Introducción: los síntomas, signos y hallazgos imagenológicos e histológicos del quiste óseo aneurismático (QOA) y el osteosarcoma telangiectásico (OT) son similares, por lo que constituyen uno de los diagnósticos diferenciales más difíciles de establecer. Presentación del caso: mujer de 19 años que asistió al servicio de urgencias de un hospital de cuarto nivel de atención en Bogotá por dolor en la cadera izquierda, donde se identificó lesión lítica en el cuello del fémur y se remitió a consulta externa. Tres días después, la paciente regresó al servicio de urgencias por dolor en la cadera izquierda e incapacidad funcional. Mediante radiografía y resonancia magnética, se identificó fractura transcervical de la cadera en el lugar de la lesión lítica, por lo que se sospechó la presencia de QOA u OT. La paciente fue llevada a cirugía y se realizó biopsia por congelación, confirmando el diagnóstico de QOA; por lo tanto, se realizó curetaje y fresado de la lesión, reducción y fijación de la fractura con sistema DHS (dynamic hip screw), y aplicación de injerto y cemento óseo. Cuatro días después del procedimiento, la paciente fue dada de alta. En el seguimiento a los ocho meses, se evidenció recuperación completa de la funcionalidad de la cadera y ausencia de dolor. Conclusión: en pacientes en los que hay una alta sospecha de este tipo de lesiones óseas, es importante realizar un estudio histopatológico para confirmar el diagnóstico de QOA u OT, e instaurar un tratamiento adecuado y oportuno, que sin duda contribuirá a un mejor pronóstico, particularmente en términos de supervivencia.
Category: Midfoot/Forefoot; Basic Sciences/Biologics; Trauma; Other Introduction/Purpose: Septic arthritis is an emergent medical condition. Bacteria, especially Staphylococcus aureus and Streptococcus species, most commonly cause it. There is an increased risk of Septic Arthritis in patients on immunosuppressive therapy and with underlying joint disease. We present a case of right foot septic arthritis in an at-risk patient with a history of rheumatoid arthritis on etanercept therapy by the rare pathogen: Mycobacterium fortuitum. Mycobacterium Fortuitum is an acid- fast bacilli that should be considered in patients with therapy resistant skin and soft tissue infections; however, there have been some reports of progression to osteomyelitis and septic arthritis in prosthetic joints. To our knowledge, this is the first case of septic arthritis in a non-prosthetic joint due to Mycobacterium fortuitum. Methods: A 58-year-old male with history of rheumatoid arthritis on etanercept presented to our clinic for 2 months of right foot pain after a puncture wound from a gardening hoe while in open footwear. The patient was treated at two different health centers where the wound was irrigated and closed. The physical exam displayed a healed dorsolateral wound over the naviculo- cuneiform area, swelling, fluctuance and warmth. An MRI suggested septic arthritis with an abscess confirmed by ultrasound. During surgery, pus was found at the Chopart's, naviculocuneiform and cuboideonavicular joints with drainage to the plantar side. The area was thoroughly irrigated. The patient was discharged with a VAC and a 6-week course of intravenous cefepime. The culture returned positive for Staphylococcus aureus and Mycobacterium fortuitum. Antibiotic was switched to ceftriaxone, doxycycline, and bactrim. After 6 weeks of treatment, the patient returned full weight-bearing with no pain and healed wounds. Results: Septic Arthritis is an orthopedic emergency; the most common cause is Staphylococcus aureus. Mycobacterium fortuitum is a rapidly growing acid-fast bacilli. Infection with M. Fortuitum is caused by bacterial colonization following drug injection, mesotherapy, surgical procedures, trauma, or domestic animal bites. It usually causes skin and soft tissue infections and can disseminate to the respiratory system. While there are multiple publications indicating that M. fortuitum causes prosthetic joint infection, we did not find any reports of septic arthritis in absence of a prosthesis. In our patient, a puncture wound had introduced the bacteria into many midfoot joints. His immunosuppressive therapy and rheumatoid arthritis history were important risk factors. Patients with history of inflammatory arthropathy have a higher risk of failure after a single surgical debridement. Antibiotic treatment of M. Fortuitum is also challenging because it has been reported to have resistance to several drugs. It is usually susceptible to sulfonamides. Conclusion: Bacterial septic arthritis requires timely diagnosis, drainage, and proper antibiotic treatment to avoid devastating outcomes. The most common cause is Staphylococcus aureus, however, a high index of suspicion should be maintained and other bacterial causes should not be ruled out. Different stains should be done for various organisms in order to choose the proper antibiotic treatment. Careful approach and treatment should always be taken in patients at higher risk of atypical microorganisms.
Syndesmosis disruption alone or accompanying an ankle fracture is a frequent injury addressed by the foot and ankle surgeon. Reduction and fixation are usually performed with the use of implants as a tight rope and/or screw(s). When treating complex articular injuries requiring multiple buttress plates, the ability to enhance fixation with syndesmotic implants can be difficult in the presence of other hardware. We propose a technique using an anterior cruciate ligament targeting drill guide to precisely place syndesmotic fixation across both plates to achieve the ideal construct for stability. In this case, we used flexible fixation for the syndesmosis.
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