P085 Chronic recurrent multifocal osteomyelitis: about 2 cases

Background Chronic recurrent multifocal osteomyelitis (CRMO) also known as aseptic osteomyelitis is a rare auto-inflammatory disease with an incidence estimated at 4/100 000 population [1]. The aim of our work was to report two cases of CRMO that illustrate challenges in the diagnosis of this rare disease. Method We report the case of two patients diagnosed with CRMO. Clinical, biological and radiological data as well as disease outcomes were described. We also collected data about treatment modalities. Results Two patients aged of 7 and 10 years respectively, without any notable pathological history, presented recurrent episodes multifocal painful swelling of limbs. In the first case, the symptoms concerned the left ankle and knee as well as the left hip, all associated with lameness and an altered general condition, with neither fever nor skin manifestations. In the second case, the swelling involved the right shoulder, right hip and the left ankle. There was no elevated CRP or ESR in any of patients. Immunological status (RF, anti-CCP, AAN) as well as the HLA-B27 antigen test were negative. In the first patient, standard radiographs showed lytic lesions of the proximal metaphysis of the tibia, the greater trochanter and the left lateral malleolus. MRI of the pelvis, knee, and sternum of the first patient revealed edematous involvement of the left greater trochanter, the right ilium, the proximal metaphyseal region of the tibia and the right edge of the sternum, whereas in the second patient, a whole-body MRI showed inflammatory signs over the left greater trochanter, the insertion of the gluteus medius and obturator externus, right trochanteric bursitis and oedema of the entire right ilium. In the first patient, bone scintigraphy showed intense uptake of radioisotopes in the left ilium, the 7 th right costo-vertebral junction, the trochanteric mass, the upper end of the tibia and the lower end of the left fibula. Bone biopsy showed bone remodeling in both cases without evidence of infection or tumor. The diagnosis of CRMO was retained, supported by the prompt response to NSAIDs and short-term corticosteroid therapy. However, the second patient presented, 8 years later, pain in the sterno-clavicular joint as well as the right hip. A relapse of the disease was confirmed by MRI. Therapeutic escalation with zoledronic acid 0.025 mg/kg intravenous infusion every six months allowed the resolution of the symptoms. Conclusion These observations illustrated a rare disorder in children, characterized by lytic lesions predominantly in the metaphysis of long bones. Bone scintigraphy allowed an early assessment of disease extension and histological examination ruled out a malignant tumor and an infection. The first-line treatment is anti-inflammatory drugs. In case of failure, bisphosphonates seem to be effective.

Corrective Intertrochanteric Osteotomy of the Femur for Aseptic Necrosis of the Femoral Head after Bloodless Reduction of Congenital Dislocation in School-Age Children

The immediate results of treatment of 72 children aged 7 to 12 years with aseptic necrosis of the femoral head after bloodless reduction of congenital hip dislocation were analyzed. When treating patients, the following types of surgical treatment were used:extra-articular or open centering of the femoral head with intertrochanteric-torsion-varizing or devarizing and rotational osteotomy of the femur with bringing down the greater trochanter in the caudal direction. In all patients, pain and lameness disappeared, internal rotation of the lower extremities when walking, and the range of motion in the hip joint improved. Improved radiometric parameters characterizing the ratio of the acetabulum and the head of the femur and the angular values of the hip joint and proximal femur.

The radiographic relationship between the cortical overlap view (COV) and the tip of the greater trochanter

For proximal femoral nailing, choosing the proper entry point with the aid of C-arm imaging is crucial. Therefore, obtaining accurate radiological views that facilitate sound identification of the tip of the greater trochanter (GT) is of utmost importance. The aim of this study was to define a radiological view characterised by reproducible radiographic landmarks which will allow the reliable identification of the tip of the GT in the anteroposterior view. Anatomical and radiographic features of 16 cadaveric femurs were analysed. The cortical overlap view (COV), characterised by the radiological overlap of the density line of the piriform fossa and the intertrochanteric crest, was identified. It marks the rotation of the proximal femur at which the GT can be accurately identified and used to determine the desired entry point for a proximal femoral nail. Trainees and fully qualified orthopedic trauma surgeons were asked to identify the correct COV in radiological imaging series. Mean internal rotation of the femur to achieve a COV was 17.5° (range 12.8°–21.8°). In the COV the tip of the GT is the highest visible point and the mean distance from the cortical overlap line to the tip of the GT is 4.45 mm. Intra- and inter-rater reliability was high with ICC(2,k) = 0.932 and ICC(2,k) = 0.987 respectively. Trainees achieved higher rates of correct COV identification than specialists. There was no significant correlation between the internal rotation of the femur to achieve the COV and femoral antetorsion. In conclusion, the COV is a highly reproducible radiological view that is characterised by radiographic landmarks easy to recognise. It allows for accurate identification of the tip of the GT, which can be used by the surgeon as a reference to determine the desired entry point for an intramedullary nail.

A case report on aggressive giant cell tumor of greater trochanter: a divergent site

Background Giant cell tumor is a tumor of benign nature which usually arises in the long bone, but it can also be seen at unusual sites. Only few cases have been reported so far regarding involvement of greater trochanter of the femur as it is a very divergent site for giant cell tumors; our case is one of them. Giant cell tumors are seen in 20–40 years of age in the metaepiphyseal regions of the long bones. If femur has to be involved, it is in the distal end usually. Case presentation We present a case of a 45-year-old female with chief complains of swelling and left hip pain since over a month. Magnetic resonance imaging was done where the location and extent of the tumor was found. What makes this case interesting is that on fine needle aspiration cytology the lesion showed multinucleated giant osteoclasts in the background of osseous matrix of spindle cells suggesting Giant cell tumor. Conclusion It is sometimes tricky to make a diagnosis of these lesions on imaging as the typical features may not be present, and hence, in such circumstances helping the clinicians with additional information like location, extent, margins is of utmost importance.

GREATER TROCHANTERIC FRACTURE IN STABLE INTERTROCHENTRIC FRACTURE

Background : stable intertrochentric femur with displaced greater trochanter is uncommon fracture pattern . intertrochentric femur fractures are associated with high morbidity and mortality , affecting both genders ,with different complexity Case report in our case report we have 75 years old male patient with history of fall sustained intertrochentric femur fracture with displaced greater trochenter treated with fixation of both fracture element Using dynamic hip screw (DHS) with trochentric stabilizing plate (TSP) in addition to tension band fixing the greater trochenter Discussion : different pattern of intertrochentric femur fracture require thorough planing for optimum management .intertrochentric femur fracture with displaced greater trochanter need further research to identify the best management option specially regard of functionality.

Treatment of Unstable Intertrochanteric Fractures in Elderly Patients Using a New Technique of Wire Tension Band Ventral Compression Wiring Combined With Artificial Femoral Head Replacement

Background: This study evaluates the effects of wire tension band ventral compression wiring technology paired with artificial femoral head replacement according to the different types of intertrochanteric fractures of the greater trochanter in elderly patients. Methods: Thirty-eight patients with unstable intertrochanteric fractures of the femur treated with artificial femoral head replacement between January 2015 and August 2019 were included. According to the fracture line of the greater trochanter, a new classification system was proposed. Type A fractures include transverse fractures from the greater trochanter tip to the base (2 patients). Type B fractures include oblique fractures from the greater trochanter tip to the base (according to the fracture line direction, type B was further divided into types B1 [4 patients], and B2 [24 patients]). the fracture line of type C fractures runs from the greater trochanter to near the femur end (8 patients). Different wire tension belt ventral compression wiring technologies were used for each fracture type. The Harris hip function score, Parker activity score, and hip pain were evaluated during the follow-up period. Fracture healing and prosthesis positioning, loosening, and dislocation were evaluated using radiographs. Results: The average follow-up period was 28.6 ± 5.8 months. Deep vein embolism was noted in one patient, heterotopic ossification in another, and steel wire fractures in another. All patients had satisfactory fracture healing and femoral prosthesis positioning and no chronic pain. The mean Harris hip function score was 7.21 ± 2.58 preoperatively and 84.74 ± 3.82 at the final follow-up (F = -48.13, P < 0.001).Conclusion: The use of different wire tension band ventral compression wiring technology based on different types of femoral rotation fractures combined with artificial femoral head replacement in elderly patients with unstable intertrochanteric fractures results in favorable clinical outcomes.