Coexisting avascular necrosis of the scaphoid and lunate

Reports of coexisting avascular necrosis of more than one carpal bone are rare. We report coexisting avascular necrosis of the scaphoid and lunate in a 56-year-old woman with no history of using steroids or injury. We treated her with a radioscapholunate fusion with two angled 2.4 mm distal radius plates to stabilise the locking plate. At her 12-month follow up there was no evidence of non-union.     

Coexisting Kienböck's and Preiser's Disease of the Wrist: Experience with Proximal Row Carpectomy with Dorsal Capsular Interposition Technique

Background

Idiopathic avascular necrosis of the lunate is known as Kienböck's disease and that of the scaphoid is known as Preiser's disease. Because the prevalence of coexisting Kienböck's and Preiser's diseases is very low, standardized stages of disease and treatments are not established.

Case Presentation

We report coexisting avascular necrosis of the scaphoid and lunate in a 68-year-old woman with no history of steroids or other risk factors. We treated her with proximal row carpectomy with capsular interposition technique. A distal-based dorsal capsular flap was prepared and repaired the palmar capsule. At the last follow-up, she had no pain and had gained improved range of wrist motion. There was no arthritic change at the newly formed radiocapitate joint.

Conclusions

In the case of collapsed lunate and scaphoid with avascular necrosis, the proximal row carpectomy procedure has an advantage. Proximal row carpectomy with dorsal capsular interposition can be performed when the lunate or scaphoid cannot be saved. Arthritic changes of the capitate head and distal radius lunate facet can be covered with the dorsal capsule.     

Bilateral glenohumeral septic arthritis secondary to mastitis with subsequent avascular necrosis: A case report

Introduction and importanceSeptic arthritis is an orthopaedic emergency. Only 3% of septic arthritis patients present with glenohumeral involvement. Polyarticular disease with shoulder involvement constitutes 1% of this group. There is currently no documented case of bilateral glenohumeral septic arthritis with avascular necrosis secondary to mastitis.Case presentationWe present a case of a 38-year-old African woman with bilateral glenohumeral septic arthritis after management for mastitis of the left breast. She had left, then right shoulder pain, fever, and reduced range of motion, with multiple arthroscopic washouts and antibiotic therapy instituted at various hospitals by various specialists, leading to the resolution of active infection. The patient developed bilateral humeral head avascular necrosis with complete collapse as evidenced on plain radiography 4 months later, and underwent hemiarthroplasty of the right shoulder. Biopsy at operation showed no active bone infection, and inflammatory markers were not elevated. She had reduced discomfort for the following 2 years but developed increasing pain on lifting and reduced range of motion. The moderate symptoms in her left shoulder managed non-operatively had remained unchanged. There were no elevated inflammatory markers 2-years post arthroplasty.Clinical discussionThis case presents an uncommon scenario of bilateral septic arthritis secondary to mastitis, with rapid progression to avascular necrosis in an individual with no classical risk factors for avascular necrosis, despite appropriate antibiotic treatment and surgical interventions. Advanced collapse necessitated hemiarthroplasty of the dominant right side.ConclusionThis case highlights the need for close radiographic follow-up in atypical presentations of septic arthritis and the dilemmas in managing advanced bilateral avascular necrosis with arthroplasty in a young patient.     

Hip avascular necrosis in a healthy pregnant woman: A case report and review of literature

BackgroundHip pain during pregnancy is very common, but hip avascular necrosis represents a very rare entity.Case reportWe report a rare case of a healthy30-year-old female patient pregnant with twins, that suffered right hip avascular necrosis in the peripartum period, her symptoms were initially neglected as a benign cause of hip pain, this led to aggressive treatment at a young age.DiscussionWith less than 100 cases reported in the literature, pregnancy is not a well-known risk factor for femoral head avascular necrosis and it should be differentiated from one of the more common hip pathologies in pregnancy which is the so-called “Pelvic pain syndrome” and transient osteoporosis of the hip.ConclusionHaving a high index of suspicion and low threshold for MRI imaging in a pregnant woman with hip pain is a must to prevent such complications.     

Avascular necrosis of lumbar facet joints associated with bilateral facet fractures

Background contextAvascular necrosis is a commonly described condition caused by a disruption of blood supply to the bones, resulting in necrosis. Although common in joints of the extremities, it is seen less often in the spine. Risk factors for avascular necrosis include steroid use, alcohol consumption, smoking, scuba diving, thrombosis, hypercoagulability, and hypertension.PurposeThe purpose was to report an unprecedented case of avascular necrosis of the lumbar facet joints and bilateral facet fractures.Study designThis is a case report.MethodsThe patient underwent L3–S1 decompression and L5–S1 discectomy, during which time avascular necrosis of the superior articular process of the L3–L4 facet joints was discovered. The patient then underwent spinal fusion with pedicle screw instrumentation. Pathologic examination of both right and left facet joints confirmed the diagnosis of avascular necrosis.ResultsAt 19-month follow up, the patient's leg and back pain had significantly improved. His spine appeared fused with no instability or implant failure.ConclusionWe have presented a case of avascular necrosis of L3–L4 facet joints resulting in fracture and instability at the L3–L4 level of the spine, which was stabilized with an L3–L4 pedicle screw spinal fusion.     

Treatment of hallux valgus by Scarf osteotomy – rates and reasons for recurrence and rates of avascular necrosis: A systematic review

BackgroundWe reviewed the rates of and reasons for hallux valgus (HV) recurrence and the rates of avascular necrosis following Scarf osteotomy.MethodsWe searched the Cochrane Library, PubMed, and Embase databases for studies reporting operative management of HV using Scarf osteotomy. The primary endpoints were reasons for and rates of HV recurrence. The secondary endpoint was the rate of avascular necrosis.ResultsWe included 15 studies with 946 operations for HV. Seven studies reported no recurrence, six reported recurrence rates of 3.6–11.3%, one reported a recurrence rate of 30%, and one reported a recurrence rate of 78%. Thirteen studies (678 feet) reported other complications from Scarf osteotomy without avascular necrosis.ConclusionsAlthough HV recurrence is not uncommon following Scarf osteotomy, patient-related factors, surgical competence, and longer follow-up are more likely to be associated with recurrence. Avascular necrosis is an infrequent complication in HV patients treated using Scarf osteotomy.     

Dorsal capsular-based vascularized distal radius graft for proximal pole scaphoid nonunion with avascular necrosis

BackgroundScaphoid nonunion involving the proximal pole with the presence of avascular necrosis is difficult to reconstruct. We aimed to determine the efficacy of surgical treatment of proximal pole scaphoid nonunion with avascular necrosis using a dorsal capsular-based vascularized distal radius graft.MethodsBetween 2000 and 2018, 64 patients with established proximal pole scaphoid nonunion with avascular necrosis were treated using a dorsal capsular-based vascularized distal radius graft. This graft was harvested from the dorsal aspect of the distal radius with its dorsal wrist capsule attachment. Fixation of the scaphoid nonunion was performed with a small cannulated screw, followed by insertion of the vascularized graft into the dorsal trough at the scaphoid nonunion site. In the last 47 patients of this series, a micro suture anchor was placed into the scaphoid to augment graft fixation.ResultsUnion rate was 86% (55 of 64 scaphoid nonunions with avascular necrosis) at a mean time of 12 weeks. Persistent non-union was noted in eight patients and fibrous union in one patient. No patients developed donor site morbidity. No graft dislodgment was noted. There was significant improvement of the wrist functional outcomes at the final follow up.ConclusionsThe dorsal capsular-based vascularized distal radius graft is a safe and effective treatment in patients with scaphoid nonunion with avascular necrosis of the proximal pole. This pedicle vascularized bone graft is derived from a location that can easily reach the proximal third of the scaphoid avoiding microsurgical dissection or anastomosis.     

Unipolar allograft reconstruction for post-traumatic avascular necrosis of the distal tibia: A review of the literature,technique, and case series

BackgroundAvascular necrosis of the distal tibial plafond following ankle trauma is an underreported and potentially devastating phenomenon. Beyond conservative treatment options, surgical intervention has been limited to ankle arthrodesis, which sacrifices motion and may have longterm sequellae for adjacent hindfoot joints. Total ankle replacement has been historically contraindicated. Unipolar allograft reconstruction provides an option for joint salvage. We present a literature overview, implantation technique, and two cases utilizing matched unipolar distal tibial allograft.MethodsTwo younger patients underwent distal tibia allograft reconstruction for tibial plafond collapse due to post-traumatic avascular necrosis. They were followed to assess for clinical improvement and radiographic graft subsidence.ResultsBoth patients returned to work and activity. One patient had no graft subsidence at four years, but the other patient became symptomatic with graft subsidence at one year.ConclusionsDistal tibia allograft reconstruction can be utilized as a joint salvage surgery for post-traumatic avascular necrosis with collapse of the tibial plafond in younger patients that prefer an alternative to arthrodesis. Results may be mixed and necessitate an engaged, activated patient.Level of evidence: IV.     

Sixty-year follow-up in an untreated patient with Kienböck disease

Abstract

Kienböck disease can be treated either conservatively or by various operations. We describe the findings of the progression of Kienböck disease over 60 years in an 84-year-old man who had had no surgical treatment. This is the longest follow-up ever reported to our knowledge of a patient with avascular necrosis of the lunate.     

股骨颈系统和空心加压螺钉治疗青壮年不稳定性股骨颈骨折短期随访

目的：探讨股骨颈动力交叉螺钉系统（femoral neck system,FNS）与3枚空心加压螺钉（cannulate compression screw,CCS）治疗青壮年不稳定性股骨颈骨折的疗效。方法：回顾分析2018年8月至2021年8月收治的52例青壮年不稳定性股骨颈骨折患者临床资料,根据内固定方式分为两组,25例行FNS固定,27例行闭合复位3枚CCS倒三角形分布内固定。记录并比较两组患者的手术时间、切口长度、术中出血量、住院费用、骨折复位质量;术后定期随访患者,比较两组患者骨折愈合时间、术后完全负重时间、术后并发症发生（骨不连、股骨颈短缩、股骨头坏死等）。术后6个月采用Harris评分评估髋关节功能。结果：两组患者手术均顺利完成,FNS组患者出血量多于CCS组、切口长度大于CCS组、住院费用高于CCS组（P<0.01）。两组患者手术时间及术中复位Garden指数比较差异均无统计学意义（P>0.05）。两组患者均获得随访,时间6~32个月。FNS组骨折愈合时间少于CCS组,术后完全负重时间早于CCS组,髋关节Harris评分高于CCS组（P<0.01）。两组患者随访期间均未发生内固定断裂并发症,FNS组发生股骨头缺血性坏死4例、股骨颈短缩2例,其中3例因股骨头缺血性坏死行全髋关节置换术;CCS组发生骨不连2例、股骨头缺血性坏死9例、股骨颈短缩11例,其中5例因骨不连、股骨头缺血性坏死行全髋关节置换术。结论：FNS具有操作简单、兼具旋转稳定和成角稳定,使患者能尽早开始功能锻炼,降低不稳定性股骨颈骨折术后并发症发生率,是治疗青壮年不稳定性股骨颈骨折的新选择。     

钽棒置入治疗早期股骨头坏死近期疗效分析

目的:探讨钽棒置入治疗早期股骨头坏死的近期临床疗效。方法:回顾分析2008年1月至2008年11月接受钽棒置入术治疗且随访资料完整的早期股骨头坏死患者25例(39髋),男9例(11髋),女16例(28髋);年龄18～54岁,平均37岁。酒精性4例(6髋),激素性6例(8髋),创伤性2例(2髋),特发性13例(23髋)。Steinberg术前分期:Ⅰ期7髋,Ⅱ期24髋,Ⅲ期8髋。疗效分析包括术前、术后Harris评分,影像学变化及以接受髋关节置换术为随访终点的股骨头生存率。结果:25例患者术后获得随访,时间6～47个月,平均37.4个月。12髋影像学出现进展,包括钽棒退出1髋,股骨头塌陷3髋,股骨头坏死面积增加8髋。6髋行全髋关节置换术,包括有影像学进展5髋占41.7%(5/12),无影像学进展1髋3.7%(1/27)。所有髋关节Kaplan-Meier生存曲线显示钽棒置入后6个月生存率为(97.4±2.5)%,1年生存率为(94.7±3.6)%,2年生存率为(88.6±5.4)%,3年生存率为(72.5±11.2)%。结论:钽棒治疗SteinbergⅠ、Ⅱ期股骨头坏死近期疗效确切,能有效延缓股骨头置换时间。     

Sliding hip screws versus cancellous screws for femoral neck fractures: a systematic review and meta-analysis

Purpose

Both sliding hip screws (SHS) and cancellous screws are used in the surgical management of intracapsular femoral neck fracture. However, there is paucity of information as to which is the superior treatment modality. We performed this systematic review and meta-analysis study to compare the clinical outcomes of SHS and cancellous screws for the treatment of femoral neck fractures in adult patients.

Methods

We searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL, up to December 2017. Randomized controlled trials (RCTs) directly comparing the clinical outcomes of SHS and cancellous screws for femoral neck fractures were retrieved with no language or publication year restrictions. Data retrieved included operative details, nonunion rate, avascular necrosis, reoperation, infection and mortality, hip pain, functional hip scores, and medical complications. These were pooled as risk ratio or mean difference (MD) with their corresponding 95% confidence interval (CI). Heterogeneity was assessed by Chi-square test.

Results

Ten RCTs involving 1934 patients were included in the final analysis. The pooled estimate showed that the SHS group was associated with more intraoperative blood loss (MD = 110.01 ml, 95% CI [52.42, 167.60], p = 0.00002) than the cancellous screws. There was no significant difference in terms of operative time, postoperative hip function, nonunion, avascular necrosis, reoperation rate, infection, fracture healing, hip pain, medical complications, and mortality rate.

Conclusion

Based on our study, the cancellous screws group was associated with less intraoperative blood loss in comparison with the SHS group. No other significant differences were found between the two interventions.

     

股骨头骨髓水肿综合征的诊治及其与股骨头缺血性坏死的鉴别诊断

目的：通过对股骨头骨髓水肿综合征诊治的观察,分析其疾病特点及其与股骨头缺血性坏死的异同。方法：自2004年1月,股骨头骨髓水肿综合征患者19例,男12例,女7例;平均年龄（46．7±10．36）岁。给予药物及物理治疗,治疗前后按照髋关节Harris评分系统进行评分。结果：治疗前平均（43．17±12．62）分,治疗后平均（86．73±14．29）分,治疗前、后评分差异有统计学意义（P〈0．05）。结论：股骨头骨髓水肿综合征疾病特点不同于股骨头缺血性坏死,是一类独立的疾病。     

右归饮对激素性股骨头坏死患者股骨近端骨髓骨活性影响的实验研究

目的：观察右归饮含药血清对激素性股骨头坏死患者股骨近端骨髓体外分化为成骨细胞的影响。方法：将右归饮含药血清加入人骨髓间充质细胞诱导分化成骨细胞的培养体系,采用观察细胞学形态、MTT法、细胞内ALP含量及矿化结节形成,并与普通血清组进行比较。结果：与普通血清组相比,形态学观察及MTT法表明,右归饮舍药血清对激素性股骨头坏死患者股骨近端骨髓体外分化成骨细胞的增殖起促进作用（P〈0．01）;矿化结节染色及细胞内ALP含量测定表明右归饮对成骨细胞的活性有促进作用（P〈0．01）。结论：右归饮对激素性股骨头坏死患者股骨近端骨髓间充质干细胞诱导分化的成骨细胞的增殖和活性起促进作用。     

Komplikationen der Chevron Osteotomie

BackgroundThe Chevron osteotomy is probably the most used technique fort he correction of hallux valgus. According to the literature complications mentioned beside the classical surgical complications are avascular necrosis, hallux varus, recurrent hallux valgus and malposition.MethodsThe therapy of complications after Chevron osteotomy is in most cases a surgical solution. Hallux varus and malposition are mostly corrected by a correctional osteotomy, the solution of a avascular necrosis ist he arthrodesis.ResultsThe incidence of complications after Chevron osteotomy is described with up to 28%. This does not correlate with patients satisfaction which is in general around 90%.ConclusionThe Chevron osteotomy is one of the most if not the most used technique fort he correction of hallux valgus. With the correct indication a high percentage of patient satisfaction can be achieved. The incidence of complications is in most studies not high and usually revisions are rare.     

全髋表面置换术治疗股骨头坏死短期随访研究

目的：研究全髋表面置换术治疗股骨头坏死的短期疗效,探讨表面置换术治疗股骨头坏死技术要求和手术指征。方法：对2006年12月至2009年12月37例（43髋）行全髋表面置换术的股骨头缺血坏死患者进行随访,男25例,女12例;年龄21～67岁,平均44.5岁。按照ARCO进行分期：3A期3髋,3B期6髋,3C期16髋,4期18髋。根据Harris评分系统对手术前后关节疼痛、活动度、畸形矫正及功能的改善进行对比,用Charnley法比较术后假体松动X线改变。结果：失访3例,34例（40髋）获得随访,37髋疼痛完全缓解,3髋行走后有酸痛不适。随访时间16～53个月,平均32.4个月。术前Harris平均评分（51.5±1.7）分,术后32.4个月平均（94.3±1.4）分,较术前提高。优37髋,良3髋,差0髋。34例都恢复了正常生活或工作,术后疼痛明显缓解,其中3例（髋）长距离行走后有轻度酸痛不适,休息后缓解。1例异位骨化BrookerⅢ型,无疼痛,不影响正常行走和生活。无术后股骨颈骨折,无脱位,无松动和翻修。结论：经过适当患者选择、术中的精细操作,全髋表面置换术治疗股骨头缺血坏死可以获得满意的短期疗效。     

髋臼骨折内固定失败术后的全髋关节置换术

目的:探讨髋臼骨折内固定失败术后继发创伤性关节炎和(或)股骨头缺血性坏死行全髋关节置换术的特点及临床疗效。方法:2009年2月至2014年10月,采用全髋关节置换术对31例(31髋)髋臼骨折内固定失败继发创伤性关节炎和(或)股骨头缺血性坏死患者进行治疗,其中男26例,女5例;受伤时平均年龄(41±12)岁。患者因髋臼骨折内固定术后3~132个月,平均(20.6±26.9)个月内继发创伤性关节炎和(或)股骨头缺血性坏死而行全髋关节置换术,全髋关节置换术均采用后外侧入路。观察术后并发症和关节活动度,并比较术前和术后随访时髋关节VAS疼痛评分和Harris髋关节评分。结果:术后27例获得随访,随访时间12~80个月,平均(43.2±11.7)个月。其中出现关节感染1例,假体松动1例,脱位1例,无继发坐骨神经损伤病例发生。所有随访病例髋关节功能和步态有明显改善;至末次随访时,VAS由术前平均(7.6±1.2)分,降低到术后平均(1.2±0.9)分,Harris评分由术前平均(45.5±13.6)分,提高到术后平均(88.5±7.8)分,差异均有统计学意义(P0.01)。髋关节除后伸外,前屈、外展、内收、内旋及外旋活动范围较术前显著增加,差异有统计学意义(P0.05)。X线片复查示:髋臼假体无不稳定发生,1例股骨柄假体下沉3 mm,2例发生异位骨化。结论:正确处理内固定物,提防潜在感染,合理重建髋臼骨缺损,是髋臼骨折内固定失败术后全髋关节置换成功的关键。     

Results of Tönnis-type acetabuloplasty in patients with developmental hip dysplasia

AimThe aim of this prospective study was to evaluate the outcome of open reduction and Tönnis acetabuloplasty as the first method of treating developmental dysplasia of the hip (DDH) in children in early childhood at walking age.Materials and methodsBetween 2005 and 2009, 34 hips of 34 children were operated on with the aforementioned method. Mean age was 25.6 (range 12–44) months, and mean follow-up was 3.6 years. During the follow-up period,the hips were evaluated using the acetabular index and for development of avascular necrosis and redislocation. Functional evaluation was also conducted.ResultsClinically, 97.3 % of patients had excellent and good results. The acetabular angle decreased from 45° preoperatively to 21° early postoperatively and at the last follow-up had improved to 18°. In two hips, type 2 avascular necrosis developed. Hip instability was not observed, and no additional surgery was performed.ConclusionTönnis acetabuloplasty is a powerful tool to increase primary stability of the hip when acetabular coverage is inadequate in DDH. Besides its acute correction ability, when performed properly, it has no unwanted effects on acetabular growth. As an isolated procedure or as a part of combined open reduction and/or femoral osteotomy, Tönnis type acetabuloplasty is a safe and effective method.     

Fracture of the astragalus in pediatric patients,an unusual entity

Introduction and importanceThe fracture of the astragalus is an unusual bone fracture (Ladero and Concejero, 2004) and is even more unusual in pediatric patients. The astragalus is a bone surrounded by cartilage and other structures making it difficult to appreciate on an X-ray which can lead to misdiagnosis (Ladero and Concejero, 2004; Inal and Inal, 2014) and could lead to not applying the right treatment and risk avascular necrosis or other sequelae.Case presentation3-year-old male with foot pain and edema+++, unable to walk or stand up since a fall 2 days before, had a doubtful diagnosis after an x-ray showed no apparent bone injury. A CT scan confirmed astragulus fracture; it was then treated adequately, thus avoiding complications that could have occurred had the fracture not been diagnosed and treated correctly.Clinical findings and interventions and outcomeThe limb was immobilized with a suropodalic cast for 5 weeks. No surgery was performed because of the patient's age and because the fracture was not displaced (Hawkins type 1) (Jasqui-Remba and Rodriguez-Corlay, 2016; Urrutia et al., 1999).Relevance and impactThere is a risk of misdiagnosis in these cases since the astragulus fracture might not show up in an X-ray, as in the case presented. A CT scan can detect the fracture and thus help consolidate the bone correctly. The correct differential diagnosis also reduces the risk of avascular necrosis, which increases due to poor blood supply to the astragalus.     

Outcome and revision rate of uncemented humeral head resurfacing: Mid-term follow-up study

BACKGROUNDGlenohumeral osteoarthritis (OA) is a common cause of pain and disability affecting nearly a third of the world’s population over 60 years of age. As in other joints, shoulder arthroplasty appears to be the most effective treatment. The implant design has evolved during time transitioning to shorter humeral stem lengths or even stemless components.AIMTo evaluate the medium-term outcome and survival of a cementless humeral head resurfacing (HHR) in a group of patients affected with OA or avascular necrosis.METHODSThis is a retrospective study of prospectively collected data using HHR in 23 patients (15 female and 8 male) after a 7.4 year follow-up. The collected data included clinical and radiographical evaluation. The Constant score, the visual analogue scale, and a clinical evaluation of range of motion were registered pre- and postoperatively. Fifteen patients affected with OA (2 cases of mild, 6 moderate, and 7 severe) and 10 with avascular necrosis (stage III according to Cruess classification) were enrolled. X-rays were evaluated to detect loosening signs, degenerative changes, and superior humeral head migration. Magnetic resonance preoperatively was also performed to assess the rotator cuff status. Tendon integrity was mandatory to implant the HHR.RESULTSIn total, 19 patients (21 shoulders) completed the follow-up. Data on 4 shoulders, in 4 patients, were lost because of prosthesis failure. The global revision rate was 16%. A statistically significant improvement in the mean Constant score, visual analogue scale, and range of motion have been reported. No signs of loosening were registered, while in 12 cases a glenoid erosion was found. The osteophytes appeared 7 times on the humeral side and 12 on the glenoid. Superior humeral migration was recorded in only 1 case.CONCLUSIONHHR remains a reasonable option in patients with an intact rotator cuff for the treatment of OA and avascular necrosis.