Purpose of the study: Brodie abscess is a purulent collection in the centre of a bone separated in its typical form from soft tissue by an impermeable barrier of compact bone tissue. This “trapped” collection causes a clinical syndrome of pain and infection. Lat diagnosis is frequent after the symptoms have evolved over months or years. The purpose of our work was to illustrate the misleading features of this bone infection using a series of 11 periarticular localisations of Brodie abscess.

Material and methods: Our study included ten patients, mean age 18 years, who were treated over a period of six years. One patient had a double localisation. The main foci were the distal femur (n=4) and the upper tibia (n=4). There was one case involving the lower tibia, on in the olecranon and one in an iliac bone. The clinical course was greater than one year in three patients, and greater than one month in four others. The clinical presentation was a septic arthritis of the knee joint in three patients and of the hip in one, with rupture of the abscess into the soft tissues in three cases and a central intra-osseous collection in four. Biological features of infection were present in all patients. Imaging (x-ray, CT) showed a bone defect in the metaphyseal or metaphyseal epiphyseal region in all cases with condensed contours and a fistulous tract to a joint or soft tissue. Surgical treatment was proposed in all cases to treat the causal lesion by saucerisation and drainage of the intra-osseous abscess. The defect was filled with an autologous graft in one case and by cement in another. The germ identified in 70% of the cases was a Staphylococcus aureus. Adapted antibiotics were delivered for eight weeks on average.

Results: One patient had a secondary fistula which developed early after excision of a central abscess of the proximal tibia; dry drainage was achieved after cover with a medial gastrocnemian flap. At mean 27 months follow-up, all lesions have cured without recurrence; blood tests returned to normal. Radiographically, the defect exhibited bone remodelling visible in the absence of surgical filling. Regarding function, there was one stiff knee due to adherence on the extensor system.

Discussion: The Brodie abscess is a form of chronic osteomyelitis. It is a rare condition generally observed in young subjects since the majority of reported cases have occurred during the second decade of life. Clinically, the Brodie abscess can be “cold” with little or no overt expression, or more readily “hot” with a syndrome of acute infection and fistulisation to soft tissue. Fistulisation to a joint can mislead the diagnosis to septic arthritis as occurred in one of our patients who underwent two revisions for septic recurrent arthritis of the knee. Most Brodie abscesses are located in the metaphysic. A double metaphyseal and epiphyseal localisation through the growth plate is rare, resulting from an old septic process with inevitable joint collection as in one of our patients aged ten years. Discovery of a second concomitant localisation can be explained by an insufficient or inadequate treatment of the initial focus as we also observed in one case. The classical radiographic image of a Brodie abscess is observed in only two-thirds of the cases. Computed tomography is highly contributive demonstrating possible infra-radiographic fistulisation to a joint or soft tissue as occurred in most of our patients. The Brodie abscess can also simulate bone tuberculosis, hydatic cyst, or bone tumour. Surgically, we adopted to therapeutic strategies: excision of the infected bone associated or not with a cancellous graft and per primam closure for cold abscesses. We have considered that cold abscesses are generally cause by germs with weak virulence; this attitude enables avoiding superinfection. The second option is excision with dressing with or without secondary cancellous graft after budding used for hot abscesses, especially when complicated by a soft tissue complication. Search for germs in blood cultures and in the excision produce was only positive in half of our cases. Staphylococcus was identified in 90%. A histology examination of the excision specimen should be systematically requested to confirm the diagnosis. Finally, the outcome of a well-treated Brodie abscess is favourable.

Conclusion: Brodie abscess is a rare condition observed in young subjects generally due to Staphylococcus aureus. Cold and hot abscesses can be differentiated by their clinical and therapeutic features. Often misleading, clinical symptoms can be detailed with modern imaging, particularly important when the radiographic aspect is atypical. A biopsy is indispensable to confirm the diagnosis.

Purpose: Fractures involving both the shaft of the femur and the proximal portion of the femur are uncommon. In a meta-analysis of cases reported between 1951 and 1985, Alho recorded 659 cases where a wide range of management strategies were used. We report here a homogeneous series of 17 patients treated with ascending locked anterograde nailing.

Material: This series of 17 patients were young (mean age 36 years). These eleven men and six women were all victims of high-energy trauma; 12 had multiple fractures. The shaft fracture involved the middle third in 15 patients, the lower third in two; the shaft fracture was open in six cases. The proximal fracture was transcervical in nine patients (7 B21, 1 B22, 1 B23) and trochanteric in six (A A32, 1 A31, 2 A12, 2 A33).

Methods: The fracture was reduced under fluorescent guidance on the orthopaedic table in the supine position followed by anterograde nailing with ascending proximal locking in the axis of the neck using a Russel and Taylor reconstruction nail. The osteosynthesis was performed on day 0 in eleven patients, during the first week in three and later in three.

Results: Results are reported for 17 patients. There was one early superficial suppuration which healed favourable after local care. Two shaft fractures exhibited nonunion and were revised to decorticalise the graft. The cervical fracture exhibited early displacement in one patient who underwent revision on day 15; bone healing did not ensue and a total hip arthroplasty was implanted at ten months. All the other fractures healed within three to five months after the first-intention treatment. The long-term follow-up has revealed one case of cephalic necrosis at five years which has required a total hip arthroplasty.

Discussion: These double fractures involving the proximal femur and the shaft of the femur account for 1 to 5% of the femur fractures reported in the literature. They are observed in young victims of high-energy trauma, often associated with other multiple injuries. Diagnosis is not always easy to establish since there may be little or no displacement of the proximal fracture, which may be recognised secondarily after standard nailing (2 out of 17 cases).

The trochanteric fractures are generally easier to diagnose and reduce, and usually heal well. The shaft fractures are more often displaced and readily comminutive, sometimes open, having absorbed the greater part of the trauma energy. These fractures heal like ordinary shaft fractures. Neck fractures are often seen in the lower portion with a vertical fracture line, with or without displacement.

Using a single centromedullary nail for the osteosynthesis of both fractures is an attractive solution. The proximal fracture must however be carefully reduced with percutaneous pins before attempting nail insertion. The postoperative period is generally uneventful. Problems may be encountered if the cervical fracture cannot be perfectly reduced, in which case two separate fixations would be preferable.

Purpose: The purpose of this work was to assess the quality of the bone reconstruction in contact with the long hydroxyapatite-coated locked femoral stem used in a consecutive series of patients undergoing revision total hip arthroplasty (RTHA).

Material and methods: This series of 20 patients underwent RTHA for aseptic loosening (n=15) or septic loosening (n=5) of an AURA prosthesis. Mean age was 70.5 years. Mean time between insertion of the first stem and revision was 11 years for the aseptic patients and 2.6 years for the septic patients. Bony lesions of the femur were assessed with the SOFCOT classification: grade I=5, grade II=4, grade III=4, and grade IV=1. A transfemoral approach with a floating femoral segment was used in 14 patients and an endofemoral approach in six. The septic loosenings were reconstructed in two operative times in four patients and in one operation in one patient. An AURA reconstruction stem was used in 15 cases and a revision stem in five. A complementary cancellous bone graft with the endofemoral approach was used in six patients.

Results: Two patients died. All others were reviewed at a mean follow-up of 26 months (range 12–46 months) for clinical and radiographic assessment (five patients also had a supplementary scan at more than three years follow-up). We had three dislocations at 15 days with no recurrence and one case of sepsis at three months which cured after wash out and adapted antibiotics. All the femoral segments healed starting on the tenth week. The PMA score improved from 9.1 to 15.66 and the Harris score from 43.5 to 85.5. At last follow-up, all femoral lesions had moved to a lower SOFCOT score. There was a tight contact between the AURA stem and the femur on the last follow-up scan which showed an increase in the cortical index from 1 to 8 cm from the metaphyseal spine of the stem. None of the patients experienced secondary unlocking or required revision for a shorter stem.

Discussion: Revision after femoral failure with bone destruction using a non-cemented hydroxyapatite-coated stem allows immediate prosthetic mechanical stability and intimate bone reconstruction in the metaphyseal diaphyseal region. This reconstruction is real even if a graft is not used and appears to be favoured by the femorotomy. Implantation of the long stem is not particularly difficult and can even make the operation easier. Femorotomy has a real advantage, particularly for the revision of septic stems or in the event of difficult explantation.