A Massive Proximal Tibia Geode - Can we Afford to Miss it?

Introduction: Osteoarthritis is now understood to be an aberrant remodeling of the joint organ caused by wear-and-tear mechanism and by a variety of inflammatory mediators. Subchondral cysts have been one of the important radiological features of knee osteoarthritis that is not well understood. We report a case of large subchondral lytic lesion which was initially thought to be a giant cell tumor and later was identified as subchondral cyst. Case Report: A 50-year-old man presented to the outpatient department with complaints of intermittent pain and swelling over the left knee associated with difficulty in performing his daily activities Patient had undergone cerclage wiring for fracture left patella fracture 8 years back following which pain started. Radiographs showed extensive degenerative change at the knee with a large, multilocular lytic lesion in the proximal tibia. Magnetic resonance imaging showed similar features with an additional lesion in the distal femur. Core needle biopsy and histopathological examination of both lesions showed fibrocollageous tissue with bone fragments and lymphocytes. Patient was treated conservatively with analgesics and physiotherapy. He had good relief of pain and is on regular follow-up till date. Discussion: Osteoarthritis knee is the most prevalent and leading cause of pain and disability worldwide. Subchondral cysts are strongly associated with osteoarthritis. Articular cartilage damage in osteoarthritis exposes the subarticular bone to injury, particularly in the weight-bearing joints. Large cysts are a well-recognized feature of other disorders such as simple bone cyst, aneurysmal bone cyst, giant cell tumor, and osteomyelitis. As these cases are rarely reported the treatment options are not standardized. Studies had shown similar cases treated both conservatively and surgically. The occurrence of the pathological fracture in these cases is high so prophylactic surgical fixation of massive geodes is advised. We decided to treat our case conservatively with analgesics and physiotherapy. The patient has good relief of pain at present and is on regular follow-up. He has been counseled that he may need a total knee replacement in the future if pain increases in severity. Conclusion: In the presence of osteolytic lesion showing very large cyst with cortical expansion and septations in radiographs with adjacent joint arthritis, the diagnosis of subchondral cyst/Geode should be strongly considered.

Six-Week Old Neglected Homolateral Lisfranc Injury - A Case Report.

Introduction: Lisfranc injury is relatively rare and is commonly missed at the initial presentation as these injuries are easily misdiagnosed as a foot sprain. We report a case of chronic foot pain following an injury which was later diagnosed to be a neglected 6 weeks old complex Lisfranc fracture dislocation. Case Report: A 53-year-old man presented with chronic foot pain and swelling which was diagnosed to be a neglected 6-week-old homolateral type of Lisfranc injury (type A Hard castle and Meyerson). We treated him with open reduction and internal fixation (ORIF) with plates and screws and achieved excellent functional outcome at 6-month follow-up period. Discussion: Lisfranc injuries are frequently undetected with estimates ranging from 20% to 80%. Anteroposterior, lateral, and medial oblique views of the foot should be included in the radiological workup following a thorough physical examination. Our case will aid the deficient literature and guide the young surgeons in management of such cases. Conclusion: Given the history and nature of the injury, it can be easily missed by a beginner and the clinician must keep a high index of suspicion when treating these injuries in emergency department. To prevent the many complications linked to this kind of injury, it requires a correct diagnosis and timely treatment in the form of closed/open reduction and fixation. Delayed presentation of such cases can be treated with ORIF and good functional outcome can be achieved.

Post-Traumatic Large Segmental Bone Loss - Does Bone Transport Obviate the Need for Successful Soft-Tissue Cover - A Case Report.

Introduction: Management of open tibial fractures with large bone segment and soft-tissue loss can be challenging. To restore the functionality of the limb, the continuity of the soft-tissue envelope and bone needs to be achieved. Case Report: A 29-year-old gentleman sustained right leg crush injury and open Gustilo Anderson Grade IIIB right tibia shaft fracture with 17.2 cm tibial shaft bone segment loss and large soft-tissue defect. An initial free flap failed. In spite of this, the functionality of the limb was restored by bone transport using Ilizarov method. Conclusion: The case report details the surgical technique and obstacles encountered and illustrate that bone transport using Ilizarov technique not only regenerates bone but can facilitate healing of soft tissues.

A Wrong Punch and a Rare Fracture! - A Case Report of Isolated Fourth and Fifth Metacarpal Base Fracture.

Introduction: Isolated displaced fourth and fifth metacarpal base fracture without a carpometacarpal joint subluxation or carpal bone fracture by a punch injury is extremely rare. The site of the fracture in the metacarpal is determined by the type and direction of punch. These fractures usually occur as a result of misdirected blow or wrong punch on a hard surface with a clenched fist. To best of our knowledge, there are only few published case reports. The difficulties in management and biomechanics of such fractures with 10 months follow-up are discussed in this case report. Case Report: A 37-year-old male right hand dominant person presented with pain and swelling of the right hand after punching a wall. The difficulties in reduction and fixation of such fracture, the functional and radiological outcome of minimally open Kirschner wires fixation of this type of fracture with 10-month follow-up and the fracture biomechanics has been discussed in this case report. Conclusion: Clenched fist injury not always means a boxer fracture. This kind of rare fracture is also a possibility and should kept as a differential diagnosis. These fractures are easily misinterpreted by a beginner. Meticulous reduction techniques and fixation will yield better results.

Neglected Acromion Fracture Causing Chronic Post-traumatic Shoulder Pain - A Case Report.

Introduction: Patient presented with persistent shoulder pain 8 months following an injury which was diagnosed to be an old non-united missed acromion fracture. The difficulties in diagnosing such fracture, the functional and radiological outcome of surgical fixation of this type of missed acromion fracture with 6-month follow-up has been discussed in this case report. Case Report: We report a case of 48-year-old male who presented to us with chronic shoulder pain following an injury which was later diagnosed to be a missed non-united acromion fracture. Conclusion: Acromion fractures are commonly missed. Non-united acromion fractures can cause significant chronic post-traumatic shoulder pain. Reduction and internal fixation can alleviate the pain with a good functional result.

Spondyloepiphyseal Dysplasia Tarda with Progressive Arthropathy Associated with Early-onset Hip Arthritis - A Case Report.

INTRODUCTION: Spondyloepiphyseal dysplasia tarda with progressive arthropathy (SEDT-PA) is a rare inherited dysfunction with autosomal recessive inheritance. SEDT-PA is also named as progressive pseudorheumatoid arthropathy of childhood as it is associated with multiple joint contractures and arthritis. We report a case of SEDT-PA managed with bilateral stage total hip arthroplasty. CASE REPORT: A 22-year-old lady presented with severe bilateral hip arthritis. Based on her clinical and radiological features described in this article, she was diagnosed as having SEDT-PA. She was managed with bilateral stage total hip arthroplasty. The pre-operative planning and technical challenges of performing this procedure have been described. CONCLUSION: Dysfunctions originally of genetic origin like spondyloepiphyseal dysplasia tarda mimics and is commonly misdiagnosed as juvenile chronic arthritis. These patients have disabling early-onset hip arthritis which requires surgery. Arthroplasty is challenging in these patients because of the low proximal femur offset but good results can be obtained after thorough pre-operative planning to tackle intraoperative difficulties.

Recurrent Non-Ossifying Fibroma in Shaft of Distal Radius- A Rare Case.

INTRODUCTION: Non-ossifying fibroma are is a common benign lesions found in children. Usually, they are found in cortical bone in metaphysis, but they can also be seen in cancellous bone. Theses lesions are known to regress spontaneously. Usually, it is asymptomatic and an incidental finding on radiograph. No intervention is required. Here, we are reporting a case of symptomatic non-ossifying fibroma of radius with unusual characteristics which required surgical intervention. CASE REPORT: An 11-year-old skeletally immature girl presented to us two 2 years back with pain and swelling over the right forearm without any restriction of moments and other constitutional symptoms. She was diagnosed to have non-ossifying fibroma and had underwent surgery for the same 4years back. Radiographic and higher imaging studies suggested non-ossifying fibroma. Since the lesion was painful and the child had difficulty in carrying heavy objects, we decided to intervene. Tumour tissue was thoroughly curetted and the defect was filled with artificial bone substitute. Biopsy confirmed the diagnosis of non-ossifying fibroma and post-operative radiograph showed some residual tumour which was noted even at one 1-year follow-up X-ray. On 3-years follow-up,the patient was symptom-free with no residual lesion and complete incorporation of the artificial bone substitute. CONCLUSION: Though Although most of the NOF regress completely without intervention, large and symptomatic lesions in unusual location require to be surgically treated. The natural history of the lesion - spontaneous regression also aids in the management.

A Rare Case of Phosphaturic Tumor/Oncogenic Osteomalacia - Diagnostic Challenges and Management Algorithm.

INTRODUCTION: Oncogenic osteomalacia is a rare paraneoplastic syndrome of acquired hypophosphatemic osteomalacia, resulting from a deficit in renal tubular phosphate reabsorption, in which fibroblast growth factor 23 seems to be implicated. CASE REPORT: A 42-year-old male presented with complaints of low back pain for the past 4 years and inability to walk for the past 3 years. Blood investigations showed hypophosphatemia and elevated serum alkaline phosphatase. Radiographs and magnetic resonance imaging revealed features of osteomalacia. DOTONAC PET-computed tomography (CT) showed a lesion in the greater trochanter suggestive of a phosphaturic mesenchymal tumor. CT-guided biopsy of the lesion was done which confirmed the diagnosis. The tumor was resected by intralesional methods (burring and cementation) with correction of hypophosphatemia by oral phosphorus supplementation. Patient clinically improved and was able to walk with support at the time of discharge. CONCLUSION: Phosphaturic tumor was localized to be in the posterior aspect of the right greater trochanter. To find the tumor was a major diagnostic challenge involving various diagnostic modalities. The occurrence of such a condition is rare and it may take even years to correctly diagnose the disease.

A Rare Case of Distal Humerus Intraosseous Arteriovenous Malformation.

INTRODUCTION: Primary intraosseous arteriovenous malformations (AVMs) are rare and have only been occasionally reported. We herein report a histologically proven case of primary intraosseous AVM in the distal humerus which mimicked an osteomyelitis on radiography. CASE REPORT: A 27-year-old male presented with complaints of the right elbow pain and stiffness for the past 3 years. He had initially taken treatment at an outside hospital where he was suspected to have right distal humerus osteomyelitis and underwent curettage and biopsy in June 2017. He presented to us in August 2018 with persistent pain even following the first surgery. Repeat radiographs and computed tomography of the right elbow showed features of osteolytic lesion involving the right lateral humeral condyle just adjacent to olecranon fossa (Fig. 1 and 2). Through posterior triceps, splitting approach para-olecranon lesion was resected by intralesional method (burring), and vancomycin-impregnated calcium sulfate (Stimulan) beads were packed in the defect as infection was suspected (Fig. 3). Clinical improvement and restoration of full range of elbow motion were observed on follow-up. Biopsy report surprisingly suggested arteriovenous malformation. CONCLUSION: Osteolytic lesion was localized in the lateral margin of the olecranon fossa (Fig. 2a and b). To reach the lesion during surgery was a major challenge as localization of the lesion was missed out by the previous surgery. The occurrence of such a condition is rare and it may take even years to correctly diagnose the disease.

A Case of Fibrous Dysplasia with Bilateral Shepherd Crook Deformity Treated with Dynamic Hip Screw Fixation.

INTRODUCTION: Fibrous dysplasia is a rare benign disorder of the skeletal system characterized by fibro-osseous proliferation with intervening areas of normal or immature bone in the intramedullary region. It can either be a monostotic (involves one bone) or a polyostotic (involves more than one bone) presentation and usually occurs equally in males and females. Deformities such as scoliosis and shepherd's crook deformity are frequently encountered in the polyostotic form. We report the management of a rare managed case of bilateral shepherd's crook deformity of the proximal femur with impending neck of femur fracture. CASE REPORT: A 22-year-old male known case of polyostotic fibrous dysplasia presented with bilateral shepherd's crook deformity of the proximal femur. Preoperatively, neck-shaft angle was 15° on the right side and 55° on the left side. The patient had severe pain on the right side due to an impending neck of femur fracture. On the right side, we first did a valgus osteotomy in the subtrochanteric region and fixed with dynamic hip screw, and after 3 months, the left proximal femur valgus osteotomy with dynamic hip screw fixation was done. Postoperatively, we achieved a neck-shaft angle of 140° on the right side and 135° on the left side. 1-year follow-up imaging showed union at both the osteotomy sites. At present, at 12-month post-operative, the patient is walking full weight-bearing without support, no apparent shortening. CONCLUSION: Valgus osteotomy is an easy and effective method to correct the shepherd's crook deformity and achieve correct mechanical alignment. Valgization of the shepherd crook deformity will prevent the development of a pathological neck of femur fracture.

Neuropathic Knee Joint - A Complication of Syrinx Following Spinal Anesthesia: A Rare Case Report and Review of Literature.

INTRODUCTION: Neurological complications due to spinal anesthesia are dysesthesia, paresthesia, cauda equina syndrome, and neuropathic joint. However, neurological complications are rare. We report a case of neuropathic joint of knee as a complication of syrinx following postspinal anesthesia. CASE REPORT: A 33-year-old female came with complaints of pain and instability of her left knee and left foot drop. She had developed weakness of her left lower limb following her cesarean section surgery done under spinal anesthesia. Clinically and radiologically, she had features of the neuropathic left knee joint which had occurred as a complication of syrinx following spinal anesthesia. CONCLUSION: The case is reported for its rarity and to highlight the possible neurological complications of spinal anesthesia.