Case Reports in Orthopedics The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. The Role of Dynamic Contrast-Enhanced MRI in a Child with Sport-Induced Avascular Necrosis of the Scaphoid: A Case Report and Literature Review Tue, 26 Jul 2016 07:58:51 +0000 Avascular necrosis (AVN) of the scaphoid in children is very rare and there is currently no consensus when conservative or operative treatment is indicated. A 10-year-old boy, practicing karate, presented with acute pain in his left wrist after falling on the outstretched hand. Imaging showed a scaphoid waist fracture with signs of an ongoing AVN. The diagnosis of AVN was confirmed with signal loss of the scaphoid on MRI T1. A dynamic contrast-enhanced MRI was performed for further assessment of the proximal pole vascularity and treatment planning. As dynamic contrast-enhanced MRI showed fair perfusion of the proximal pole, an adequate healing potential with conservative treatment was estimated. We achieved union and good function with cast immobilization for fourteen weeks. This case study showed dynamic contrast-enhanced MRI to be a valuable tool in assessing whether conservative or operative treatment is indicated to achieve union and good functional outcome. Baris Beytullah Koc, Martijn Schotanus, Bob Jong, and Pieter Tilman Copyright © 2016 Baris Beytullah Koc et al. All rights reserved. A Rare Case of Tuberculosis with Sacrococcygeal Involvement Miming a Neoplasm Wed, 20 Jul 2016 09:16:34 +0000 Infection of the lumbosacral junction by tuberculosis is quite rare and occurs in only 1 to 2% of all cases of spinal tuberculosis; moreover, isolated sacrococcygeal or coccygeal tuberculosis is much rarer. Failure to identify and treat these areas of involvement at an early stage may lead to serious complications such as vertebral collapse, spinal compression, and spinal deformity. In the present paper, we report an uncommon case of spinal tuberculosis with sacrococcygeal location revealed by a chronic low back pain that was successfully managed. Computed tomography scan and magnetic resonance imaging of the pelvis revealed a lytic lesion affecting both of sacrum and coccyx causing osseous destruction and suggesting a malignant process. A surgical biopsy was performed to establish the tissue diagnosis. Histopathological report confirmed the diagnosis of skeletal tuberculosis. The patient was treated with antibacillary chemotherapy for a period of 9 months. The follow-up period was of 36 months. There was a full recovery and the patient was asymptomatic. Walid Osman, Meriem Braiki, Zeineb Alaya, Thabet Mouelhi, Nader Nawar, and Mohamed Ben Ayeche Copyright © 2016 Walid Osman et al. All rights reserved. Spontaneous Minced Cartilage Procedure for Unexpectedly Large Femoral Condyle Surface Defect Mon, 18 Jul 2016 14:12:57 +0000 Articular cartilage defects at the knee joint are being identified and treated with increasing frequency. Chondrocytes may have strongest potential to generate high-quality repair tissue within the defective region, in particular when large diameter defects are present. Autologous chondrocyte implantation is not available in every country. We present a case where we spontaneously covered an acute cartilage defect, which was significantly larger than expected and loose during initial arthroscopic inspection after reading preoperative MRI, by mincing the separated fragment and directly implanting the autologous cartilage chips into the defective region. G. M. Salzmann, G. A. Baumann, and S. Preiss Copyright © 2016 G. M. Salzmann et al. All rights reserved. Coracoid Process Avulsion Fracture at the Coracoclavicular Ligament Attachment Site in an Osteoporotic Patient with Acromioclavicular Joint Dislocation Sun, 17 Jul 2016 12:54:42 +0000 Coracoid fractures are uncommon, mostly occur at the base or neck of the coracoid process (CP), and typically present with ipsilateral acromioclavicular joint (ACJ) dislocation. However, CP avulsion fractures at the coracoclavicular ligament (CCL) attachment with ACJ dislocation have not been previously reported. A 59-year-old woman receiving glucocorticoid treatment fell from bed and complained of pain in her shoulder. Radiographs revealed an ACJ dislocation with a distal clavicle fracture. Three-dimensional computed tomography (3D-CT) reconstruction showed a small bone fragment at the medial apex of the CP. She was treated conservatively and achieved a satisfactory outcome. CP avulsion fractures at the CCL attachment can occur in osteoporotic patients with ACJ dislocations. Three-dimensional computed tomography is useful for identifying this fracture type. CP avulsion fractures should be suspected in patients with ACJ dislocations and risk factors for osteoporosis or osteopenia. Yoshihiro Onada, Takahisa Umemoto, Kimitaka Fukuda, and Tomomichi Kajino Copyright © 2016 Yoshihiro Onada et al. All rights reserved. A Misguiding Osteoid Osteoma in the Bicipital Tuberosity of the Radius Sun, 17 Jul 2016 12:48:04 +0000 Osteoid osteoma is a benign bone tumor that appears most frequently in young patients. It is more common in males and it concerns mostly the long bones of the lower limb. A 20-year-old young woman presented to our outpatient department with pain in her left elbow. The symptoms began four years ago. At first, her symptoms were attributed to ulnar neuritis, confirmed by nerve conduction studies. In the following two years, she had undergone two surgical operations for decompression of the ulnar nerve. As a result, she reported poor results, which forced her to take frequently anti-inflammatory drugs for some years. When the patient presented to us, we planned a three-phase bone scan and an elbow MRI, which revealed the lesion. Based on the image findings of osteoid osteoma, we proceeded to the surgical removal of the tumor. Since then, the patient is pain-free and has a full range of motion of the affected elbow. Osteoid osteoma usually mimics multiple pathologies in the upper limb especially joint disease posing a challenge for the physician. The diagnosis requires high index of suspicion and a prompt diagnostic and surgical management. Konstantinos Ditsios, Nikolaos Papadakis, Ioannis Theodoroudis, Lazaros Kostretzis, Panagiotis Konstantinou, Iosafat Pinto, and Anastasios Christodoulou Copyright © 2016 Konstantinos Ditsios et al. All rights reserved. INFIX/EXFIX: Massive Open Pelvic Injuries and Review of the Literature Thu, 14 Jul 2016 14:25:36 +0000 Introduction. Open pelvic fractures make up 2–5% of all pelvic ring injuries. Their mortality has been reported to be as high as 50%. During Operation Enduring Freedom protocols for massive open pelvic injuries lead to the survival of injuries once thought to be fatal. The INFIX is a subcutaneous anterior fixator for pelvic stabilization which is stronger than external fixation. The purpose of this paper is to describe the use of INFIX and modern algorithms for massive open pelvic injuries. Methods. An IRB approved retrospective review describes 4 cases in civilian practice with massive open pelvic injuries. We also review the modern literature on open pelvic injures. Discussion. Key components in the care of massive open pelvic injuries include hemorrhage control by clamping of the aorta or REBOA when necessary and fecal/urinary diversion. The INFIX can be used internally, as a partial INFIX partial EXFIX, or as an EXFIX. Its low profile allows for easy application of wound vacs and wound care and when subcutaneous avoids pin tract infections. Conclusion. Massive open pelvic injuries are a difficult problem. Following modern protocols can help prevent mortality. Rahul Vaidya, Kerellos Nasr, Enrique Feria-Arias, Rebecca Fisher, Marvin Kajy, and Lawrence N. Diebel Copyright © 2016 Rahul Vaidya et al. All rights reserved. Morel-Lavallée Lesion of the Knee in a Recreational Frisbee Player Thu, 14 Jul 2016 06:27:41 +0000 Traumatic swelling/effusion in the knee region is a relatively common presenting complaint among athletes and nonathletes. Due to its broad differential diagnosis, a comprehensive evaluation beginning with history and physical examination are recommended. Knee joint effusion can be differentiated from other types of swelling by careful physical examination. Imaging, including plain radiography, ultrasound, and magnetic resonance imaging (MRI), is preferred modality. Aspiration of a local fluctuating mass may help with the diagnosis and management of some of these conditions. We present a case of a 26-year-old gentleman with superomedial Morel-Lavallée lesion (MLL) of the knee with history of a fall during a Frisbee game. His MLL was successfully treated with therapeutic aspiration and compression wrap without further sequelae. MLL is a rare condition consisting of a closed degloving injury caused by pressure and shear stress between the subcutaneous tissue and the superficial fascia or bone. Most commonly, MLL is found over the greater trochanter and sacrum but in rare cases can occur in other regions of the body. In most cases, concurrent severe injury mechanisms and concomitant fractures are present. MLL due to sports injuries are very rare. Therapeutic strategies may vary from compression wraps and aspiration to surgical evacuation. Alison Shmerling, Jonathan T. Bravman, and Morteza Khodaee Copyright © 2016 Alison Shmerling et al. All rights reserved. Ultrasound Guidance in Performing a Tendoscopic Surgery to Treat Posterior Tibial Tendinitis: A Useful Tool? Tue, 12 Jul 2016 08:44:58 +0000 A 25-year-old man with a pronation-external rotation type of fracture was surgically treated using a fibular plate. Five years later, he underwent resection of bone hyperplasia because of the ankle pain and limitation of range of motion. Thereafter, the left ankle became intermittently painful, which persisted for about one year. He presented at the age of 43 with persistent ankle pain. Physical and image analysis findings indicated a diagnosis of posttraumatic posterior tibial tendinitis, which we surgically treated using tendoscopy. Endoscopic findings showed tenosynovitis and fibrillation on the tendon surface. We cleaned and removed the synovium surrounding the tendon and deepened the posterior tibial tendon groove to allow sufficient space for the posterior tibial tendon. Full weight-bearing ambulation was permitted one day after surgery and he returned to his occupation in the construction industry six weeks after surgery. The medial aspect of the ankle was free of pain and symptoms at a review two years after surgery. Although tendoscopic surgery for stage 1 posterior tibial tendon dysfunction has been reported, tendoscopic surgery to treat posttraumatic posterior tibial tendinitis has not. Our experience with this patient showed that tendoscopic surgery is useful not only for stage 1 posterior tibial dysfunction, but also for posttraumatic posterior tibial tendinitis. Akinobu Nishimura, Shigeto Nakazora, Aki Fukuda, Ko Kato, and Akihiro Sudo Copyright © 2016 Akinobu Nishimura et al. All rights reserved. A Case of Legg-Calvé-Perthes Disease due to Transient Synovitis of the Hip Mon, 11 Jul 2016 12:07:36 +0000 Transient synovitis (TS) of the hip develops spontaneously in childhood; it usually has a good prognosis and is a self-limiting disease. However, its pathology is not well known. We describe a case of Legg-Calvé-Perthes disease (LCPD) that seemingly developed due to TS. Even if TS is diagnosed on the basis of the patient’s medical history and imaging findings, physicians should consider the possibility of LCPD and perform a careful observation if joint effusion continues and/or a symptom does not improve within 4 weeks. Tadahiko Ohtsuru, Yasuaki Murata, Yuji Morita, Yutaro Munakata, and Yoshiharu Kato Copyright © 2016 Tadahiko Ohtsuru et al. All rights reserved. Sword-Like Trauma to the Shoulder with Open Head-Splitting Fracture of the Head Tue, 05 Jul 2016 10:48:36 +0000 Head-splitting fractures occur as a result of violent compression of the head against the glenoid; the head splits and the tuberosities may remain attached to the fragments or split and separate. Isolated humeral head-splitting fractures are rare injuries. Favorable results with osteosynthesis can be difficult to achieve because of the very proximal location of the head fracture and associated poor vascularity. We present a case of a 67-year-old man who sustained a severe, sword-like trauma to his left shoulder after a road traffic accident with associated isolated open Gustilo-Anderson IIIA humeral head-splitting fracture. Bony union was achieved with minimal internal fixation but the clinical outcome deteriorated due to accompanying axillary nerve apraxia. To our knowledge, this type of sword-like injury with associated humeral head-split fracture has not previously been reported. Andreas Panagopoulos, Konstantinos Pantazis, Ilias Iliopoulos, Ioannis Seferlis, and Zinon Kokkalis Copyright © 2016 Andreas Panagopoulos et al. All rights reserved. Traumatic Periprosthetic Acetabular Fracture Treated with One-Stage Exchange and Bone Reconstruction Using a Synthetic Bone Graft Substitute Thu, 30 Jun 2016 11:29:40 +0000 A case of a traumatic periprosthetic acetabular fracture in an elderly patient, which was treated by one-stage hip exchange with implantation of an antiprotrusio cage and reconstruction of the acetabular bone loss with an injectable calcium sulphate/hydroxyapatite bone graft substitute, is reported. The paste-like bone graft substitute was injected through the holes of the antiprotrusio cage. After a setting time of 15 minutes, a low-profile cup was cemented onto the cage using polymethylmethacrylate and a new stem was inserted. The patient was encouraged to ambulate three days postoperatively weight-bearing as tolerated. At the one-year follow-up visit the patient was ambulatory and full weight-bearing without any walking aids. The follow-up radiographs demonstrated stable position and articulation of the revision hip arthroplasty with no signs of loosening of the antiprotrusio cage. However, the most interesting finding was that the bone graft substitute had remodelled to a great extent into bone. This calcium sulphate/hydroxyapatite composite shows high osteoconductive potential and can be used to regenerate bone stock in revision arthroplasty. Jan Svacina Copyright © 2016 Jan Svacina. All rights reserved. Surgical Management of Intracanal Rib Head Dislocation in Neurofibromatosis Type 1 Dystrophic Kyphoscoliosis: Report of Two Cases and Literature Review Thu, 30 Jun 2016 08:11:45 +0000 There is still no consensus on the management of severe intracanal RH dislocation in neurofibromatosis type 1 dystrophic kyphoscoliosis. This study notes the early cord function impairment signs, reports a serious complication in a susceptible cord, identifies possible mechanisms of injury, and discusses the management of intracanal RH dislocation presented in the literature. First report is as follows: a 12-year-old female with cord compromise and preoperative neurology that underwent thoracotomy and anterior release. The RH was left in situ following a rib excision. During the posterior stage of the procedure she presented with complete loss of all IOM traces prior to any correction manoeuvres. The neurology recovered 72 h postop and the final correction and instrumented fusion were uneventfully completed 15 days postop. Second report is as follows: a 10-year-old male, whose only neurology was a provoked shock-like sensation to the lower limbs following direct pressure on the rib cage. He underwent an uneventful posterior RH excision and instrumented correction and posterior spinal fusion. In conclusion, any possible cord dysfunction sign should be sought during examination. Decompression of the spinal cord by resecting the impinging bony part, even in the absence of neurological symptoms, is advised before any attempt to release or correct the deformity. George I. Mataliotakis, Nikolaos Bounakis, and Enrique Garrido-Stratenwerth Copyright © 2016 George I. Mataliotakis et al. All rights reserved. Nontraumatic Myositis Ossificans of Hip: A Case Presentation Wed, 29 Jun 2016 10:44:56 +0000 In most of the cases trauma is the leading etiology and the nontraumatic myositis ossificans (MO) is a very rare condition. We present an MO case without any trauma occurring. A 36-year-old female patient with a history of pain and restriction of range of motion of the left hip was admitted. Hip motions were restricted with 10–60° of flexion, 10° of internal rotation, 20° of external rotation, 10° of abduction, and 10° of adduction. There was no history of trauma and familial involvement. The biopsy of the lesion revealed mature bone tissue confirming our diagnosis of MO. The mass was removed surgically and postoperatively the patient was treated with a single dose radiotherapy with 800 gyc. MO is a benign and well differentiated bone formation or in other words heterotopic ossification of the muscle tissue. It has a prevalence of less than 1/1 million. Trauma is the most frequent etiological factor seen in almost 60–75% of the cases. Nontraumatic MO is very rare in the literature. Our patient had no history of trauma or familial involvement. Combination of the surgical excision with radiotherapy in the treatment of the MO of the hip may give satisfactory results. Yunus Oc, Muhammed Sefa Ozcan, Hasan Basri Sezer, Bekir Eray Kilinc, and Osman Tugrul Eren Copyright © 2016 Yunus Oc et al. All rights reserved. Spontaneous Regression of Herniated Lumbar Disc with New Disc Protrusion in the Adjacent Level Sun, 26 Jun 2016 10:11:04 +0000 Spontaneous regression of herniated lumbar discs was reported occasionally. The mechanisms proposed for regression of disc herniation are still incomplete. This paper describes and discusses a case of spontaneous regression of herniated lumbar discs with a new disc protrusion in the adjacent level. A 41-year-old man was admitted with radiating pain and numbness in the left lower extremity with a left posterolateral disc extrusion at L5-S1 level. He was admitted to hospital with low back pain due to disc herniation caudally immigrating at L4-5 level three years ago. He refused the surgical intervention that was offered and was treated conservatively at that time. He had no neurological deficit and a history of spontaneous regression of the extruded lumbar disc; so, a conservative therapy, including bed rest, physical therapy, nonsteroidal anti-inflammatory drugs, and analgesics, was advised. In conclusion, herniated lumbar disc fragments may regress spontaneously. Reports are prone to advise conservative treatment for extruded or sequestrated lumbar disc herniations. However, these patients should be followed up closely; new herniation at adjacent/different level may occur. Furthermore, it is important to know which herniated disk should be removed and which should be treated conservatively, because disc herniation may cause serious complications as muscle weakness and cauda equine syndrome. Tayfun Hakan and Serkan Gürcan Copyright © 2016 Tayfun Hakan and Serkan Gürcan. All rights reserved. Stress Fracture and Nonunion of Coronoid Process in a Gymnast Thu, 23 Jun 2016 14:59:13 +0000 Background. Gymnasts have high mechanical loading forces of up to 14 times body weight. Overuse lesions are typical in wrists and stress fractures in the olecranon, while isolated fractures of the coronoid process are uncommon. We present a case of retraumatized nonunion stress fracture of the ulnar coronoid process. Case Description. A 19-year-old gymnast presented with elbow pain after training. Imaging confirmed an old fracture of the coronoid process. We describe a 6-month multiphase return to competition rehabilitation program, which allowed him to compete pain-freely. Literature Review. Acute and overuse injuries in gymnasts are known but no nonunion of the coronoid process has been described before. Only one case of stress fracture of coronoid process in a gymnast was reported. Purpose and Clinical Relevance. We could successfully and conservatively return to sport a reactivated nonunion of a stress fracture of the coronoid process. T. Hetling, P. Bourban, and B. Gojanovic Copyright © 2016 T. Hetling et al. All rights reserved. A Ruptured Digital Epidermal Inclusion Cyst: A Sinister Presentation Wed, 22 Jun 2016 13:13:25 +0000 Epidermal inclusion cysts are benign cutaneous lesions caused by dermal or subdermal implantation and proliferation of epidermal squamous epithelium as a result of trauma or surgery. They are typically located on the scalp, face, trunk, neck, or back; however they can be found anywhere on the body. Lesions are asymptomatic unless complicated by rupture, malignant transformation to squamous cell carcinoma, or infection at which point they can clinically appear as more sinister pathologies. We present the case of a 45-year-old laborer with a ruptured epidermal inclusion cyst, manifesting clinically and radiographically as a malignancy. Following MRI, definitive surgical management may appear to be a logical progression in management of the patient. This case however is a good example of why meticulously following surgical protocol when evaluating an unknown soft tissue mass is imperative. By following protocol, an alternate diagnosis was made and the patient has since gone on to a make a full recovery without life transforming surgery. Iain Bohler, Phillip Fletcher, Amanda Ragg, and Andrew Vane Copyright © 2016 Iain Bohler et al. All rights reserved. Fabella Syndrome as an Uncommon Cause of Posterolateral Knee Pain after Total Knee Arthroplasty: A Case Report and Review of the Literature Tue, 21 Jun 2016 09:18:02 +0000 The fabella is a sesamoid bone that is located in the lateral head of the gastrocnemius muscle and has been identified on magnetic resonance imaging in 31% of Japanese people. In the present case, a 65-year-old woman experienced posterolateral knee pain, accompanied by a clicking “sound” during active knee flexion, after undergoing total knee arthroplasty for knee osteoarthritis. Eight months of conservative therapy failed to produce an improvement, with progressive osteoarthritic change of the fabella identified on plain radiography. Based on this evidence, a diagnosis of fabella syndrome was made and the patient underwent a fabellectomy. Fabellectomy provided immediate resolution of posterolateral knee pain and the clicking sound with knee flexion, with the patient remaining symptom-free 18 months after fabellectomy and with no limitations in knee function. Fabellectomy eliminated symptoms in all of five case reports that have been previously published and is regarded as an effective first choice for treating fabella syndrome after total knee arthroplasty. Eriko Okano, Tomokazu Yoshioka, Takaji Yanai, Sho Kohyama, Akihiro Kanamori, Masashi Yamazaki, and Toshikazu Tanaka Copyright © 2016 Eriko Okano et al. All rights reserved. Lower Limb Reconstruction with Tibia Allograft after Resection of Giant Aneurysmal Bone Cyst Mon, 20 Jun 2016 16:01:53 +0000 Aneurysmal bone cysts (ABCs) are benign, expansible, nonneoplastic lesions of the bone, characterized by channels of blood and spaces separated by fibrous septa, which occur in young patients and, occasionally, with aggressive behavior. Giant ABC is an uncommon pathological lesion and can be challenging because of the destructive effect of the cyst on the bones and the pressure on the nearby structures, especially on weight-bearing bones. In this scenario, en bloc resection is the mainstay treatment and often demands complex reconstructions. This paper reports a difficult case of an unusual giant aneurysmal bone cyst, which required extensive resection and a knee fusion like reconstruction with tibia allograft. Joaquim Soares do Brito, Joana Teixeira, and José Portela Copyright © 2016 Joaquim Soares do Brito et al. All rights reserved. Scoliosis Surgery in Cystic Fibrosis: Surgical Considerations and the Multidisciplinary Approach of a Rare Case Sun, 19 Jun 2016 10:39:53 +0000 Spinal deformity in patients with cystic fibrosis (CF) is usually mild requiring no treatment. These patients are rarely considered as surgical candidates for scoliosis correction, as the pulmonary condition and other comorbidities increase the risk of general anaesthesia and recovery. This paper reviews all the literature up to date with regard to scoliosis in patients with CF and reports this unique case of a 14-year-old Caucasian girl with progressive scoliosis, who was treated surgically at the age of 17. She underwent a posterior spinal fusion T2-L3 with the use of unilateral segmental instrumentation. Preoperative workup included respiratory, cardiac, anaesthetic, endocrine, and dietician reviews, as well as bone density optimisation with zoledronic acid and prophylactic antibiotics. Surgical time was 150 minutes and intraoperative blood loss was 47% of total blood volume. Postoperative intensive care included noninvasive ventilation, antibiotic cover, pain management, chest physiotherapy, pancreatic enzyme supplementation, and nutritional support. She was discharged on day 9. At follow-up she had a good cosmetic outcome, no complaints of her back, and stable respiratory function. Multidisciplinary perioperative care and meticulous surgical technique may reduce the associated risks of major surgery in CF patients, while achieving adequate deformity correction and a good functional outcome. George I. Mataliotakis, Athanasios I. Tsirikos, Karen Pearson, Don S. Urquhart, Carolyn Smith, and Andrew Fall Copyright © 2016 George I. Mataliotakis et al. All rights reserved. Anatomic Locking Plate Fixation for Scaphoid Nonunion Mon, 06 Jun 2016 09:48:10 +0000 Nonunion can occur relatively frequently after scaphoid fracture and appears to be associated with severity of injury. There have been a number of techniques described for bone grafting with or without screw fixation to facilitate fracture healing. However, even with operative fixation of scaphoid fractures with bone grafting nonunion or malunion rates of 5 to 10 percent are still reported. This is the first report of an anatomic locking plate for scaphoid fracture repair in a 25-year-old right hand dominant healthy male. Joshua Mirrer, Just Yeung, and Anthony Sapienza Copyright © 2016 Joshua Mirrer et al. All rights reserved. Occult Cranial Cervical Dislocation: A Case Report and Brief Literature Review Sun, 05 Jun 2016 09:26:59 +0000 Study Design. Retrospective case report and review. Objective. Cranial cervical dislocation (CCD) is commonly a devastating injury. Delay in diagnosis has been found to lead to worse outcomes. Our purpose is to describe a rare case of occult cranial cervical dislocation (CCD) and use it to highlight key clinical and radiographic findings to ensure expedited diagnosis and proper management avoiding delays and subsequent neurologic deterioration. Method. Case report with literature review. Results. We describe a unique case of occult cranial cervical dislocation where initial imaging of the cervical spine failed to illustrate displacement of the occipital-cervical (O-C1) articulation or C1-C2 articulation. Careful evaluation of subtle radiographic clues suggested a more severe injury than initial review. Additional imaging was obtained due to these subtle clues confirming true cranial cervical dislocation allowing subsequent treatment with no neurologic sequelae. Conclusion. A high index of suspicion of CCD may prevent injury in select patients who present without gross cord compromise. Careful consideration of associated fractures, soft tissue injuries, and mechanism of injury are essential clues to the correct diagnosis and management of injuries to the craniocervical junction (CCJ). Joshua B. Shatsky, Timothy B. Alton, Carlo Bellabarba, and Richard J. Bransford Copyright © 2016 Joshua B. Shatsky et al. All rights reserved. Fabella Fractures after Total Knee Arthroplasty with Correction of Valgus Malalignment Wed, 01 Jun 2016 07:28:48 +0000 The incidence of fabella fractures is considered to be extremely low. This report presents two patients with femorotibial osteoarthritis and considerable preoperative valgus malalignment, who developed a fracture of the fabella (as demonstrated by radiography) after total knee arthroplasty with intraoperative correction of the valgus malalignment. Special attention should be paid to the fabella for not missing a fabella fracture in these patients. Thomas Christian Kwee, Ben Heggelman, Robert Gaasbeek, and Maarten Nix Copyright © 2016 Thomas Christian Kwee et al. All rights reserved. Tuberculous Spondylitis following Intravesical Bacillus Calmette-Guerin for Bladder Cancer Mon, 30 May 2016 12:55:39 +0000 We present a rare case of tuberculous spondylitis following intravesical Bacillus Calmette-Guerin (BCG) therapy for bladder cancer. An 82-year-old man presented with low back pain. Past medical history revealed bladder cancer diagnosed and treated 16 months previously by intravesical BCG. Magnetic resonance imaging of the thoracic spine showed destruction of the T5 and T6 vertebrae and an epidural soft tissue mass with anterior dural sac compression. Due to the progression of vertebral destruction, posterior spinal segmental fusion was performed. Mycobacterium bovis (M. bovis) was identified using multiplex polymerase chain reaction of surgical tissue specimens. The patient was started on an antituberculosis treatment regimen including isoniazid, rifampicin, and ethambutol. After surgery, his back pain resolved completely. At the latest examination, the patient was pain-free with no functional limitations or recurrent infection in clinical or imaging findings. Patients undergoing BCG therapy should be monitored for possible hematogenous spread of mycobacteria to the spine for months or even years after treatment. Masashi Miyazaki, Toyomi Yoshiiwa, Toshinobu Ishihara, Masanori Kawano, and Hiroshi Tsumura Copyright © 2016 Masashi Miyazaki et al. All rights reserved. Weber B Fracture of the Lateral Malleolus with Concomitant Anterior Talofibular Ligament Injury following an Ankle Supination Injury Sun, 29 May 2016 13:40:16 +0000 The Lauge-Hansen (LH) classification attempts to predict patterns of ankle injuries based upon the preceding mechanism of injury. Although it is widely used in clinical practice, it has been criticized mainly due to numerous reports of cases conflicting the prediction system. Here, we report a case of a 32-year-old male who sustained a Weber B fracture of the lateral malleolus following a supination ankle injury, which was treated conservatively, following which the patient presented with ankle instability and was found to have concurrent anterior talofibular ligament tear. Critical review of the LH classification along with its shortcomings is discussed. Mohammed Khalid Faqi, Abdulla AlJawder, Fahad Alkhalifa, and Ali H. Almajed Copyright © 2016 Mohammed Khalid Faqi et al. All rights reserved. A Case Report of Isolated Cuboid Nutcracker Fracture Thu, 26 May 2016 09:38:00 +0000 Isolated cuboid fractures are very rare, since they typically occur in combination with midfoot fractures or dislocations. A 61-year-old man presented at our hospital with pain and swelling on the outside of his right foot. The lateral column of his right foot was shortened by approximately 6.5 mm on X-ray. CT showed displacement of the joint surface between the cuboid and the fourth metatarsal, with a 3.5 mm depression. An MRI revealed no other injuries. Based on these findings, we diagnosed the patient with an isolated nutcracker fracture of the cuboid. Using a 1.9 mm arthroscope, we examined the Lisfranc joint. Then the depressed fragments were elevated until the regular joint line was restored. A bone biopsy needle was then used to fill in the large defect with artificial bone. In this case, we did not plate the fracture. Six months after surgery, patient could walk without pain. We report a very rare case of isolated nutcracker fracture of the cuboid. In addition, we suggest our new treatment plan of this fracture. Takaaki Ohmori, Shinichi Katsuo, Chiaki Sunayama, Katsunori Mizuno, Tomohiro Ojima, Kotaro Yamakado, Tomonari Ando, Shin Watanabe, Seigaku Hayashi, and Hiroyuki Tsuchiya Copyright © 2016 Takaaki Ohmori et al. All rights reserved. Late Occurring Medial Migration of a Lag Screw in Gamma Nailing Mon, 23 May 2016 11:52:39 +0000 An 81-year-old female was treated for a pertrochanteric multifragmentary fracture of the proximal femur with a third-generation Gamma nail. After 3 months she presented herself again with acute pain and inability to bear weight on the leg. Radiographs showed medial migration of the lag screw. She was treated with a total hip arthroplasty, after which she was successfully discharged. In this case report the possible causes of this late and unusual complication are discussed. S. van Hoef, M. C. H. W. Fuchs, and R. H. M. ten Broeke Copyright © 2016 S. van Hoef et al. All rights reserved. Hemodynamic Instability after Low-Energy Thigh Contusion Caused by Injury to the Femoral Artery: A Case Report and Literature Review Wed, 18 May 2016 12:28:31 +0000 Acute vascular injuries have been described in relation to high-energy trauma accidents or in patients undergoing surgery in the femoral area. We describe a healthy patient who sustained a direct, low-energy contusion in the thigh and presented haemodynamic instability. Arteriography was used to locate the point of bleeding, and embolisation and vessel occlusion were carried out to stop the haemorrhage. The genetic study identified the COL3A1 gene mutation; accordingly, the patient was diagnosed with the Ehlers-Danlos syndrome type IV (vascular type). Juan Miguel Rodríguez-Roiz, José Ballesteros-Betancourt, Raquel García-Tarriño, Victor Antonio Rodríguez-Roiz, and Manuel Llusa Copyright © 2016 Juan Miguel Rodríguez-Roiz et al. All rights reserved. Lipoma Arborescens: Review of an Uncommon Cause for Swelling of the Knee Mon, 16 May 2016 13:41:20 +0000 Lipoma arborescens is a rare cause of chronic monoarticular arthritis, with only a few cases reported in the literature. It is most commonly seen in the knee, but cases in other joints such as the wrist, shoulder, and elbow have also been described. It is a benign condition, in which the subsynovial tissue is replaced diffusely by mature fat cells. We describe a case involving the knee and discuss the symptoms, diagnosis, and treatment. M. De Vleeschhouwer, E. Van Den Steen, G. Vanderstraeten, W. Huysse, J. De Neve, and L. Vanden Bossche Copyright © 2016 M. De Vleeschhouwer et al. All rights reserved. Femoral Varus Osteotomy for Hip Instability after Traumatic Fracture Dislocations of the Hip Associated with Femoral Head Fractures: A Report of Two Cases Mon, 16 May 2016 12:52:12 +0000 Fracture of the femoral head and the acetabulum with traumatic dislocation of the hip is a severe injury representing various types and unfavorable outcome. We showed a 45-year-old man with Pipkin type-IV fracture and coxa valga. An immediate closed reduction was achieved followed by open reduction and internal fixation via a posterior approach 6 days later. However, dislocation occurred three times without traumatic events after three weeks. CT demonstrated no displacement of posterior fragments or implant failure. Femoral intertrochanteric varus osteotomy was performed to gain concentric stability and successfully resolved recurrent dislocation. Another 45-year-old woman with Pipkin type-IV fracture and coxa valga also underwent closed reduction initially and then continued conservative treatment. After eight weeks, when she started gait training, progressive pain became symptomatic. Persistent hip pain at weight bearing was not improved in spite of arthroscopic synovectomy and osteochondroplasty. Two years after injury, femoral intertrochanteric varus osteotomy was indicated and her refractory pain was resolved gradually. We suggest that femoral varus osteotomy should be considered for superolateral subluxation associated fracture dislocation of the hip in Pipkin type-IV and coxa valga. Shuichi Miyamoto, Junichi Nakamura, Satoshi Iida, Chiho Suzuki, Seiji Ohtori, Sumihisa Orita, and Kazuhisa Takahashi Copyright © 2016 Shuichi Miyamoto et al. All rights reserved. Black Colouration of the Knee Articular Cartilage after Spontaneously Recurrent Haemarthrosis Thu, 12 May 2016 08:16:36 +0000 Mild discolouration of the articular cartilage is known to gradually occur during aging. However, pathological tissue pigmentation is occasionally induced under several specific conditions. In the present case, we performed total knee replacement in a patient with recurrent haemarthrosis. However, during the operation, we observed severe black colouration of the knee articular cartilage, due to the deposition of hemosiderin and lipofuscin. To our knowledge, this is the first report of severe cartilage pigmentation, due to hemosiderin and lipofuscin deposition in articular cartilage. Kazu Matsumoto, Daichi Ishimaru, Hiroyasu Ogawa, and Haruhiko Akiyama Copyright © 2016 Kazu Matsumoto et al. All rights reserved.