Posterior Cruciate Ligament Agenesis Requiring Surgical Reconstruction.

Agenesis of the posterior cruciate ligament (PCL) is a rare disorder often found in conjunction with various other abnormalities within the knee. A 15-year-old adolescent boy presented with an absent PCL, leading to intermittent symptoms. At the age of 20 years, the patient underwent arthroscopically assisted PCL reconstruction. The patient was permitted to weightbear immediately after the procedure and started physical therapy 4 weeks after the procedure. No complications were encountered at the 2-year follow-up.

A Rare Disease Presentation of Malignant Fungating Acral Melanoma of the Hand.

Malignant melanoma is relatively uncommon and accounts for 1%-3% of all malignant tumors. Malignant melanoma of the hand is exceptionally rare and highly malignant, with rapid progression if left untreated. Early clinical symptoms can be overlooked, and the tumor is often at a late stage when patients seek care, prompting amputation of the affected region. We present a case of a 48-year-old man who presented with a rapidly progressive, large, fungating mass of the distal aspect of the little finger diagnosed as malignant melanoma. We describe the presentation and treatment of this patient, who ultimately underwent partial amputation of the fifth metacarpal. Histologic analysis demonstrated nodular melanoma.

Intraoperative Fluoroscopy Versus Postoperative Radiographs in Assessing Distal Radius Volar Plate Position: Reliability of the Soong Classification.

Purpose: Fluoroscopic imaging remains the standard intraoperative imaging modality for volar locking plate fixation of distal radius fractures, and correlation with postoperative radiographs remains unclear. The purpose of this study was to assess the reliability of the Soong classification system between intraoperative fluoroscopy and postoperative radiographs for distal radius volar plate position. Methods: Eleven hand surgery resident physicians (3 in postgraduate year 2, 2 in postgraduate year 3, 3 in postgraduate year 4, and 3 in postgraduate year 5) and 4 attending physicians classified images using the Soong classification system. Fluoroscopic and radiographic lateral images from 30 patients were randomized and deidentified. Thirty percent of the images were duplicated for intraobserver reliability. Seventy-eight images were randomized and presented to each observer in 1 consecutive session. Cohen kappa values were calculated for intraobserver reliability, and Fleiss kappa values were calculated for interobserver reliability. Results: Intraobserver reliability demonstrated moderate reliability overall. The intraobserver reliability was highest among postgraduate year 4 residents and attending physicians demonstrating substantial reliability. Lateral intraoperative fluoroscopic and postoperative radiographic imaging demonstrated no difference in intraobserver reliability overall. Interobserver reliability was highest among postgraduate year 5 residents demonstrating moderate reliability and attending physicians demonstrating substantial reliability. Conclusions: There was no difference in the intraobserver reliability of the Soong classification system between the lateral images of intraoperative fluoroscopy and postoperative radiographs. Fluoroscopic analysis using the Soong classification system is a reliable method to determine plate prominence and has demonstrated increasing reliability based on year of training. Fluoroscopic analysis using the Soong classification system and direct visualization during surgery for the assessment of plate prominence is recommended, with the understanding that higher Soong grades are associated with increased rates of complications. Type of study/level of evidence: Diagnostic III.

Bilateral Calcaneus Transfers for the Treatment of Congenital Tibial Deficiencies: A Novel Surgical Technique and Case Report.

Tibial deficiency (also known as tibial hemimelia) is a rare condition with variable presentation. A 2-month-old patient presented with absent bilateral tibias. When the patient was 1 year, a novel reconstructive surgery was done. A bilateral fibular resection with pedicled calcaneus transfer was done, allowing for transfer of the calcaneus along with the overlying glabrous skin and soft tissues to the end of the femur. The patient was permitted to weight-bear after the 4-week postoperative follow-up. At the six-month follow-up, the patient was able to pull to stand and walk with assistance without any reports of pain.

Rapid Recovery Pathway for Postoperative Treatment of Adolescent Idiopathic Scoliosis.

INTRODUCTION: Postoperative pain protocols play a critical role in recovery and prognosis. Rapid recovery pathway (RRP) is a novel multimodal postoperative analgesic platform with accelerated rehabilitation. METHODS: A retrospective review of 44 patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion between 2014 and 2016 was conducted. Outcomes of a conventional postoperative pain pathway were compared with patients who received RRP postoperatively. RESULTS: RRP patients had shorter length of stay (3.3 vs 4.4 days, P < 0.0001), duration with Foley (1.4 vs 2.3 days, P = 0.01), and fewer days for physical therapy clearance (2.2 vs 3.5 days, P < 0.0001). Overall pain score for RRP patients was lower (1.6 vs 2.9, P = 0.0005). The number of days with patient-controlled analgesia was shorter (1.7 vs 2.6 days, P = 0.002), and daily pain scores were consistently lower in RRP. Overall narcotic use was not significantly different (P = 1). CONCLUSION: Implementation of a standardized RRP with multimodal pain management and early mobilization strategies resulted in reduced daily and overall pain scores, earlier clearance by physical therapy, decreased length of stay, and patient-controlled analgesia usage, but overall no difference in narcotic consumption. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

A unique case report of a high-pressure paint injection injury of the hand with associated carbapenemase resistant Pseudomonas aeruginosa infection.

High pressure injection injuries to the hand should not be taken lightly as urgent surgical debridement is required to ensure favorable outcomes. Empiric antibiotic administration is recommended; however, few studies focus on the secondary infection risk associated with these high pressure injection injuries. We present a rare case of a patient presenting with carbapenem resistant Pseudomonas aeruginosa following a high pressure paint gun injury of the thumb. Urgent surgical debridement with administration of broad-spectrum antibiotic coverage for both gram-negative and gram-positive bacteria is recommended. The injection of foreign materials can cause extensive tissue damage and immunosuppression facilitating growth of opportunistic bacteria that are often rare in healthy adults. We advocate for obtaining cultures at initial debridement to optimize treatment in these unique and rare injection injuries. Concerns should be raised as carbapenem resistant bacteria become more prevalent in the community.

Metastatic Acetabular Fracture: A Rare Disease Presentation of Recurrent Head and Neck Paraganglioma.

We present a case of a rare metastatic bone lesion of the acetabulum, associated with a pathologic fracture, found to be metastasis from a malignant carotid body paraganglioma upon histological analysis. We present a report of the patient's clinical course following the identification of metastatic disease to the right acetabulum, as well as a review of paragangliomas and their propensity for metastasis.

A Novel Technique for a Successful Closed Reduction of a Bosworth Fracture-Dislocation of the Ankle.

The Bosworth fracture is defined as a bimalleolar fracture-dislocation of the ankle, with entrapment of the fibula behind the posterior tubercle of the distal tibia. In the current orthopedic literature, not only is this fracture pattern rare, but this type of fracture-dislocation has also been reported to be near impossible to close reduce, with the majority requiring early open reduction and internal fixation to prevent complications and poor clinical outcomes. Reported early complications include compartment syndrome and soft tissue complications from repeated closed reduction attempts. Complications associated with delayed operative intervention include post-traumatic adhesive capsulitis of the ankle and ankle stiffness. We present a case study of a 34-year-old male who sustained a Bosworth fracture-dislocation of the right ankle after a skateboarding accident. We describe a successful closed reduction performed in the emergency department, with a novel closed reduction technique. The patient tolerated the procedure well, with no complications. He was then scheduled for open reduction and internal fixation five days afterward, and upon post-operative follow-up, he recovered well with no complications. This technique focuses on reduction forces applied to the proximal fibular fragment, which is entrapped behind the posterolateral portion of the tibia. We believe that the key to successful reduction is applying an anterolateral/internal rotation force to this entrapped fragment. If successful, this fracture pattern may not require admission for compartment checks or early open reduction and internal fixation, thereby preventing complications and poor clinical outcomes. Our technique allows for a successful closed reduction of Bosworth fractures; however, further research exploring this reduction technique is warranted.

Retraction: Is Refracture a Concern Following Closed Management of Tibia Shaft Fractures in Children?

[This retracts the article DOI: 10.7759/cureus.7206.].

Is Refracture a Concern Following Closed Management of Tibia Shaft Fractures in Children?

PURPOSE: Tibia shaft fractures account for 15% of all pediatric fractures. These fractures are often treated nonoperatively with closed reduction and long leg casting. In children treated nonoperatively, refracture can cause significant frustration to both the patient and their family in addition to a delay in resuming normal activities for several months. The purpose of this study was to investigate the rate of refracture of tibia shaft fractures treated nonoperatively at our institution. METHODS: We performed a retrospective chart review of pediatric patients at one institution with the diagnosis of a tibia shaft fracture who were treated nonoperatively between January 1, 2000 and December 31, 2016. Exclusion criteria included those without complete retrievable radiographs or without radiographic confirmation of healed fracture. Patients who sustained a proximal or distal metaphysical tibia fracture or a toddler fracture were also excluded. Additionally, those with less than three months of clinic follow-up or an underlying metabolic bone disease were excluded. Data such as age, sex, body mass index, mechanism of injury, location of fracture, initial displacement, angulation, treatment, length of immobilization, and complications were recorded. The primary outcome for our study was the presence of refracture. Refracture was defined as a repeat fracture of the tibia at the same location within 18 months of the original fracture. RESULTS: A total of 64 patients met the inclusion criteria and were included in the study. Of the 64 patients, only one patient sustained a refracture. The refracture occurred eight months after the initial injury and required operative intervention. This rate of refracture is equated to roughly 1.5%. CONCLUSION: Conservative management of closed tibia shaft fractures with casting is an ideal treatment for pediatric fractures. Conservative management allows for avoidance of surgical intervention and low refracture rates. This study provides support regarding the adequacy of conservative management with limited complications. Although the rate of refracture still exists, patients and families should be counseled that the rate of healing without complications is about 98.5%.

An Uncommon Presentation of an Uncommon Bone Tumor: A Case Study of a Pathologic Fracture of an Intertrochanteric Aneurysmal Bone Cyst.

Aneurysmal bone cyst (ABC) is a benign, destructive lesion characterized by a expansile fluid-filled cystic structure primarily affecting children and young adults. Common treatment modalities include arterial embolization, curette, intralesional injections and en bloc resection with instrumentation placement. We present the case of a 22-year-old patient presenting to the emergency department with an ABC in the intertrochanteric region of the right femur and a minimally displaced pathologic femoral neck fracture. Open biopsy with curettage, bone grafting and cephalomedullary nailing were performed with fracture stabilization and favorable recovery. Reports of these lesions presenting with pathologic fracture are scarce. We discuss treatment modalities and guidelines for ABCs and pathological fractures. Future studies are needed to assess clinical guidelines for the management of ABCs and pathological fractures.