Derotational Subtrochanteric Osteotomy and External Fixation for the Treatment of Neurogenic Hip Dislocation in Children with Cerebral Palsy: Could This Be a Viable Method of Treatment?

Purpose The treatment of painful and chronic dislocated hip in children with severe cerebral palsy (CP) is particularly demanding and controversial. Numerous surgical techniques have been described, and their outcomes vary a lot. The purpose of the present study is to evaluate a new method, which combines varus derotational subtrochanteric osteotomy (VDSO) and external osteosynthesis: (VDSOEO). Methods Six non-ambulatory children with spastic quadriplegia and chronic dislocated painful hips were treated. The technique involved a small incision on the subtrochanteric site of the osteotomy, followed by retention with a single-sided external osteosynthesis with rotational correction capability [swiveling clamp (SC)] for the reduction of the femur head in the acetabulum, and finally by the osteotomy. Hardware was removed without a second intervention four-six months postoperatively and after the osteotomy was healed. Evaluation of the method was based on clinical, functional, and radiological criteria. Results  Four patients achieved improved radiological scores. Two patients demonstrated resubluxation during the period of the osteotomy's healing process. However, no patients experienced pain, and all were able to sit post-surgery, while caregivers reported improved capacity for nursing care. Conclusions It is our strong belief that this approach can improve the quality of life in children with severe CP and painful and chronic dislocated hips. It is a viable and definitely less invasive procedure than classic pelvic or femur osteotomies.

Femoral Nerve Palsy Secondary to Iliopsoas Spontaneous Haematoma in a Patient Under Warfarin Treatment.

Femoral nerve palsy secondary to iliopsoas non-traumatic haematoma is a scarce complication with a treatment approach that remains controversial between conservative and surgical intervention. We present a case of a 64-year-old male patient under warfarin medication, who developed severe left hip and anterior thigh pain and femoral nerve palsy with no history of trauma. Laboratory studies revealed a prolonged international normalized ratio level of 4.5, and imaging studies revealed a large haematoma surrounding the left iliopsoas muscle (35 cm x 9 cm x 6 cm). The patient was treated conservatively with discontinuation of his anticoagulation remedy and vitamin K administration and recovered almost fully after eight months, following a rehabilitation programme. Patients who are on anticoagulants should raise a high index of suspicion. Conservative management can provide a good outcome; it requires, however, a long period of rehabilitation.

Lower Limb Pain Attributed to Bone Marrow Edema Syndrome: A Commonly Ignored Pathology.

Bone marrow edema syndrome (BMES) is a highly uncommon, self-limited syndrome of unclear etiology. The syndrome most commonly affects middle-aged men. Magnetic resonance imaging is essential for the diagnosis because of the characteristic pattern of bone marrow edema. The diagnosis of BMES is a challenge for clinicians. Other causes of lower extremity pain, with poor prognosis, must be excluded. We present three cases of BMES. All three patients initially complained of mild lower extremity pain, which progressively deteriorated and led to a severe limitation of their daily activities. They were all treated conservatively by weight-bearing restriction and symptoms resulted within a few months. The aim of the present study is to outline this rare, benign pathology.

Spontaneous Knee Hemarthrosis Due to Hypofibrinogenemia Following Tigecycline Treatment for Periprosthetic Joint Infection.

Tigecycline, a recently approved antibiotic, has a broad spectrum of antimicrobial activity. Its unique structure and properties make tigecycline a valuable option for the treatment of infections caused by many multidrug-resistant organisms. We present a case of an 82-year-old patient who developed a significant decrease of fibrinogen levels after the addition of tigecycline to his antibiotic regimen. The patient was treated for a periprosthetic knee joint infection caused by a multidrug-resistant extended-spectrum beta-lactamase-producing Escherichia coli. The reduction of fibrinogen levels, in this case, prompted severe spontaneous hemarthrosis. Tigecycline treatment was discontinued and coagulation disorders were normalized within the next few days. After several days, the joint had to be surgically debrided. Hypofibrinogenemia is a very scarcely reported side effect of tigecycline that can cause spontaneous hemarthrosis.

The Use of Vacuum Closure-assisted Device in the Management of Compound Lower Limb Fractures with Massive Soft Tissue Damage.

The simultaneous exposure of tissue and bone poses specific management challenges. Patients with extended soft tissue damage and high-grade compound fractures present a demanding clinical challenge, requiring a complex approach and multiple orthopaedic, plastic, and vascular-reconstructive procedures. Management involves combinations of wound debridement and closure by secondary intention, use of vacuum-assisted closure (VAC) devices, and various reconstructive plastic surgery methods. We present three consecutive complicated cases, involving compound fractures of the lower limb with massive soft tissue damage (Gustilo-Anderson type IIIB) that were managed with debridement, application of external fixation and VAC device. The mean wound size was 24 cm in length and 12 cm in width. The aim of treatment was to cover the bone with soft tissue and achieve healing of the fracture without persistent infection. Wound healing was achieved in all three cases within 30-42 days (mean 34). In one case, the skin graft was applied on day 33. Utilizing this method as part of a multi-directional approach, the VAC system helps the patient recover faster. Moreover, it acts as a feasible and valuable method to treat compound fractures with massive soft-tissue defects. VAC can replace microsurgical soft-tissue transfer, reduce the risk of infection and allow salvaging the limb.

The Sensitivity of Magnetic Resonance Imaging and Ultrasonography in Detecting Rotator Cuff Tears.

Shoulder pain is a common cause of morbidity in the general population. Differential diagnosis may be difficult. Soft tissue shoulder disorders are the most common causes of shoulder pain. Noninvasive imaging techniques can reveal rotator cuff (RC) pathologies. These include ultrasonography (US) and MRI. Minimally invasive techniques such as magnetic resonance arthrography (MRA) can also be recruited when required. We conducted a retrospective study of 61 consecutive patients with shoulder pain, who had undergone preoperative imaging in the form of US or MRI and subsequently proceeded to arthroscopic surgery. Nineteen patients had a US and 42 had an MRI preoperative imaging evaluation. This evaluation was compared to the operative findings. The US sensitivity was 87%, while specificity was 63%. The MRI accuracy rose to a sensitivity of 95% when specificity was 72%. The positive predictive value (PPV) was 64% for US and 76% for MRI. The negative predictive value (NPV) was 87% for US and 94% for MRI. The overall accuracy of the ultrasound was 73% and of the MRI 83%.

Patella Height in Different Ethnic Populations: An Observational Multicenter Study.

Patella height appears to have a crucial role in knee biomechanics. Patellar malalignment and maltracking are therefore believed to be associated with development and progression of patellofemoral pain and disease. Published data are scant regarding the effect of everyday tasks on patella height and patellofemoral disease. We included 150 subjects in a retrospective observational study. Group A had 75 subjects (24 male and 51 female, with a mean age of 58.5 yr), whose daily activities included squatting (the traditional Muslim praying position called Sujud). Group B had 75 subjects (42 male and 33 female, with a mean age of 47.6 yr), who were non-Muslim. Patella height was measured using Insall-Salvati (IS) and Blackburne-Peel (BP) ratios. The mean IS ratio was 0.86 (confidence interval [CI]: 0.7-1.02) for group A and 1.1 (CI: 0.96-1.23) for group B. The mean BP ratio was 0.66 (CI: 0.49-0.83) for group A and 0.89 (CI: 0.73-1.04) for group B. We found 26 subjects (34.7%) in group B to have patella alta, when measured by either ratio, compared to one subject (1.3%) in group A (p < 0.01) with patella alta. We found 61 subjects (81.3%) in group A to have patella baja, when measured by either ratio, compared to 21 subjects (28%) in group A (p < 0.01) with patella baja. In group A, the IS ratio was reduced in 29 subjects (38.7%), the BP ratio was reduced in 59 subjects (78.7%), and both were reduced in 27 subjects (36%). A similar pattern was noted for group B. Our results show that a significant increase in patella baja was associated with repeated squatting/kneeling, compared to the predominance of patella alta in the control group. On the basis of these findings, we hypothesize that biomechanical stresses associated with repeated hyperflexion of the knee asymmetrically affect the more flexible quadriceps muscle fibers greater than patella tendon fibers. Thus, repeated hyperflexion in everyday tasks leads to elongation of quadriceps fibers and patella baja.

An Unusual Presentation of a Massive Acromioclavicular Joint Ganglion Cyst Geyser Sign Secondary to Massive Rotator Cuff Tear and Cuff Arthropathy.

A Geyser sign is a rare manifestation of acromioclavicular joint (ACJ) ganglion cysts that are seen in patients with massive rotator cuff tears and arthritis of the ACJ. We present a case report of a 70-yr-old male who was presented to our hospital with a massive AC ganglion cyst measuring 7 × 8 cm with normal shoulder function tests. Imaging studies revealed a massive rotator cuff tear, advanced cuff arthropathy, degeneration of the ACJ, and a Geyser sign (seen with magnetic resonance imaging). The cyst was initially aspirated but recurred, so open debridement distal clavicle resection and ganglion cyst excision were performed. Eight months following debridement, the patient visited the outpatient department with cyst recurrence and limited shoulder movement. A reverse shoulder arthroplasty was performed with good clinical results.

Distal Oblique Bundle in the Distal Interosseous Membrane of the Forearm: Review of Current Knowledge.

The distal oblique bundle has been recognized as a distinct structure of the distal interosseous membrane of the forearm since 2009, when Noda et al. named it. Our minireview will attempt to summarize knowledge gathered and provide guidelines toward possible questions that arise when reading studies about this topic. It is our strong belief that the distal oblique bundle is worth investigating in full, since it seems to have an important role as a stabilizer of the distal radioulnar joint. Due to the efforts of a small number of surgeons and authors, the groundwork for understanding its purpose has been laid, but more research needs to be done.

Nontraumatic Osteolysis of the Distal Clavicle: Diagnostic Approach and Management.

Osteolysis of the distal clavicle is a rare radiological manifestation. It can be of traumatic or nontraumatic origin and is usually seen in weight-lifting trainers as a result of stress-induced osteolysis of the distal clavicle, a phenomenon known as stress failure syndrome. We present a rare case of nontraumatic osteolysis of the distal clavicle in a 65-year-old, male, non-weight lifter who was referred to our outpatient clinic. Osteolysis was revealed on plain radiographs and was confirmed with magnetic resonance imaging. Diagnostic approach, differential diagnosis, and management of this rare manifestation are discussed.

Morganella Morganii: An Unusual Case-Report of Shoulder Septic Arthritis.

Morganella morganii is a gram-negative, anaerobic, facultative bacillus that is part of the natural flora of the gastrointestinal system. In the rare event of joint effusion, it is known for its slow-paced progression of symptoms and occasional attacks and remissions leading to septic arthritis, and it is difficult to recognize and to address with a timely response. We present a case of a 95-year-old male hospitalized due to left shoulder septic arthritis. The symptoms commenced as simple discomfort in the joint, and 10 days later this was followed with pain and dysfunction, diffusion, and mild fever. Blood and pus cultures were obtained on the day of admission; arthroscopic debridement was performed the next morning; and wide-spectrum antibiotic treatment was initiated. Both blood and pus cultures isolated Morganella morganii, and the antibiotic regimen was adjusted to the antibiogram. Clinical and laboratory scores demonstrated signs of improvement, and the patient recovered within 3 months.

Pandrug-resistant Acinetobacter Baumannii Infection Identified in a Non-intensive Care Unit Patient: A Case Study.

Acinetobacter baumannii is a major cause of hospital-acquired infections, particularly in patients treated in intensive care units (ICUs). It can be a causal agent of conditions like pneumonia, bacteremia, meningitis, soft-tissue, and urinary tract infections, and is associated with high mortality rates. We present a case of a 72-year-old male patient treated for fractured neck of femur who went on to develop an infection from a pandrug-resistant Acinetobacter baumannii isolated in blood and urine cultures during his hospitalization in trauma and orthopedic ward. The patient was operated on the second day following his injury with a cephalomedullary nail device and became febrile with rigors on day six. His clinical condition deteriorated over the next days and his inflammatory markers reached a peak value on day 10 post-injury. Acinetobacter baumannii was isolated from blood and urine cultures and a regimen combining rifampicin, tigecycline, and vancomycin in their maximum doses was initiated. The patient was discharged on day 26 post-injury. Before discharge, he had received the above-mentioned intravenous antibiotic regimen for 14 days. He had also been afebrile for six days and undergone three consecutive negative blood culture samples.

Scapulothoracic Dissociation and Clavicle Fracture with Associated Brachial Plexus Palsy.

Scapulothoracic dissociation is the traumatic separation of the scapula from the thoracic wall. It is the outcome of rare, high-energy trauma to the shoulder girdle and may include vascular and neurologic damage of the upper extremity. Of the few cases presented in the literature, the majority refer to polytrauma patients. We present a rare variant of scapulothoracic dissociation combined with comminuted fractures of both the scapula and the clavicle associated with brachial plexus palsy. There were also vertebral fractures of the spinous processes of C6, T4, T5, and T6, of the transverse processes of T1 and T2, and of the anterior and middle column of T12. An open reduction and internal fixation of the clavicle was performed, and the patient was hospitalized in the intensive care unit and on the ward. The patient had a good recovery, involving extensive physiotherapy during hospitalization and after discharge to a rehabilitation center. Scapulothoracic dissociation can have potentially disastrous implications. The diagnosis is sometimes challenging because it usually involves polytrauma patients who have multiple life-threatening injuries. The diagnosis and management of this injury is of significant importance, and immediate surgical intervention should be performed when required.

Failure of a Medial Unicompartmental Knee Replacement due to Metal Allergy.

Metal hypersensitivity is an uncommon complication of knee arthroplasty that can lead to significant functional impairment and aseptic prosthesis failure. We describe the case of a 65-yr-old female patient who presented with persistent pain, swelling, and instability 1 yr after medial unicompartmental knee arthroplasty (UKA). The patient had no history of trauma or fall. The initial clinical examination showed good range of movement in the knee joint and no signs of infection or inflammation. Initial radiographs did not reveal aseptic loosening of the implant. Inflammatory markers were normal and the patient was sent for a bone scintigraphy that revealed increased uptake of the femoral implant. Pain deteriorated during the proceeding weeks, and repeated radiographs revealed loosening and dislocation of the femoral implant. We performed a nickel lymphocyte proliferation skin allergy test that resulted in a positive reaction. Revision total knee arthroplasty was performed using an oxynium (zirconium metal alloy) implant with intraoperative tissue pathology and postoperative leukocyte transformation testing that confirmed metal hypersensitivity as the cause for aseptic implant failure. This case report demonstrates that clinical and laboratory signs suggesting metal hypersensitivity in knee arthroplasty can suggest early loosening and failure of the implant.

SEPSIS SECONDARY TO DELAYED PRESENTATION OF NECROTISING FASCIITIS OF THE THIGH-PRESENTATION OF TWO CASES WITH A POOR OUTCOME.

Necrotizing fasciitis is an extremely virulent form of infectious fasciitis. It affects skin, subcutaneous fat, and superficial and deep muscular fascia by rapidly progressive necrosis. We present two cases, a 54-year-old female patient and a 46-year-old male patient, who presented to the emergency department of our hospital 30 days and 14 days after the onset of symptoms, respectively, with progressively deteriorating pain and swelling of the thigh, accompanied by fever, nausea, sweating, shortness of breath, and sepsis. Clinical, laboratory, and imaging findings suggested thigh fasciitis, which was secondary to osteomyelitis of the femoral head in one case. Despite the urgent surgical exploration and debridement, multiple courses of various schemes of intravenous antibiotics administered, the numerous surgical debridements and interventions performed, and the prolonged hospitalization in the intensive care unit, both patients died due to multiple-organ failure and disseminated intravascular coagulation. Necrotizing fasciitis is of surgical urgency with a high mortality rate, and early surgical intervention is of vital importance. In both of these cases, delayed presentation to the hospital was of great significance to the final outcome.