Atypical Presentation of Gouty Tophus as Posterior Cruciate Ligament Cyst: A Case Report.

Introduction: Gouty tophi generally develop around 10 years after the first attack of gout in untreated patients and are commonly found around feet, hands, and elbows. However, tophi can also occur as first sign of disorder. Tophaceous gout presenting in young at the posterior cruciate ligament (PCL) is extremely rare and difficult to diagnose because of its atypical presentation and no hallmark features in magnetic resonance imaging (MRI). Case Report: Here, we report a 25-year-old man manual worker with no prior history of gout has presented with left knee pain and locking episodes for 3 weeks, X-ray shows no abnormality, on advanced imaging with MRI, a well-defined cyst noted adjacent to PCL toward lateral aspect. During arthroscopy, a cyst was seen between anterior cruciate ligament and PCL with the extrusion of chalky paste-like material on puncturing the cyst. The tophus was biopsied and excised arthroscopically with excellent outcome. Conclusion: This case report demonstrates that gout does not only always cause severe joint pain from inflammatory arthritis, but can also cause mechanical pain and locking of joint atypically presenting as intra-articular tophi. Hence, gout should also be considered in differential diagnosis of intra-articular cyst. Arthroscopic removal and continuous urate-lowering therapy provide excellent outcomes for such atypical presentations.

A Rare Case of Neglected Traumatic Anterior Dislocation of Hip in a Child.

INTRODUCTION: Post traumatic hip dislocations are very rare in children. Neglected anterior hip dislocations in children are not described in literature so far. Here, we present a case of 6 weeks old anterior hip dislocation successfully managed by open reduction. CASE PRESENTATION: A 9-year-old male child presented with neglected anterior hip dislocation on left side. Open reduction carried out through direct anterior approach to hip. Congruent reduction is achieved. At final follow up of 1 year, the child had unrestricted activities of daily living and no radiological signs of osteonecrosis or any joint space reduction. CONCLUSION: There is paucity of literature over neglected post traumatic anterior hip dislocations in children. The treatment options vary from closed reduction after heavy traction to sub trochanteric osteotomy. However, we feel that open reduction through direct anterior approach is the preferred mode of management whenever considered possible.

Undiagnosed Hoffa fracture of medial femoral condyle presenting as chronic pain in a post-polio limb.

Isolated coronal fracture of medial femoral condyle with intact lateral femoral condyle is extremely rare. A high index of suspicion is necessary for early diagnosis especially in cases of undisplaced fractures. Here we report a case of medial Hoffa fracture in a post-polio limb presenting as chronic pain. Management of such fractures in limbs affected by late sequelae of poliomyelitis is particularly problematic in view of osteoporosis and osseous hypoplasia. The fracture was approached through medial parapatellar arthrotomy and fixation was done with cannulated cancellous screws in anteroposterior direction. Union was achieved at 16 weeks.

Coronal fractures of the medial femoral condyle: a series of 6 cases and review of literature.

Isolated coronal fracture of medial femoral condyle with intact lateral femoral condyle is extremely rare. We present our experience with such 6 cases of coronal fractures of medial femoral condyle. We reviewed all case records of cases of coronal fractures of femoral condyle which presented to our centre from Jan 2000 to Jun 2009. Of 72 such cases, 56 were of lateral condyle, 9 were bicondylar, and 7 were only medial femoral condyle fractures. However, one of the 7 cases was a skeletally immature child with a physeal injury and hence excluded. All the 6 patients with medial femoral condyle fractures were retrospectively evaluated both clinically and radiologically. Of the 6 patients with medial condyle fractures, three patients had an isolated medial femoral condyle fracture, while three of them had associated fractures. Four of these patients were identified at the initial presentation. However, the fracture was missed during initial evaluation in one of the patients, while another patient presented with neglected medial Hoffa fracture after 6 months of injury. Mechanism of injury was direct impact to the medial side of knee in flexion in 4 out of 6 cases. All cases were operated through medial or antero-medial approach, and fixation was achieved in all with antero-posterior screws. All cases united at a mean period of 4.6 months. Coronal fractures of the medial femoral condyle are very rare, and there is a highly likelihood of these fractures being missed by an average orthopaedic surgeon. A high index of suspicion is necessary for early diagnosis especially in cases of undisplaced fractures. Being intra-articular, the ideal management includes open reduction and internal fixation. Medial or antero-medial approach with antero-posterior screws is the preferred method for fixation.

Salvage of infected total knee arthroplasty with Ilizarov external fixator.

BACKGROUND: Knee arthrodesis may be the only option of treatment in cases of chronic infected total knee arthroplasty (TKA) with concomitant irreparable extensor mechanism disruption, extensive bone loss or severe systemic morbidities. Circular external fixation offers possible progressive adjustment to stimulate the bony fusion and to make corrections in alignment. We evaluated the results of knee arthrodesis with one or two stage circular external fixator for infected TKA. MATERIALS AND METHODS: 16 cases of femoro-tibial fusion were retrospectively evaluated. Male-to-female ratio was 10:6. Mean age of the patients was 62.2 years. Cierney-Mader classification was used for anatomical and physiological evaluation while the bone stock deficiency was classified into mild, moderate and severe. Surgical technique involved either single or two stage arthrodesis using circular external fixator. RESULTS: Union was achieved in 15 patients (93.75%). The mean duration for union (frame application time) in these patients was 28.33 weeks (range 22 to 36 weeks). Analysis showed that in the group with frame application time of less than 28 weeks, the incidence of mild to moderate bone deficiency was 83.33%, while in the frame application time more than 28 weeks group the incidence was 20% (P-value 0.034). Similarly the incidence of Cierney-Mader 4B (Bl, Bs, Bls) was found to be 33.33% in the group of frame application time of less than 28 weeks, while it was 90% in the group with frame application time more than 28 weeks (P-value 0.035). CONCLUSION: Circular external fixator is a safe and reliable method to achieve knee arthrodesis in cases of deep infection following TKA. Severe bone stock deficiency and Cierney- Mader type B host are likely risk factors for prolonged frame application time. We recommend a two-stage procedure especially when there is compromised host or severe bone loss.

Isolated Hoffa fracture of the medial femoral condyle in a skeletally immature patient.

Intraarticular coronal fracture of the femoral condyle is rare, and an isolated medial Hoffa fracture in a child is extremely rare. To our knowledge, such a case has not yet been reported in the literature. Early diagnosis and prompt treatment are essential for a good long-term outcome. We report a case of 12-year-old male who suffered a traffic accident and sustained an isolated medial Hoffa fracture. Open reduction was performed using a subvastus approach and the joint surface congruity restored and secured by two large fragment partially threaded screws placed from anterior to posterior in the epiphysis. At the 36-month follow-up, the fracture was united, and the patient had full extension and approximately 130° flexion of knee. There was no varus or valgus instability or limb length discrepancy. This case highlights the importance of early diagnosis and prompt treatment in the form of epiphyseal fixation for the management of these fractures in skeletally immature individuals.

A rare case of bicondylar Hoffa fracture associated with ipsilateral tibial spine avulsion and extensor mechanism disruption.

Intra-articular coronal fractures (Hoffas fractures) of distal femur are rare. Although bicondylar involvement in these fractures has been reported in the literature in association with high velocity traumata, the occurrence of these fractures involving extensor mechanism rupture and avulsion of ipsilateral tibial spine is extremely rare. To our acquaintance, such a fracture pattern has not yet been reported in the literature so far. In this article, we report one such case and discuss the importance of early diagnosis and prompt internal fixation in the management of such cases.We believe that these rare combinations of injuries should be treated aggressively by early open reduction and anatomic rigid internal fixation in order to achieve good recovery of function.

Are both the knees of the same size? Analysis of component asymmetry in 289 bilateral knee arthroplasties.

BACKGROUND: Variations in the anatomy of knee are well described, however the true incidence of component asymmetry in bilateral total knee arthroplsties is rarely reported. Incidence of component asymmetry in bilateral total knee arthroplasties (TKA) was retrospectively analysed in 289 cruciate retaining total knee arthroplasties. MATERIALS AND METHODS: Medical records of these 289 patients were evaluated for the incidence of asymmetry of either femoral or tibial components. Clinical outcomes were compared between the cases of asymetrical components to that of symmetrical components. RESULTS: Incidence of femoral component asymmetry was found to be 9.2% and tibial component asymmetry to be 8.7%. Of 289 cases, TKA 178 were done in a single day (group A), while 111 were done at 2- to 3-day intervals (group B). Asymmetric and symmetric knees were equally distributed among both groups, male and female patients in both groups, and the incidence of component asymmetry was similar between all four different implants - Optetrak-CR (Exactech, Gainesville, FL, USA), Nexgen-CR (Zimmer, Warsaw, IN, USA), PFC-Sigma CR (DePuy, Warsaw, IN, USA), Genesis II CR (Smith and Nephew, Memphis, TN, USA) we used. The pre- and postoperative range of motion and pre- and postoperative knee society scores were compared between the symmetric and asymmetric cases in both the groups and the difference was found to be insignificant. CONCLUSION: We conclude that incidence of component asymmetry in bilateral total knee arthroplasty is around 9 % and independent sizing of both knees during bilateral arthoplasty is recommended rather than simply relying on the contralateral knee measurements.

Management of idiopathic clubfoot by the Ponseti technique: our experience at a tertiary referral centre.

BACKGROUND: Clubfoot or congenital talipes equinovarus is a common congenital abnormality of uncertain etiology. The purpose of this study was to assess the results of the Ponseti method in India and to investigate the demography of relapse and resistant cases. METHODS: A total of 86 children (146 feet) below 1 year of age who had presented to the paediatric orthopedic outpatient department of our institution between June 2003 and January 2007 with unilateral or bilateral idiopathic clubfoot deformity were included in our study and treated conservatively by use of the Ponseti technique. RESULTS: 128 feet responded to the Ponseti casting technique initially and 18 feet were resistant to the conservative treatment. Of the responsive feet, for 20 feet there was a relapse of the deformity. Evaluation of the results showed that poor compliance with splintage was the most common cause of relapse; delayed presentation and atypical clubfeet resulted in high resistance to this technique. Correction achieved at our centre was 82.18%. This is less than in many recent studies and could be attributed to increased incidence of delayed presentation, poorer compliance, and atypical feet in our population. CONCLUSION: We conclude that the Ponseti technique is recommended for management of clubfoot and strict compliance with splintage is essential to prevent relapses. People of lower socioeconomic status are at high risk of relapse and must be targeted to create awareness among them about the importance of compliance with splintage.

Application of the Ponseti principle for deformity correction in neglected and relapsed clubfoot using the Ilizarov fixator.

We treated 15 cases of neglected and relapsed clubfeet by the Ilizarov distraction method using the Ponseti principle in 12 children (mean age 7.3 years). The deformities were corrected around the talar head in the sequence of the cavus, adduction, varus and finally equinus (as per the Ponseti principle). Clinical and functional outcome after 2.5 years was significant (P<0.05) with a mean reduction of 11.7 in Dimeglio's score and an average Laaveg and Ponseti functional score of 75.47. The average time taken for correction was 4.2 weeks. Differential distraction according to the Ponseti principle leads to early correction with minimal number of residual deformities and complications.

Total Knee Arthroplasty as Salvage for Non Union in Bicondylar Hoffa Fracture: a report of two cases.

INTRODUCTION: Bicondylar Hoffa fracture is a rare injury with implant failure and non unions as known complications. CASE REPORT: Two cases of Bicondylar Hoffa fractures with implant failure and nonunion treated successfully with long stem total knee arthroplasty are reported here. At a minimum follow up of 2 years both the implants were well fixed and the fractures have united. The knee society scores in both the patients improved from 14 and 19 to 86 and 82 respectively. To our knowledge there are no reports of such rare fractures managed successfully with non hinged arthroplasty. CONCLUSION: A long stem total knee arthroplasty can be used as a treatment option in cases of nonunion bicondylar Hoffa fractures.

Neglected irreducible posterolateral knee dislocation.

Knee dislocations are rare injuries. Posterolateral knee dislocations are only a small subset of them. There is a paucity of literature regarding the management of such neglected cases. We report here, a case of neglected irreducible posterolateral knee dislocation treated with open reduction and isolated posterior cruciate ligament reconstruction followed by gradual rehabilitation with good outcome at 3 years followup.

Arthrodiastasis and surgical containment in severe late-onset Perthes disease: an analysis of 14 patients.

Late-onset Perthes disease usually carries a poor prognosis. In severe cases there may be increasing pain, decreased range of motion and hinge abduction which forms a contraindication for surgical containment. We have managed 14 such patients in a two-stage procedure. Arthrodiastasis done as a first stage dramatically reduced pain and Trendelenburg limp while at the same time leading to a substantial improvement in range of motion and hinged abduction. Once the contraindications to surgical containment were overcome by arthrodiastasis, we proceeded with a varus osteotomy of the femur in a second stage in the hope that the femoral head would remodel to some extent with time and would improve the final functional outcome.

Low-grade fibromyxoid sarcoma of the talus: a case report.

Low-grade fibromyxoid sarcoma is a rare tumor, which most commonly arises from the deep soft tissues of the lower extremities in young men. Diagnosis of this tumor can be difficult because of its deceptively benign histopathologic appearance. Specifically, the lesion is characterized by alternating fibrous and myxoid areas with variable cellularity and a whorled growth pattern. Like many soft tissue tumors, low-grade fibromyxoid sarcoma is also characterized by strong immunoreactivity to the human proto-oncogene BCL-2. Cytogenetically, the lesion has also been associated with the t (7,16) (q33;p11) translocation, with the characteristic resultant FUS and CREB3L2 fusion gene. In this report, we describe the rare case of a low-grade fibromyxoid sarcoma that appeared to develop as a primary malignancy in the neck of the talus of a young man who presented with recurrent ankle pain after a previous surgery for a cystic lesion at the same site.

MRI evaluation of femoral and acetabular anteversion in developmental dysplasia of the hip. A study in an early walking age group.

MRI assessment of acetabular and femoral anteversion was done in 45 children with developmental dysplasia of the hip in an early walking age group of 12 to 48 months. Femoral anteversion, acetabular anteversion, acetabular anteversion of the cartilage anlage and acetabular index were measured by MRI in 45 dislocated hips and in a control group of 37 normal contralateral hips of index cases. We found that there was no statistically significant difference between these two groups for femoral anteversion. The acetabular anteversion was found to be significantly increased in the dislocated group compared to the normal group. Similar results were obtained for the cartilage anlage of the acetabulum. There was a positive correlation between acetabular anteversion and acetabular index, while there was no correlation between femoral anteversion and other parameters. We conclude that femoral anteversion is not increased, while the acetabulum is excessively anteverted on the dislocated side in developmental dysplasia of the hip in an early walking age group. Analysis of femoral and acetabular anteversion is an essential part of pre operative planning in developmental dysplasia of hip, and for this MRI is a good modality as it is radiation free.

En bloc resection of osteosarcoma of the proximal fibula. An analysis of 8 cases.

Osteosarcoma of the proximal fibula is a rare entity that poses a surgical challenge. Limb salvage is the goal of treatment, and this entails sacrifice of the common peroneal nerve as well as the anterior tibial artery. Also the loss of the lateral collateral ligament and biceps attachment leads to unavoidable knee instability which requires special reconstructive procedures. From 2002 to 2008, eight patients with osteosarcoma of the fibular head were treated in our institution with Malawer type II resection. Seven of these patients are still alive without evidence of disease. Our results indicate that the sacrifice of the common peroneal nerve ensures a wide margin of resection which in turn correlates with long-term survival. Furthermore, our technique of reconstruction of lateral knee structures has produced good functional outcome without significant postoperative knee instability.