A Rare Case of Melorheostosis Presenting with Extra-osseous Lesions Around the Knee: Case Report.

Introduction: Melorheostosis was initially identified in 1922 by Leri and Joanny. It is often referred to as candle bone disease, melting wax syndrome, or Leri disease. This mesenchymal condition is uncommon, benign, and non-heritable. There is still a lack of clarity regarding the underlying cause of the condition. The estimated incidence is 0.9% per million. No inherited traits have been identified, and both sexes are equally affected. Pain or swelling is the most typical symptoms, and the onset is insidious. People often call this condition "candle disease of the bone" because the radiological signs of it look like dripping candle wax. Case Report: A 56-year-old female presented with an 8-year history of the left knee pain, swelling, and movement restriction. On examination, a hard, bony lump measuring 12×5 cm was located on the outer aspect of the left knee. The skin over the lump's surface was neither erythematous nor warm. Plain radiographs revealed a wide, dense, undulating, or irregular cortical hyperostosis, resembling candle wax, spreading along the length of the fibula bone as well as an extra-osseous calcification mass across the lateral aspect of the left knee. The patient underwent excision with complete left knee motion. Conclusion: Melorheostosis' actual etiology is yet unknown. There is no established treatment for this condition. Only symptomatic treatment helps patients feel better; in some circumstances, the excision of a bone mass yields more beneficial results.

Outcomes of the Posterior Approach for the Treatment of Radial Head Fractures and Associated Elbow Injuries: A Retrospective Observational Study.

BACKGROUND: The lateral approach to the radial head remains the routinely used approach for surgical fixation or replacement despite the risk of injury to lateral soft tissue structures. Multiple approaches are required when dealing with complex elbow injuries involving other bony and soft tissue structures which lead to greater soft tissue dissection, prolonged immobilization, and a higher rate of elbow stiffness. This article utilizes a single posterior approach involving the Boyd interval in the surgical management of radial head fractures with an associated elbow injury. METHODS: Thirteen patients with radial head fractures and related elbow injuries treated with the posterior approach to the elbow were retrospectively analyzed. All patients were operated on by a single surgeon and followed up for a minimum of 18 months postoperatively. Functional evaluation of the patients was performed at the final follow-up which comprised a range of movements of the elbow, visual analogue scale (VAS), Disability of Arm, Shoulder, and Hand (QuickDASH), and the Mayo Elbow Performance Score (MEPS). RESULTS: The mean VAS score was 2.16, QuickDASH score, and Mayo elbow score were 7.15 ± 2.96 and 78.46 ± 8.26 respectively. The flexion-extension arc of the elbow was 128.46 ± 4.27 degrees and the supination-pronation arc was 133.92 ± 4.04 degrees at one-year follow-up. Two patients developed early postoperative complications (elbow stiffness and ulnar nerve neuropraxia) and recovered spontaneously. No patients developed neuropraxia of the posterior interosseous nerve (PIN). CONCLUSION: The single incision posterior (Boyd) approach to the elbow offers complete access to the radial head, olecranon, coronoid, and lateral ligamentous structures in complex elbow injuries and provides good functional outcomes in our small observational study.

Zoledronic Acid Does Not Retard Bone Union: A Randomized Controlled Trial in Fragility Intertrochanteric Femur Fractures.

BACKGROUND: Fragility hip fracture is a leading cause of death in the elderly and is common in postmenopausal women and elderly people. In the treatment of osteoporosis, bisphosphonates (BPs) are often considered first-line medications. Zoledronic acid is the most potent and long-acting BP in clinical use and is administered as an intravenous infusion. In the context of acute fractures, the use of BPs has been controversial due to conflicting reports of their positive and negative effects on fracture healing. The purpose of this study was to determine the effect of zoledronic acid on fracture healing in intertrochanteric (IT) fragility fractures. METHODS: The study was conducted in a tertiary healthcare center after receiving scientific and ethical approval. The study included 136 patients of either gender over the age of 50 who presented with an IT femur fracture after minor trauma between November 2020 and November 2022. The total number of patients had been classified into two groups, and grouping involved random sampling: Group T (test group, n = 68; zoledronic acid injections were given on postoperative day 3) and Group C (control group, n = 68; interventions were given after fracture healing). Patients were evaluated using the Radiographic Union Score for Hip (RUSH) and Singh Index for radiological outcomes and the Harris Hip Score (HHS) for functional outcomes. The patients were followed for six months. RESULTS: The overall mean age was 73.25 years; in Group T, it was 72.5 ± 11.9 years, and in Group C, it was 73.7 ± 11.8 years. Of 136 patients, 69 (51%) were males and 67 (49%) were females. The average fracture healing time in Group T was 12.2 ± 3.6 weeks, while it was 13.0 ± 2.8 weeks in Group C. Functional outcomes, including HHS, were found to be better in Group T than in Group C (p < 0.005). No significant difference was observed between the two groups with respect to the radiological union, the RUSH score, or Singh Index, implying no negative effect of zoledronic acid. CONCLUSIONS: This study demonstrates that postoperative intravenous zoledronic acid therapy does not retard fracture healing. Osteoporosis management is frequently neglected because of a surgeon's fear of ZOL retarding fracture healing and a lack of awareness among patients, resulting in low compliance. Thus, opportunistic administration of zoledronic acid postoperatively can be beneficial and will increase compliance for osteoporosis management and fracture prevention to 100%.

Ilizarov Fixator-Assisted Management of Neglected Femur Fractures by Open Intramedullary Nailing: A Case Series.

Femoral shaft fractures are major life- and limb-threatening injuries. Such injuries, when neglected for months or years, can lead to a range of debilitating consequences. In the Indian subcontinent, there are multiple such cases that are presented to tertiary care hospitals late due to a lack of awareness and low socioeconomic constraints. These neglected cases on presentation are usually in a state of nonunion or malunion, with gross shortening and deformity affecting adjacent joint mobility. The management of neglected femur shaft fractures (NFFs) demands uphill tasks, such as achieving mechanical stability, restoring length and alignment, and having strong rehabilitation schedules. The functional outcomes of these cases are always not proportional to their radiological counterparts and must be taken care of separately. In this study, intramedullary nailing of the fracture after initial distraction with the Ilizarov fixator aims to reduce deformity and shortening while restoring near-optimal functional life. The study aimed to evaluate the functional and radiological outcomes of NFFs operated with distraction by an Ilizarov fixator followed by intramedullary nailing. METHODS: Fourteen cases of NFFs presented to Kalinga Institute of Medical Sciences, Bhubaneswar, India, between January 2020 and June 2022 were recruited for the study. After preoperative evaluation and explanation of available treatment options to patients, they were operated on with a two-stage procedure of Ilizarov fixator application, followed by intramedullary interlocking nailing, with a period of gradual distraction in between. They were then followed up for a minimum of 12 months to assess functional and radiological outcomes. RESULTS: The average time for all of the fractures to heal was 25.2 weeks. The average knee flexion increased from 28.2 degrees before surgery to 87.1 degrees after surgery. All 14 patients could walk with complete weight bearing on the operated limb postoperatively after proper pain control measures were taken. The mean Tegner Lysholm knee score was 77.8. There was residual limping in six of the cases, which could be attributed to muscle atrophy and/or shortening in the affected limbs. In three cases, skin blisters were formed due to the acute nature of the distraction, but they all healed with a scab and scar, otherwise uneventfully. The shortening, in 13 cases, came down to 4 cm or less, which was managed with a shoe raise. The one case with a residual 5 cm shortening had a short, limping gait, and it was attributed to an extremely overriding osteopenic femur preoperatively. CONCLUSION: A two-stage operation with distraction by an Illizarov fixator followed by an intramedullary fixation provides the basic advantage of not having to excise an excessive amount of bone, which may be required in primary open reduction and intramedullary fixation. It also allows the patient to carry on his daily activities as mobilization is not restricted, which is the case in an individual to whom skeletal traction is applied. Hence, in any NFF case, this algorithm of management can be considered a frontrunner in the comprehensive management of disability and deformity.

Management of Scaphoid Nonunion (SNU) With Ilizarov Ring Fixator Using Two Olive Wire Compression Without Bone Grafting: A Case Series.

BACKGROUND: The scaphoid is the most commonly fractured bone among the carpal bones seen in orthopedic practice. The majority have good favorable prognosis, but some develop nonunion of fracture despite optimal treatment, which can lead to further complications if left untreated. It is recommended that displaced scaphoid nonunions (SNUs) should be reduced and fixed to prevent degenerative changes from occurring, even if they are asymptomatic. Many treatments have been described, from a percutaneous fixation with a k-wire or screw to open reduction and internal fixation with or without bone grafting, but none of them is the gold standard. AIM: To evaluate the outcome of an SNU treated with an Ilizarov fixator using two olive wires without bone graft. METHODS: Eleven cases of non-union scaphoid fractures were considered in the study which was presented to the Department of Orthopedics of Kalinga Institute of Medical Sciences during the period of March 2015 to March 2018. This study has been approved by the scientific and ethical committees. The anatomical location of the fracture was graded according to the MAYO classification. An Ilizarov frame was applied with two cross olive wires for achieving compression at the fracture area and maintained for six weeks. A final outcome was assessed using the scaphoid outcome score. RESULTS: One out of 11 patients operated on during the study period was lost in follow-up, so 10 patients were considered for analysis of the results. There were nine male patients and one female patient. The majority were right-sided and dominant-handed, with varied occupations. The average duration of nonunion, when presented, was 10.7 months (a range of 6-20 months). The average follow-up was 43.6 months (range 27-60 months). Union was achieved in an average of 12.9 weeks (range 10-18 weeks). All the patients returned to their pre-injury activity level in a mean of 17.1 weeks (range 13-23 weeks). Grip strength improved from a mean of 29.5 kg preoperatively to 39.4 kg postoperatively. At the final follow-up, the mean scaphoid outcome score was 9.1. An excellent outcome was obtained in five cases (50%), a good outcome in three cases (30%), a fair outcome in one case (10%), and in one case (10%), a poor outcome. CONCLUSION: With our technique of Ilizarov fixation and compression with two cross olive wires, SNU can be treated safely even without opening the non-union site and even without bone grafting. Since we excluded SNU patients with humpback deformity, carpal instability, carpal collapse, or avascular necrosis (AVN), our results might not be directly comparable to those of other SNU series in the literature. These would have predisposed to a poor outcome. Since we did not assign the patients at random, it is challenging to compare the Ilizarov technique to other widely used SNU treatments and determine whether it is more effective. However, the study's results are encouraging and show that the Ilizarov method using two olive wires for compression.

Functional and Radiological Outcome in Atypical Subtrochanteric Femur Fracture After Surgical Fixation: A Retrospective Observational Study.

BACKGROUND: Treatment for osteoporosis can have catastrophic side effects, including the uncommon fracture known as an atypical femur fracture (AFF), which is related to the long-term usage of antiresorptive agents. Bisphosphonate therapy may lead to significant and chronic suppression of bone turnover, impairing the bone's remodelling property and finally leading to incomplete or complete atypical femur fracture. AFF was defined by the American Society for Bone and Mineral Research (ASBMR) Task Force in 2010 and is far less prevalent than proximal femur (hip) fracture, with an incidence of 2 to 78 per 100,000 patients per year following two to eight years of bisphosphonate therapy, respectively. Due to the rarity of the fracture, it is still not clear what the functional and radiological outcome will be after surgery. AIM: To identify the functional and radiological outcomes of surgical fixation of atypical femur fractures. METHODS: The study was conducted in a tertiary healthcare centre after scientific and ethical clearance from the competent authority. Between January 2018 and December 2021, individuals who were diagnosed with an atypical subtrochanteric femoral fracture associated with the use of bisphosphonates and treated surgically were retrospectively evaluated. The study's inclusion and exclusion criteria were used to include 20 patients. The features of an atypical subtrochanteric fracture were congruent with the radiographic findings. Most of the patients were treated with internal fixation with intramedullary osteosynthesis in standard with or without plate osteosynthesis. They were then followed up for a year to look at the functional and radiological outcomes. RESULTS: All of the 20 patients who were included had an atypical subtrochanteric fracture, with 15 of them being female and 5 of them being male. The patients' mean age at surgery was 65.12 (range 49 to 82) years, and their average history of bisphosphonate use was 3 (range 2.5 to 5) years. All patients were treated surgically. We found that five months was the mean period for bone union (p = 0.990). Within six months, bone union was achieved in 11 patients (55 %) (p = 0.884). Five patients (about 25%) had implant failure and non-union, requiring two to three revision surgeries. At three, six, and nine months, the mean visual analogue score (VAS) was 4.14, 3.12, and 1.85, respectively. The modified Hip Harris Score had a mean of 72.66 and 15 patients (about 75% of them) could walk normally again after a fracture. The mean of the modified HHS was 72.66, and the VAS at three, six, and nine months was 4.14, 3.12, and 1.85, respectively. CONCLUSION: AFFs are rare fractures that must be treated effectively, and most of them require surgery. Successful treatment of AFF is possible by the use of intramedullary fixation, which enhances axial stability, serves as an internal splint, and lessens the likelihood of implant failure. A good functional and radiological prognosis can come from a stable fixation and a fracture that has been reduced anatomically.

Osteofibrous Dysplasia of the Clavicle Managed with Intravenous Bisphosphonates: A Case Report and Review of Literature.

Introduction: Osteofibrous dysplasia is a fibro-osseous benign lesion of childhood and infancy that are commonly seen in the anterior shin of the tibia. Osteofibrous dysplasia in the clavicle is rare and in this study, we reported a case of osteofibrous dysplasia arising in the midshaft of the clavicle. Case Report: An 11-year boy presented with complaints of pain and swelling over his left clavicle and was unable to do overhead abduction following a fall while playing 2 years back. Initially, the patient was diagnosed with a left clavicle fracture and was treated conservatively. The pain subsided after 3 months. The patient had re-injury after 6 months, following which pain and swelling of the left clavicle were gradually progressive. On examination, there was a diffuse swelling extending from the medial end to the lateral end of the left clavicle, which was tender, and bony-hard in consistency. The range of movements of the left shoulder was painful and terminally limited. A percutaneous core-needle biopsy was done, suggestive of a benign fibro-osseous lesion. An open biopsy was done from the tumor-normal bone junction, and caseous materials were found inside the medullary canal, the microscopic finding shows fibroblastic proliferation and osteoblastic proliferation laying down the woven bone. We treated the case with intravenous pamidronate injection in 6 months intervals for 2 years. The patient improved symptomatically achieving a full range of movements of the affected shoulder with good radiological consideration of the lesion. Conclusion: Osteofibrous dysplasia is uncommonly seen in the clavicle, and if it is seen, it may mimic osteomyelitis clinically. It should be differentiated from other lesions by radiological, histopathological, and immunohistochemistry findings.

Dual Mobile Total Hip Replacement in Super Obesity: A Case Report and Review of Literature.

Introduction: More than 13 million people in the US are morbidly obese. It is associated with various medical and anesthetic complications. Higher rate of dislocation in total hip replacement (THR) associated with morbid obesity due to thigh girth, low muscle mass and high-fat content. Morbid obesity is associated with a 38% increase in the 10-year mortality rate compare to non-obese after undergoing primary total hip arthroplasty (THA). Hip dislocation after THR is one of the earliest complications, and for every ten-point increase in BMI, the risk of dislocation increases by 113.9%. Case Report: We present a case report of a 69-year-old super-obese woman with a BMI of 62.2, who presented with repeated dislocation post THR. The patient was managed successfully with implant removal and implantation of dual mobile THR prosthesis. Conclusion: Morbid obesity with a need for arthroplasty is challenging. It needs proper planning, thorough preoperative preparation, proper intraoperative care and identification with adequate post-operative complications management. Preoperative bariatric surgery, dual mobile liner and constrained implants have shown good result in decreasing dislocation rate. The liner of dual mobile THR is efficient to prevent post-operative dislocation in morbidly obese and super-obese patients.