Background: Osteoarticular disease is the most common complication of brucellosis and has been described in 10–85% of patients. Spondylitis is the most prevalent clinical form, also arthritis, bursitis, tenosynovitis, sacroileitis and osteomyelitis have been also described.

Method: We describe our experience concerning three patients with brucellar prosthetic joint infection in Israel.

Results

Case 1: A 38 year old artist was admitted for revision of total hip replacement due to increased pain accompanied by loosening of the prosthesis. Four years prior admission total hip arthroplasty was performed due to psoriatic arthritis treated by methotrexate. Revision surgery demonstrated necrotic tissue which grew Brucella melitensis. Doxycycline and rifampicin were administered for 12 weeks. Second stage revision was performed on the 6th week of antibiotic therapy with favorable results.

Case 2: A 62 year old Arab male underwent right total knee arthroplasty 4 years prior admission due to osteoarthritis. Past medical history included hip arthritis. A second TKA was performed due to septic arthritis caused by Staphylococcus epidermidis and Acinetobacter baumanii. The first stage of the arthroplasty grew Brucella melitensis.

Antibiotic treatment and second stage revision surgery were followed successfully.

Case 3: A 67 year old Arab male was admitted due to fever, right pelvic and back pain lasting for 6 weeks. Five years prior admission the patient underwent left total knee arthroplasty. Computerized tomography was normal. Following admission severe left knee pain developed. Joint aspirate grew Brucella melitensis. Antibiotic treatment and two stages revision surgery were performed successfully.

In all three cases consumption of unpasteurized dairy products was documented. All three patients had serum brucella antibody titer of 1:1600.

Conclusion: Brucella melitensis should be added to the differential diagnosis of prosthetic joint infection, mainly in the Mediterranean basin and the Arabian Gulf. Only two other cases of brucella prosthetic joint infections were reported involving prosthetic knees.

Background: Osteoporotic tibial fractures may be a challenge both in diagnosis and treatment. The aim of treatment is obtaining joint congruity and normal alignment, joint stability, adequate soft tissue healing and functional range of motion. The goal is prevention of degenerative osteoarthritis. In the majority of cases the treatment of tibial plateau fractures consists of open reduction and internal fixation.

Objectives: The presentation of two aspects of the osteoporotic fracture – the insufficiency fracture and fixation of the fractures by a more appropriate method.

Patients: We present our experience with 7 cases treated during the past 2 years. Two of these cases presented with no story of trauma, normal X-rays and were diagnosed clinically and on CT and bone scanning. The other 5 cases resulted of minor trauma and operative treatment was in order, using a modified fixation technique – a small fragment plate.

Results: The patients suffering from fractures with normal X-rays suffered from insufficiency fractures and were treated conservatively. The patients suffering from depressed, split or comminuted fractures were treated by open reduction and internal fixation with a small fragment plate.

Discussion and Conclusion: Insufficiency fractures often are misdiagnosed as exacerbation of chronic metabolic or inflammatory diseases and a fracture is not suspected until intense augmentation of radionuclide is seen on bone scan. Screening of patients presenting wit non-traumatic knee pain has shown a prevalence insufficiency fractures of the tibial plateau between 3 to 8% of the cases. These cases may be much more common than we commonly presume.

The fractures in need of reduction and fixation of the plateau fracture involve raising the depressed articular fragment, the possible addition of bone graft augmentation and buttressing of the osteochondral fragment with a plate. These buttress plates may hold the cortical rim of the plateau but many times fail in maintaining the reduction of the intra-articular surface of the plateau. This again results in degenerative changes in the joint and pain.

Internal fixation of these fractures with small fragment plates may be a solution to this problem, as demonstrated by the 5 presented cases treated operatively. The plates are smaller in size and are held by more screws, which are more proximal to the articular surface. This way they allow better control and maintenance of the anatomic reduction and in combination with an a-traumatic dissection and less stress shielding effect, result in a low rate of local complications.

We report four patients with unilateral postpartum sacroiliitis presenting with agonising unilateral pain, an elevated ESR, elevated alkaline phosphatase levels, leucocytosis and positive bone scans. The diagnosis of a non-infectious inflammatory cause was supported by the postpartum onset, the response to non-steroidal anti-inflammatory drugs, negative aspiration cultures in two cases and the lack of changes in the sacroiliac joints on long-term follow-up radiographs.

Four cases of osteomyelitis of the pelvis are reported to demonstrate the several clinical syndromes to which this disease can give rise. Extensive surgical drainage and antibiotic treatment led to recovery in all cases.

A consecutive series is reported of 17 patients who underwent early surgical treatment for acetabular or unstable pelvic fractures associated with ipsilateral fractures of the femur. Treatment included external and internal fixation, and required careful consideration of the surgical approach and the positioning of the patient. The multiple injuries sustained by these patients required simultaneous procedures by several surgical teams. All the femoral fractures were internally fixed at the initial operation and eight patients had primary definitive treatment of all their other fractures as well. In nine patients the definitive treatment of their other fractures was delayed for an average of 11 days. There were no deaths, and no serious infections. The long-term morbidity resulted from the associated injuries and not from the pelvic or femoral fractures.

We report two cases of Serratia marcescens infection at the sites of spinal fractures and emphasise the fact that neurological deterioration soon after spinal fracture may be due to acute vertebral osteomyelitis.