elevation of the intra-compartmental pressure which leads to decreased tissue perfusion, thus ischemic damage to the tissue ensues. Chronic exertional syndrome is usually related to repetitive physical activity, usually in young people and athletes. The physical activity performed by the patient causes a rise in intra-compartmental pressure and thereby causes pain. The patient discontinues the activity and the pain subsides within minutes of rest. Chronic exertional syndrome is reported to occur in the thigh, shoulder, arm, hand, foot and gluteal region, but most commonly in the leg, especially the anterior compartment. The diagnosis of chronic exertional syndrome is primarily based on patients' medical history, supported by intramuscular pressure measurement of the specific compartment involved. Treatment of chronic exertional syndrome, especially the anterior and lateral compartment of the leg is mainly by surgery i.e. fasciotomy. If the patient is reluctant to undergo a surgical procedure, the conservative treatment is based on abstention from the offending activity, changing footwear or using arch support. However, the conservative approach is not as successful as surgical treatment.

[Atypical femoral fractures in long-term osteoporotic treatment with bisphosphonates].

Recently, atypical femoral fractures, especially at the proximal part, were reported in the literature. Most of the reports discussed the relationship between those atypical fractures and chronic use of bisphosphonate drugs as prophylactic treatment for osteoporosis. As a result, the FDA (US Food and Drug Administration) published a statement on October 2010, which was the conclusion of a multidisciplinary working group. The FDA decided to add warnings for every bisphosphonate drug which was given as prophylactic treatment for osteoporosis in the USA. In this review, we will present the bisphosphonate drugs, the presenting symptoms of patients who suffer from the pathologic fracture, the radiologic characteristics and the surgical treatment. We will present the work of a Task Force of the American Society for Bone and Mineral Research and the FDA statements.

Longstanding knee joint preserved functional outcome following medial femoral condyle resection. A case report.

Giant cell tumor of the bone (GCT) is a relatively uncommon benign aggressive tumor that occurs near the articular surface of major joints. Standard treatment of GCT is comprised of local resection followed by local adjuvant therapy. Unicondylar osteoarticular resection is usually followed by a reconstructive procedure to restore the biomechanical demands of the joint. The present report describes a patient with satisfactory knee stability and functional outcome 32 years following medial femoral condyle resection with no reconstructive arthroplasty.