Bilateral Gluteus Maximus Contracture in a Young Child: A Case Report and Review of Literature.

INTRODUCTION: Gluteus maximus contractures are uncommon in India. Only a few cases of this disease are reported in the Indian population. Common etiologies include congenital, post-injection, traumatic, and neuromuscular disorders. We report a case of bilateral isolated gluteus maximus muscle contracture due to repeated intramuscular injection. CASE REPORT: A 9-year-old male child from a village of North India presented to outpatient with difficulty in sitting cross-legged and squatting for the past 6-7 years. After clinical examination and relevant investigation, he was diagnosed as having bilateral isolated gluteus maximus contractures. He was treated with open release of contractures on both sides followed by physiotherapy. He was followed for 1 year and there was a significant improvement in his clinical symptoms and quality of life. CONCLUSION: Gluteus maximus muscle contractures can easily be diagnosed on clinical examination. Patients present with characteristic clinical symptoms which should not be missed. Plain radiographs are usually normal. Magnetic resonance imaging findings typically show fibrotic bands and gluteal atrophy. Surgical release of contracture followed by gradual physiotherapy shows remarkable improvement in symptoms and quality of life for the patient.

An unusual Pattern of Flexor Digitorum Profundus Avulsion Injury with a Large Extra-articular Bony Fragment.

INTRODUCTION: Avulsion injury of the flexor digitorum profundus (FDP) tendon, commonly known as jersey finger, is seen in contact sports players such as rugby and football. There are mainly three patterns of this type of injury as mentioned in the Leddy and Packer classification on the basis of the level of retraction of the tendon. Subsequently, a Type IV injury was added by Smith, where the tendon was also separated from the avulsed bony fragment. It is the level of tendon retraction and the status of the long and the short vincula post-injury that determines the outcome of repair in these types of injuries. CASE REPORT: Here, we report an unusual case of jersey finger injury in a 45-year-old male patient, where the FDP tendon was found in front of the middle phalanx with a large, fractured fragment of the middle third of the distal phalanx attached to it. This type of injury pattern has not been acknowledged in the commonly used classification systems. The patient was operated with open reduction and K-wire fixation of the bony fragment with a good functional outcome. CONCLUSION: While treating the cases of jersey finger injuries in sports players and general population, one should be aware of such rare patterns which can then be easily managed with proper pre-operative planning.

Evaluation of modified Ponseti technique in treatment of complex clubfeet.

BACKGROUND: Complex clubfoot does not respond to ponseti method. In 2006 Ponseti et al published the results of treatment of such complex club foot by modified ponseti technique, since then it has become standard method of treatment for complex clubfoot. There has been only few published result of this method and hence, here we are evaluating our experience with 16 patients (27 clubfeet) with complex clubfeet treated at our center by modified ponseti method. METHOD: Parents of patient fulfilling the criteria for complex clubfoot were consented and registered under the study. Pirani score at presentation, at prescription of foot abduction brace and at final follow up was noted. total number of casts required for desired correction, number of cast before and after tenotomy, need of tendoachilles tenotomy, relapse and complications were documented. RESULT: Average follow up duration was 14.762 months (Range 6 month to 22 months). Of the total 16 patients 11 had bilateral complex clubfoot and 5 had unilateral complex clubfoot, the mean pirani score at the time of presentation was 5.5741 (range 4.5-6), Mean pirani score at latest follow up was 0.0556. Average no. of casts required for the complete correction with modified ponseti method was 7.44 (ranging from 6 to 10 casts). All 27 feet (100%) required tendo achillies tenotomy. Percutaneous tenotomy was done in 19 feet while 8 feet required Mini-Open tenotomy (due to thick pad of fat tendon was not palpable). Relapse rate was 11.11% (3 feet) [all had relapse of equinus, fore foot adduction treated by remanipulation by modified ponseti technique, retenotomy and casting]. An excellent result was achieved with at final follow-up in all 27 feet. CONCLUSION: In our experience modified ponseti technique for treatment of complex clubfoot is a successful method of treatment if aided with tendoachilles tenotomy, also it has reduced the requirement of surgical intervention in such patients.Level of Evidence - Level IV.

Results of Supracondylar "V" Osteotomy for the Correction of Genu Valgum Deformity.

BACKGROUND: Medial close wedge, lateral open wedge, dome and "V" osteotomies are the commonly to correct the genu valgum (GV) deformity. However, the ideal method for the correction of coronal plane deformity is controversial. This prospective study is to evaluate the functional and radiological result of supracodylar "V" osteotomy to correct GV deformity. MATERIALS AND METHODS: "V" osteotomy was done in all patients with clinically significant GV deformity and was fixed with crossed K-wires. Weight-bearing mobilization was started after radiological union. Patients were evaluated for correction in different clinical and radiological parameters. The function of the knee was assessed by Bostman's score. The subjective score was used to assess the parent's satisfaction after the procedure. RESULTS: 187 limbs with genu valgum deformity (47 males and 71 females) were included in this study. We observed a significant improvement in the mean intermalleolar distance, clinical and radiological tibiofemoral angle and lateral distal femoral angle, from 17.3 to 3.9 cm, 23.8°to-4.5°, 25.6° to 6.1°, 76.6° to 88.4°, respectively. The mean Bostman score improved from 20.6 to 28.1. The parent's satisfaction assessed subjectively was 95.3 points. CONCLUSION: This osteotomy along with the fixation with K-wires is a safe, effective, reproducible technique with a short learning curve and a procedure requiring no repeat surgery for implant removal, with good functional results, and without major complications.

Closed Reduction, Osteotomy, and Fibular Graft Are Effective in Treating Pediatric Femoral Neck Pseudarthrosis After Infection.

BACKGROUND: When treatment of acute septic arthritis of the hip is delayed, severe sequelae can occur. This may take the form of coxa breva, vara, or valga. Pseudoarthrosis of the femoral neck is a rare complication with only a few studies to guide treatment. QUESTION/PURPOSES: In a small series of patients with pseudarthrosis of the femoral neck after acute septic arthritis, we wanted to determine (1) whether femoral neck union can be achieved using a variety of surgical approaches; (2) whether these patients satisfied criteria outlined by Hunka and Choi, defined as a stable hip, a flexion arc ≥ 70° and no fixed adduction or abduction contractures, fixed flexion deformity not more than 20°, pain relief, and restoration of activities of daily living after surgery; and (3) any treatment-related complications if observed. METHODS: We reviewed the charts of patients who had presented to the orthopaedics outpatient department at Lady Hardinge Medical College and Associated Hospitals with the diagnosis sequelae of septic arthritis of the hip. Between 2003 and 2014, a total of 54 pediatric patients (61 hips) with sequelae of a septic hip had undergone various hip reconstructive procedures. Of these, 16 patients (30%) were diagnosed with pseudarthrosis of the femoral neck and were included in this study. All patients with this diagnosis were treated surgically. In this group, the median age at first contact with our treating team was 48 months (range, 18-96 months). The age of onset of the initial infection was 0.3 months to 84 months (median, 8 months). These 16 patients underwent a total of 24 surgical procedures to achieve union at the pseudoarthrosis site. We performed close reduction, fibula graft, and valgus osteotomy in most of the patients. Wagner's double intertrochantric osteotomy with a fibula graft was done in patients in whom there was a short femoral neck along with pseudoarthrosis. In all patients, the pseudarthrosis site was not exposed. Median followup was 6 years (range, 3-12 years). No patient was lost to followup before 3 years. Union was defined when there was complete radiologic healing at the pseudoarthrosis site. All the patients were clinically evaluated as per Choi's criteria. Parents were also asked about daily activities and pain. Other related complications were also recorded. RESULTS: Fifteen of 16 patients achieved union at the pseudarthrosis site within 6 to 24 months (median, 9 months). Ten patients underwent a single procedure to achieve union, whereas four patients underwent two surgical procedures and two patients underwent three procedures. Fifteen patients achieved Choi's criteria and one patient could not achieve this. While attempting this reconstruction, complications occurred in the form of deep infection and avascular necrosis. CONCLUSIONS: Surgical reconstruction of pseudarthrosis of the femoral neck after pyarthrosis of the hip is difficult, but a successful result may be possible in many patients. Every effort should be made to achieve pseudarthrosis repair while the femoral head remains viable on radiographs. Once union is achieved, clinical function and hip stability improve. At early followup, many patients have adequate ROM with minimal pain, an acceptable limp, and are able to do indoor and outdoor activities without support. Long-term results are unknown, and we caution that treating the sequelae of childhood hip disease is challenging. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Genochondromatosis type I: A clinicoradiological study of four family members.

Genochondromatosis is an extremely rare autosomal dominant disorder, which manifests during childhood and tends to regress in adult life. The bony lesions are symmetrically distributed with characteristic localization at the metaphysis of proximal humerus and distal femur. Two types have been described based on the involvement of clavicle. Usually asymptomatic, sometimes patients may present with pathological fractures. In this communication, we describe four members of a family with Genochondromatosis type I, with some additional clinical and radiological findings not reported previously.

Transient osteoporosis of the hip in a non-pregnant woman.

Transient osteoporosis of the hip is a rare, self-limiting condition, occurring most commonly in middle-aged men, but also sometimes in women, usually in late pregnancy. It is characterised by gradual onset of hip pain aggravated by weight bearing without any associated history of trauma and systemic illness. It is usually of unknown aetiology, but pregnancy is a recognised risk factor for women. Other conditions that can mimic transient osteoporosis of the hip on MRI are osteonecrosis, osteomyelitis and neoplasms. We present a case of a 38-year-old non-pregnant woman with transient osteoporosis of the hip, managed conservatively, leading to a full recovery. Treatment is conservative, including protected weight bearing, physical therapy and non-steroidal analgesics. The patient was completely painless and symptom free at 2-year follow-up.

Comparative study of complete subtalar release and Joshi's external stabilization system in the management of neglected and resistant idiopathic clubfoot.

BACKGROUND: Various procedures have been used for the management of neglected and resistant clubfoot. The aim of our study was to assess the clinical and radiological correction by Joshi's external stabilization system (JESS fixator) and Simons subtalar release in resistant and neglected idiopathic congenital talipes equinovarus in children between the ages of 1 and 2 years. METHODS: A total of 50 resistant and neglected clubfeet were randomly divided into two equal groups of 25 feet each. Group I was treated with JESS fixator and group II was treated with complete subtalar release as described by Simons. Assessment of correction achieved was done both clinically and radiologically. Functional outcome was assessed with Ponseti scale. RESULTS: The change in clinical deformity and radiological correction of deformity were statistically significant within each group, but not significant when compared to each other. In group I excellent results were obtained in 17 (68%) and good in 8 (32%) of the feet. In group II, excellent results were found in 16 (64%) and good in 9 (36%) feet out of the 25 feet. Pin-site infections were seen in two cases in group I and serious skin problems occurred in two feet in group II. CONCLUSION: We conclude that there were no statistical significant differences between the outcomes of the two techniques in this short-term follow-up of 2.4 years. Thus, functional distraction using JESS can be utilized as an alternative method in cases of neglected and resistant clubfoot.

Bilateral asymmetric dislocations of hip joints: an unusual mechanism of injury.

Asymmetric bilateral dislocations of the hips are rare injuries. Among the small number of reports in the literature, most have attributed the cause to high-velocity motor crashes. These dislocations are often seen to be associated with fractures of the proximal femur or the acetabulum. We present a case of a 45-year-old man with bilateral asymmetric dislocation of hips which were purely ligamentous in nature, without any fracture. He sustained his injuries due to a fall while getting on a moving bus. It was an unusual mechanism of injury as compared to the other cases of asymmetric hip dislocations reported in published studies. Both hips were reduced under general anaesthesia within three hours of the trauma. Skin traction and non-weight-bearing rehabilitation were continued for six weeks. After 35 months of followup, the patient remains asymptomatic. Early diagnosis and timely reduction of such dislocations under anaesthesia are necessary for prevention of complications.

One-stage osteotomy and fixation using a long proximal femoral nail and fibular graft to correct a severe shepherd's crook deformity in a patient with fibrous dysplasia: a case report.

We report a case where a one-stage osteotomy and fixation, using a long proximal femoral nail and fibular graft, was performed to correct a severe shepherd's crook deformity (70-degree varus and 50-degree retroversion) of the femoral neck with a pathological stress fracture in a patient with fibrous dysplasia. The neck shaft angle was corrected to 125 degrees. At the 57-month follow-up, the patient was free of pain and had no limp or evidence of recurrence.

Neglected, open, multiple carpal-metacarpal fracture dislocations of the hand--an unusual entity and its management.

A rare case of neglected, open, multiple carpal-metacarpal fracture dislocations complicated by wound infection, soft-tissue contractures, and Sudeck's dystrophy is reported. Satisfactory cosmetic and functional results at 2 years were achieved with staged distraction using Ilizarov's fixator to stretch soft tissues and gain length, followed by open reduction and internal fixation.