A Case of Chronic Rupture of Achilles Tendon Managed Using a Combination of Multiple Surgical Techniques.

Achilles tendon rupture is a common injury that occurs due to sudden dorsiflexion of the plantar-flexed foot. Both acute and chronic ruptures are frequently misdiagnosed and mistreated. Acute Achilles tendon rupture commonly occurs in middle-aged individuals (30-40 years). Although several operative procedures are available for Achilles tendon repair, the management of choice remains controversial and debatable. A 27-year-old male came to our clinic complaining of pain over the left ankle for the last five months. History revealed trauma caused by a heavy metal object five months ago. Physical examination revealed tenderness and swelling over the left heel. Ankle plantar flexion was restricted, and painful and squeeze test was positive. Magnetic resonance imaging was suggestive of a tear of the Achilles tendon in the left ankle. Surgical management was done with multiple techniques which included flexor hallucis longus tendon graft augmentation, end-to-end suturing (Krackow technique), V-Y plasty, and bioabsorbable suture anchor. Although complications such as scar stiffness and wound gaping are common in such cases, the postoperative outcome was excellent in our case according to the American Orthopedic Foot and Ankle Score.

A Rare Case of Bilateral Hip Tumoral Calcinosis With Intertrochanteric Fracture Treated by Closed Reduction Internal Fixation (CRIF) Using a Proximal Femoral Nail.

Tumoral calcinosis, also referred to as Teutschländer disease is a rare familial disorder characterized by painless, periarticular lumps or masses. Large amorphous calcific concentrations that surround the joints are the defining feature. These lesions have fibrous septa that divide them into lobules and may often show fluid/calcium levels (milk of calcium/suspended hydroxyapatite crystals). In our case report, a 24-year-old male came to the outpatient department (OPD) with complaints of pain over the right hip for two days and swelling over both hips for six years. He was apparently well two days prior to the hospital visit, when he met with a road traffic accident, falling off his bike. A plain radiograph of the pelvis and bilateral hip joints along with cross-table lateral views were done, which depicted a typical appearance of amorphous and multilobulated ("cloud-like") calcifications located in a periarticular distribution in both hips along with an intertrochanteric fracture in the right hip. A CT scan, done for better delineation of the calcific masses and fracture pattern, showed no obvious erosion or osseous destruction by the adjacent soft-tissue masses. Laboratory investigations revealed a serum calcium level of 8.8 mg/dl and a serum phosphorous level of 6.0 mg/dl.  The patient was taken up for surgery after routine pre-operative investigations and a pre-anaesthesia check-up. Closed reduction internal fixation (CRIF) was done using a proximal femoral nail (PFN). A biopsy of the soft-tissue masses was sent for histopathology, which was suggestive of lobules of calcific material surrounded by histiocytic giant cells. The patient responded well to the treatment with no residual discharge from the incision site, and his treatment was continued with phosphate binders as prescribed by the endocrinologist.

A Rare Case of Preiser Disease Affecting a Young Female.

Avascular necrosis of the carpal scaphoid is known as Preiser disease. Avascular necrosis is usually caused by non-traumatic or idiopathic etiology. In this case report, we present the case of a 23-year-old female patient who came to our outpatient department with complaints of pain and swelling over the left wrist joint for seven months. The patient did not give any history of trauma or long-term steroid intake. Clinically, the patient had tenderness over the left anatomical snuff box. A plain radiograph of the wrist joint did not suggest any abnormality. MRI was done to confirm the diagnosis. MRI showed altered marrow signals in the scaphoid, which was suggestive of avascular necrosis of the scaphoid, also known as Preiser disease. Proximal row carpectomy was done for the patient, and wrist range of motion exercises were started after one week postoperatively. Full range of motion of the wrist joint was achieved at three weeks postoperatively without no residual deformity.

A Rare Case of Destruction of the First Metatarsophalangeal Joint in a Patient With Gout.

Gout is a crystal deposition disorder caused due to the deposition of monosodium urate crystals in joints and other tissues secondary to hyperuricemia. Podagra is the term for gout of the first metatarsophalangeal joint. In our case report, a 30-year-old male patient came to our OPD with complaints of swelling over the first metatarsophalangeal joint for one year, which was insidious in onset, localized, and had a sudden increase in size over the past three months. The patient also complained of an inability to properly wear his shoe. A plain radiograph was done, which was suggestive of an expansile lesion with the destruction of the first metatarsophalangeal joint and the erosion of the joint surface extending to the head of the first metatarsal and the proximal phalanx of the great toe. Lab investigations revealed a serum uric acid level of 10.2 mg/dl and an acid phosphatase level of 8.92 U/L. Excision of the lesion was done and a frozen section biopsy was sent intra-operatively which confirmed the presence of monosodium urate crystals. A fibular strut graft was taken to fill the defect using a square nail passing through the first metatarsophalangeal joint and a Kirschner wire was added to the interphalangeal joint to maintain the stability of the reduction. The foot was immobilized for six weeks following which the Kirschner wire was removed and range-of-motion exercises started. There was no residual deformity, and the patient responded well to the treatment.