Case Reports in Orthopedics The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Nonsurgical Corrective Union of Osteoporotic Vertebral Fracture with Once-Weekly Teriparatide Thu, 30 Jul 2015 12:17:12 +0000 Osteoporotic vertebral fractures usually heal with kyphotic deformities with subsidence of the vertebral body when treated conservatively. Corrective vertebral union using only antiosteoporotic pharmacotherapy without surgical intervention has not been reported previously. An 81-year-old female with osteoporosis presented with symptomatic fresh L1 vertebral fracture with intravertebral cleft. Segmental vertebral kyphosis angle (VKA) at L1 was 20° at diagnosis. Once-weekly teriparatide administration, hospitalized rest, and application of a thoracolumbosacral orthosis alleviated symptoms within 2 months. Corrective union of the affected vertebra was obtained with these treatments. VKA at 2 months after injury was 8° (correction, 12°) and was maintained as of the latest follow-up at 7 months. Teriparatide has potent bone-forming effects and has thus been expected to enhance fracture healing. Based on the clinical experience of this case, teriparatide may have the potential to allow correction of unstable vertebral fractures without surgical intervention. Naohisa Miyakoshi, Akira Horikawa, and Yoichi Shimada Copyright © 2015 Naohisa Miyakoshi et al. All rights reserved. Surgical Correction of Posttraumatic Scapulothoracic Bursitis, Rhomboid Major Muscle Injury, Ipsilateral Glenohumeral Instability, and Headaches Resulting from Circus Acrobatic Maneuvers Sun, 26 Jul 2015 11:08:34 +0000 We report the case of a 28-year-old transgender (male-to-female) patient that had a partial tear of the rhomboid major tendon, scapulothoracic bursitis, and glenohumeral instability on the same side. These conditions resulted from traumatic events during circus acrobatic maneuvers. Additional aspects of this case that make it unique include (1) the main traumatic event occurred during a flagpole exercise, where the patient’s trunk was suspended horizontally while a vertical pole was grasped with both hands, (2) headaches were associated with the periscapular injury and they improved after scapulothoracic bursectomy and rhomboid tendon repair, (3) surgical correction was done during the same operation with an open anterior capsular-labral reconstruction, open scapulothoracic bursectomy without bone resection, and rhomboid tendon repair, (4) a postoperative complication of tearing of the serratus anterior and rhomboid muscle attachments with recurrent scapulothoracic pain occurred from patient noncompliance, and (5) the postoperative complication was surgically corrected and ultimately resulted in an excellent outcome at the one-year final follow-up. John G. Skedros, Tanner D. Langston, and Colton M. Phippen Copyright © 2015 John G. Skedros et al. All rights reserved. Fracture of the Modular Neck in Total Hip Arthroplasty Wed, 22 Jul 2015 10:02:19 +0000 Modularity of the components in total hip arthroplasty has had an increase in popularity in the last decades. We present the case of a 53-year-old man with a history of avascular necrosis of the femoral head due to a hypophyseal adenoma. A total hip modular arthroplasty was implanted. Three and a half years after the surgery the patient attended the emergency room due to acute left hip pain with no prior traumatism. Radiological examination confirmed a fracture of the modular neck. A revision surgery was performed finding an important pseudotumoral well-organized periprosthetic tissue reaction. Through an extended trochanteric osteotomy the femoral component was removed, and a straight-stem revision prosthesis implanted. There are several potential advantages when using modularity in total hip arthroplasty that surgeons may benefit from, but complications have arisen and must be addressed. Various circumstances such as large femoral head with a long varus neck, corrosion, patient’s BMI, and activity level may participate in creating the necessary environment for fatigue failure of the implant. A. Hernandez, A. Gargallo-Margarit, V. Barro, I. Gallardo-Calero, and A. Sallent Copyright © 2015 A. Hernandez et al. All rights reserved. Carpal Tunnel Syndrome Caused by Tumoral Calcinosis Tue, 21 Jul 2015 13:02:48 +0000 We present a case of carpal tunnel syndrome caused by systemic tumoral calcinosis. A 54-year-old woman experienced hand numbness that persisted for nine months. She had no family history or medical problem. A plain radiograph of her right wrist showed a calcified mass on the volar side of the wrist joint. The patient also experienced pain in her contralateral wrist joint and both right and left shoulders, which had calcification on radiography around the joint. Her condition was diagnosed as carpal tunnel syndrome caused by systemic tumoral calcinosis and a resection biopsy was performed. Histopathological analysis of the biopsied specimen showed basophile deposition inside the fibrous connective tissue. At 14 months after the treatment, she no longer had pain or numbness in her fingers and there was no recurrence of the mass. This patient’s condition is considered as a case of nonfamilial, systemic primary tumoral calcinosis. Since incomplete resection leads to a recurrence of the lesion, a follow-up radiography examination is needed to monitor symptom recurrence. Atsuyuki Inui, Takahiro Suzuki, Takeshi Kokubu, Ryosuke Sakata, Yutaka Mifune, and Masahiro Kurosaka Copyright © 2015 Atsuyuki Inui et al. All rights reserved. Postpartum Sacral Stress Fracture: An Atypical Case Report Sun, 12 Jul 2015 11:50:59 +0000 Sacral stress fractures are common in elderly people. However, sacral stress fracture should be always screened in the differential diagnoses of low back pain during the postpartum period. We present a case of sacral fracture in a thirty-six-year-old woman with low back pain and severe right buttock pain two days after cesarean section delivery of a 3.9 Kg baby. The diagnosis was confirmed by MRI and CT scan, while X-ray was unable to detect the fracture. Contribution of mechanical factors during the cesarean section is not a reasonable cause of sacral fracture. Pregnancy and lactation could be risk factors for sacral stress fracture even in atraumatic delivery such as cesarean section. Our patient had no risk factors for osteoporosis except for pregnancy and lactation. Transient or focal osteoporosis is challenging to assess and it cannot be ruled out even if serum test and mineral density are within the normal range. Andrea Speziali, Matteo Maria Tei, Giacomo Placella, Marco Chillemi, and Giuliano Cerulli Copyright © 2015 Andrea Speziali et al. All rights reserved. Biologic Augmentation of the Ulnar Collateral Ligament in the Elbow of a Professional Baseball Pitcher Thu, 09 Jul 2015 06:06:45 +0000 Tears of the ulnar collateral ligament (UCL) of the elbow are common injuries in overhead athletes. Although surgical reconstruction of the UCL has improved outcomes, not all athletes return to their previous level of competition and when this goal is achieved, the time required averages one to two years. Therefore, additional techniques are needed to further improve return to play and the rate of return to play in overhead athletes. A construct comprising a dermal allograft, platelet rich plasma (PRP), and mesenchymal stem cells (MSCs) has been shown to successfully improve healing in the rotator cuff. Given the promising provisional findings, we postulated that this construct could also improve healing if applied to the UCL. Therefore, the purpose of the present report was to examine the feasibility of utilizing a dermal allograft, PRP, and MSC construct to augment UCL reconstruction in a professional baseball pitcher. No complications were encountered. Although limited to minimal follow-up, the patient has demonstrated excellent progress and has returned to activity. James K. Hoffman, Nicole M. Protzman, and Amit D. Malhotra Copyright © 2015 James K. Hoffman et al. All rights reserved. Two Cases of Contact Anterior Cruciate Ligament Rupture Combined with a Posterolateral Tibial Plateau Fracture Wed, 08 Jul 2015 11:02:14 +0000 Background. The combined occurrence of ACL rupture with a posterolateral tibial plateau fracture has not yet been reported. Two cases of such injuries have been treated in our department for the past three years. Findings. The two patients both suffered injuries from traffic accidents. The radiological examinations showed a ruptured ACL with fracture of the posterolateral tibial plateau. Reconstruction of the ACL was performed via a standard anatomical single bundle ACL reconstruction technique with autologous tendon by arthroscopy. A posterolateral tibia plateau approach was used to reduce and fix the fractured area with the aid of lag screws. After a one-year follow-up, the two patients recovered well and physical examinations showed full knee range of motion with no evidence of ACL instability. Conclusions. The cause of this type injury of ACL rupture with a posterolateral tibial plateau fracture was thought to be by a violent internal tibial rotation/anterior tibial translation without any valgus or varus knee force mechanism during the accident. Satisfactory clinical results were achieved with a standard anatomical single bundle ACL reconstruction by arthroscopy and ORIF for the posterolateral plateau fracture. Both patients reported excellent knee function and fracture healing. Liangjun Jiang, Haobo Wu, and Shigui Yan Copyright © 2015 Liangjun Jiang et al. All rights reserved. Neoprene Orthopaedic Supports: An Underrecognised Cause of Allergic Contact Dermatitis Tue, 07 Jul 2015 10:15:39 +0000 Thioureas, often contained within neoprene to provide water resistance, are an important cause of allergic contact dermatitis (ACD) in those who use neoprene products. We wish to present three cases of thiourea-induced ACD from three different orthopaedic supports containing neoprene. The first case was a 67-year-old woman who developed an itchy rash on her heel three weeks after using a neoprene insole for plantar fasciitis. The second case was a 47-year-old man who developed an itchy rash on his wrist after wearing neoprene wrist splints for psoriatic arthropathy. The third case was a 77-year-old woman who experienced a severe erythematous rash with blistering from a neoprene elbow brace she received following a humeral fracture. All patients were patch tested to the British Society of Cutaneous Allergy Standard and rubber series and a cut piece from all the relevant supports. At 96 hours, all patients had a + reaction to mixed dialkylthiourea, diethylthiourea, and the supports’ material. No other positive patch test reactions were identified. As neoprene is fast becoming one of the most popular materials used for orthopaedic supports, awareness of this reaction and close liaison between dermatologists and orthopaedic surgeons are therefore essential to allow for early recognition of this complication. S. Hawkey and S. Ghaffar Copyright © 2015 S. Hawkey and S. Ghaffar. All rights reserved. Recurrent Postoperative Spinal Epidural Hematoma in a Patient with Protein S Deficiency Tue, 07 Jul 2015 07:08:43 +0000 A 71-year-old man underwent cervical laminectomy and developed two symptomatic epidural hematomas during the acute postoperative period. On both occasions, drain obstruction was the predominant cause. Congenital Protein S deficiency was diagnosed postoperatively. Protein S is a vitamin K-dependent natural anticoagulant and is essential for inhibiting thrombosis in microcirculation. We assume that Protein S deficiency followed by perioperative bed-rest and surgical invasiveness led to severe hypercoagulability and subsequent drain obstruction. The present findings suggest that both bleeding disorders and hypercoagulability are risk factors for postoperative symptomatic epidural hematoma. Masato Anno, Takashi Yamazaki, Nobuhiro Hara, and Keishi Hayakawa Copyright © 2015 Masato Anno et al. All rights reserved. A Dual Biomechanical Failure: Exeter Stem and Pubic Rami Insufficiency Fracture, following Hybrid Total Hip Arthroplasty Mon, 06 Jul 2015 09:44:34 +0000 Introduction. Incidence of Exeter stem fracture is extremely uncommon. Pubic rami insufficiency fractures following arthroplasty are also rare. To our knowledge no cases of spontaneous stem failure with previous insufficiency fractures have yet been reported. Case Presentation. This report describes a case of spontaneous fracture through a cemented Exeter stem in a 66-year-old patient who had previously undergone a hybrid total hip replacement and was found to have bifocal pubic rami insufficiency fractures. The patient presented 18-year postprimary surgery with spontaneous fracture of the middle third of the cemented femoral stem and adjacent proximal femur. Conclusion. This report demonstrates a unique case of Exeter stem fracture with previous pelvic insufficiency fractures. The case adds to the rare occurrences of Exeter stem failure in the literature and highlights the risk of potential insufficiency fractures in patients undergoing total hip replacement. Inderpaul Samra and Christos Paliobeis Copyright © 2015 Inderpaul Samra and Christos Paliobeis. All rights reserved. Treatment of Bifocal Cyst Hydatid Involvement in Right Femur with Teicoplanin Added Bone Cement and Albendazole Mon, 06 Jul 2015 08:49:53 +0000 Although bone involvement associated with cyst hydatid is rarely seen, it can cause unintended results such as high recurrence rate, infection, sepsis, or amputation of relevant extremity. Because of this reason, its treatment is difficult and disputed. In the case of bifocal bone cyst hydatid in right femur, along with albendazole treatment, result of resecting cyst surgically and its treatment with teicoplanin with added bone cement is given. In conclusion, since the offered treatment method both supports bone in terms of mechanical aspect and also can prevent secondary infection, the method is thought to be a good and safe treatment approach. Ozhan Pazarci, Zekeriya Oztemur, and Okay Bulut Copyright © 2015 Ozhan Pazarci et al. All rights reserved. Diabetic Muscle Infarction of the Tibialis Anterior and Extensor Hallucis Longus Muscles Mimicking the Malignant Soft-Tissue Tumor Sun, 05 Jul 2015 07:55:31 +0000 One of the most common causes of skeletal muscle infarction is diabetic muscle infarction (DMI), a rare complication associated with poorly controlled diabetes. We report an atypical case of DMI localized in the tibialis anterior (TA) and extensor hallucis longus (EHL) muscles of an elderly individual. A 64-year-old man with type 2 diabetes mellitus presented with a 6-month history of a palpable mass in his lower left leg. Magnetic resonance imaging (MRI) revealed that the mass exhibited heterogeneous signals on T1- and T2-weighted images and slight heterogeneous enhancement within the muscles on fat suppressed T1-weighted images. Because histopathological analysis revealed mostly necrotic muscle tissues but no neoplastic cells, we resected the affected muscles. A typical symptom of DMI is severe abrupt-onset pain in the region of the affected muscles, but the patient did not complain of pain. Therefore, the diagnosis and treatment for DMI were delayed, and widespread irreversible muscle necrosis developed. MRI findings of DMI can be similar to that of a malignant soft-tissue tumor. So, it is necessary to consider the malignant soft-tissue tumor as one of the differential diagnoses of DMI. Yoshikuni Mimata, Kotaro Sato, Karen Tokunaga, Itsuko Tsukimura, Hiroshi Tada, and Minoru Doita Copyright © 2015 Yoshikuni Mimata et al. All rights reserved. Chronic Exertional Compartment Syndrome in a High School Soccer Player Wed, 01 Jul 2015 10:12:51 +0000 Chronic exertional compartment syndrome (CECS) is a relatively rare condition that affects young adult athletes and often causes them to present to the emergency department. If left untreated, those who continue to compete at high levels may experience debilitating leg pain. Physicians may have difficulty differentiating CECS from other syndromes of the lower leg such as medial tibial stress syndrome, stress fractures, and popliteal artery entrapment. The gold standard for diagnosing CECS is intramuscular compartment pressure monitoring before and/or after 10 minutes of exercise. Some patients may choose to stop participation in sports in order to relieve their pain, which otherwise does not respond well to nonoperative treatments. In patients who wish to continue to participate in sports and live an active life, fasciotomy provides relief in 80% or more. The typical athlete can return to training in about 8 weeks. This is a case of a high school soccer player who stopped competing due to chronic exertional compartment syndrome. She had a fascial hernia, resting intramuscular pressure of 30 mmHg, and postexercise intramuscular pressure of 99 mmHg. Following fasciotomy she experienced considerable life improvement and is once again training and playing soccer without symptoms. James J. Bresnahan and William L. Hennrikus Copyright © 2015 James J. Bresnahan and William L. Hennrikus. All rights reserved. Anterior Cruciate Ligament Reconstruction in Ehlers-Danlos Syndrome Sun, 28 Jun 2015 14:26:57 +0000 This report details the reconstruction of the anterior cruciate ligament in an 18-year-old man with Ehlers-Danlos syndrome (EDS). The reduced mechanical properties of the tissue in EDS can pose a challenge to the orthopaedic surgeon. In this case, we describe the use of a hamstring autograft combined with a Ligament Advanced Reinforcement System (LARS). There was a good radiographical, clinical, and functional outcome after two years. This technique gave a successful outcome in the reconstruction of the ACL in a patient with EDS and therefore may help surgeons faced with the same clinical scenario. John Williams, Jonathan Hutt, and Mark Rickman Copyright © 2015 John Williams et al. All rights reserved. Pulmonary Artery Cement Embolism after a Vertebroplasty Sun, 28 Jun 2015 09:20:18 +0000 Background Context. Vertebroplasty is a minimally invasive procedure most commonly used for the treatment of vertebral compression fractures. Although it is relatively safe, complications have been reported over time. Among those complications, massive cement pulmonary embolism is considered a rare complication. Here we report a case of massive diffuse cement pulmonary embolism following percutaneous vertebroplasty for a vertebral compression fracture. Study Design. Case report. Methods. This is a 70-year-old female who underwent vertebroplasty for T11 and T12 vertebral compression fracture. Results. CT-scan revealed an incidental finding of cement embolism in the pulmonary trunk and both pulmonary arteries. Since the patient was asymptomatic, she was monitored closely and she did not need any intervention. Conclusion. Vertebroplasty is a minimally invasive procedure used for treatment of vertebral compression fracture. Despite the low rate of complications, a pulmonary cement embolism can occur. The consequences of cement embolism range widely from being asymptomatic to embolism that can cause paralysis, radiculopathy, or a fatal pulmonary embolism. Anas Nooh, Fahad H. Abduljabbar, Ahmed H. Abduljabbar, and Peter Jarzem Copyright © 2015 Anas Nooh et al. All rights reserved. Obliteration of Intercondylar Notch Mimicking Flexion-Extension Gap Imbalance in a Cruciate Retaining Total Knee Arthroplasty Mon, 22 Jun 2015 12:08:25 +0000 Following total knee arthroplasty (TKA), the most frequent cause of extension deficit and limitation of range of motion in early postoperative period is related to improper tensioning of soft tissues and failure to balance extension and flexion gaps. If a cruciate retaining (CR) prosthesis is the planned implant, then attention should be given to balancing the posterior cruciate ligament (PCL), and any factor that alters this balance may also cause deterioration of knee balance in postoperative period. Here, we report on an unusual case referred from another hospital because of continuous pain and restriction of knee motion in early postoperative period following CR-designed TKA that was initially thought to be due to flexion-extension imbalance. However, during the revision procedure, extruded cement to the intercondylar notch was found to be both mechanically blocking terminal extension and limiting flexion by possible mechanism of irritation of the synovial nerve endings around the stretched anterior fibers of PCL during flexion. This case was successfully treated by removal of extruded cement from intercondylar notch to decompress PCL, polyethylene exchange, and secondary patellar resurfacing. Harun Resit Gungor, Esat Kiter, Semih Akkaya, Nusret Ok, and Cagdas Yorukoglu Copyright © 2015 Harun Resit Gungor et al. All rights reserved. Surgical Repair of an Atraumatic Avulsion of Patellar Tendon at the Tibial Tuberosity in an Adult Patient Mon, 22 Jun 2015 06:46:42 +0000 Atraumatic avulsion of the tibial attachment of patellar tendon in adults is a very rare injury with only few published case reports. Here we are sharing the successful management and follow-up of a similar case with a different suture material for repair of the tendon, the FiberWire. We believe that the management we are discussing allows for early return to activity with good functional outcome. Lorenzo Maria Di Giacomo, M. Shahid Khan, Michele Bisaccia, R. Rende, G. Rinonapoli, and A. Caraffa Copyright © 2015 Lorenzo Maria Di Giacomo et al. All rights reserved. Congenital Ulnar Drift in a Surgeon Thu, 18 Jun 2015 11:50:57 +0000 Windblown hand is a term used in many instances to describe ulnar deviations of the fingers with or without other malformations. In 1994 Wood reviewed all of the descriptions of cases of windblown hand and pointed out how many variants of congenital ulnar drift there are, suggesting that the many variations seen may all belong to a larger type of arthrogryposis. While the most common cause of ulnar deviation of the fingers is rheumatoid arthritis, it can also be caused by other conditions such as windblown hand or Jaccoud’s arthropathy. While most hand surgeons are familiar with presentations of congenital ulnar drift, few of them are knowledgeable about Jaccoud’s arthropathy as this is usually discussed within medical communities such as Rheumatology. We present a case of a surgeon who has had noticeable ulnar deviation of the digits at the level of the metacarpophalangeal joint since his early 20s. We propose that the current case is a demonstration of a type of windblown hand that has some hereditary component but is not immediately obvious at birth and presents physically more like Jaccoud’s arthropathy than traditional windblown hand. Desirae McKee, Shannon Eliasson, and John Griswold Copyright © 2015 Desirae McKee et al. All rights reserved. Multiple Adjacent Isolated Thoracic Spinous Process Fractures in High-Energy Trauma Wed, 17 Jun 2015 08:30:41 +0000 Isolated thoracic spinous process fractures involving multiple adjacent vertebral segments are a rare occurrence in the setting of high-energy trauma. These findings should prompt further investigation to exclude other concomitant osseous or ligamentous injuries. Evaluation by computed tomography is often most useful to detect these fractures. Proper treatment of extensive multilevel injury is poorly defined in the literature. In our experience, conservative management consisting of initial bracing with graduated lifting restrictions has produced excellent functional results. Jacob M. Kirsch, Amit Nathani, and Rakesh D. Patel Copyright © 2015 Jacob M. Kirsch et al. All rights reserved. Neglected Anterior Dislocation of the Knee with Common Peroneal Palsy Mon, 15 Jun 2015 09:02:48 +0000 Knee dislocations usually follow high velocity injuries and are increasingly being treated with immediate reduction and staged repair of the ligaments. Neglected knee dislocations are rare and more difficult to treat with inferior outcomes. We present a rare case of neglected anterior dislocation of the knee treated by surgical arthrodesis. Thomas Matthai, Kaushik Bhowmick, P. R. J. V. C. Boopalan, and James C. George Copyright © 2015 Thomas Matthai et al. All rights reserved. Kingella kingae Causing Septic Arthritis of the Knee in an Immunocompetent Adult Sun, 14 Jun 2015 13:41:52 +0000 The bacterium Kingella kingae is a species of Gram-negative coccobacillus usually found in the oropharynx. This is an emerging pathogen reported to cause bacteraemia, endocarditis, and osteoarticular infections in children and endocarditis in the immunocompromised adult. However, there are few cases of isolated joint infections reported in the immunocompetent adult. Due to specific isolation techniques required, delay in diagnosis can compromise patient outcome. We report a rare case of septic arthritis of the knee in an immunocompetent adult caused by K. kingae. J. Ricketts, N. N. T. Rehmatullah, and P. Sutton Copyright © 2015 J. Ricketts et al. All rights reserved. Synovial Chondromatosis of the Ankle Joint: Clinical, Radiological, and Intraoperative Findings Sun, 14 Jun 2015 07:36:12 +0000 Synovial chondromatosis, also termed synovial osteochondromatosis, is a rare benign disorder characterized by the presence of cartilaginous nodules in the synovium of the joints, tendon sheaths, and bursae. It most commonly involves large joints, such as the knee, hip, and shoulder, but its presence in smaller joints has also been reported. Nevertheless, ankle involvement is unusual. The diagnosis is commonly made following a thorough history, clinical, physical, and radiographic examination. We report a case of a young patient with primary synovial chondromatosis of the ankle joint and present the clinical, radiographic, and intraoperative findings. Sedeek Mohamed Sedeek, Q. Choudry, and S. Garg Copyright © 2015 Sedeek Mohamed Sedeek et al. All rights reserved. Ipsilateral Acetabular and Femoral Neck and Shaft Fractures Wed, 10 Jun 2015 13:34:38 +0000 Floating hip injuries and ipsilateral femoral neck and shaft fractures are rare. Additionally, the simultaneous occurrence of these injuries is extremely rare, and only one case report of the simultaneous occurrence of these injuries has been published. Here, we report the case of a patient with ipsilateral acetabular and femoral neck and shaft fractures following a suicide attempt. The patient experienced nonunion of the femoral neck and shaft after the initial operation and therefore underwent reconstruction using a femoral head prosthesis with a long stem and interlocking screws. Our procedure may be used in primary and/or secondary reconstruction for ipsilateral acetabular and femoral neck and shaft fractures. Hideto Irifune, Suguru Hirayama, Nobuyuki Takahashi, and Eichi Narimatsu Copyright © 2015 Hideto Irifune et al. All rights reserved. Carpal Tunnel Syndrome with Wrist Trigger Caused by Hypertrophied Lumbrical Muscle and Tenosynovitis Wed, 10 Jun 2015 12:52:14 +0000 We present a case of carpal tunnel syndrome involving wrist trigger caused by a hypertrophied lumbrical muscle with flexor synovitis. The case was a 40-year-old male heavy manual worker complaining of numbness and pain in the median nerve area. On active flexion of the fingers, snapping was observed at the carpal area, and forceful full grip was impossible. Tinel’s sign was positive and an electromyographic study revealed conduction disturbance of the median nerve at the carpal tunnel. Magnetic resonance imaging revealed edematous lumbrical muscle with synovial proliferation around the flexor tendons. Open carpal tunnel release was performed under local anesthesia. Synovial proliferation of the flexor tendons was found and when flexing the index and middle fingers, the lumbrical muscle was drawn into the carpal tunnel with a triggering phenomenon. After releasing the carpal tunnel, the triggering phenomenon and painful numbness improved. Ayuko Shimizu, Masayoshi Ikeda, Yuka Kobayashi, Ikuo Saito, and Joji Mochida Copyright © 2015 Ayuko Shimizu et al. All rights reserved. A Challenging Case of Multifocal Mycobacterium marinum Osteoarticular Infection in a Patient with Anorexia Nervosa Sun, 07 Jun 2015 11:07:59 +0000 Disseminated infection due to Mycobacterium marinum is rare but has been described in immunosuppressed and transplant recipients. We describe a case of multifocal osteoarticular involvement by this pathogen in a patient with anorexia nervosa. Serial surgical debridements and a prolonged course of antimicrobial therapy including intravenous amikacin, imipenem, and oral ethambutol and azithromycin were needed to treat the infection. Cell mediated immune deficits related to the patient’s anorexia nervosa predisposed her to a severe infection with M. marinum. Aggressive surgical intervention in conjunction with multiple antimicrobial agents helped cure the infection. Katie Sharff, Zaw Min, and Nitin Bhanot Copyright © 2015 Katie Sharff et al. All rights reserved. Meniscal Bearing Dislocation of Unicompartmental Knee Arthroplasty with Faint Symptom Sun, 07 Jun 2015 09:42:48 +0000 We experienced two cases of atypical lateral dislocations of meniscal bearing in UKA (unicompartmental knee arthroplasty) without manifest symptoms. The dislocated bearing, which jumped onto the wall of tibial components, was found on radiographs in periodic medical examination although they could walk. Two thicker size bearing exchanges were promptly performed before metallosis and loosening of components. Continual examination is important to mobile bearing type of UKA because slight or less symptoms may disclose such unique dislocation. One case showed malrotation of the femoral component on 3D image. Anteroposterior view hardly disclosed the malrotation of the femoral component. Epicondylar view is an indispensable view of importance, and it can demonstrate the rotation of the femoral component. The the femoral distal end is wedge shaped and is wider posteriorly. If the femoral component is set according to the shape of medial condyle, the femoral component shifts to medial site compared with tibial component in flexion. It can account for such rare dislocation as follows. If excessive force applies on most medial side of the bearing during flexion, the lateral part of the bearing pops and the force squeezes it laterally simultaneously. Finally, the bearing jumps onto the lateral wall of the tibial component. Tadashi Fujii, Yoshio Matsui, Marehoshi Noboru, Yusuke Inagaki, Yoshinori Kadoya, and Yasuhito Tanaka Copyright © 2015 Tadashi Fujii et al. All rights reserved. Polyarticular Septic Arthritis in an Immunocompetent Adult: A Case Report and Review of the Literature Wed, 03 Jun 2015 09:36:16 +0000 Septic arthritis is a clinical emergency requiring prompt diagnosis and treatment to avoid significant morbidity and mortality. Polyarticular septic arthritis (PASA) accounts for 15% of all infectious arthritides and rarely occurs in immunocompetent adults. Staphylococcus aureus is the most commonly isolated organism, with infection primarily affecting knees, shoulders, elbows, and hips. The morbidity associated with PASA is very high, and mortality in treated cases of PASA may be as high as 50% of cases. We report a case of PASA with associated epidural abscess in a healthy adult male, who presented with complaints of arthralgia and limited range of motion of his left shoulder, wrist, and ankle. He also presented with low back pain and motor weakness associated with an epidural abscess spanning L2-S1, with multilevel vertebral osteomyelitis. Surgical washout of the affected joints as well as decompressive laminectomies was performed, and he received a standard course of intravenous antibiotics. Staphylococcus aureus was isolated from joint aspirations and from blood cultures. The patient had a full neurological and functional recovery postoperatively with no sequelae. To the best of our knowledge this is the only case report of Staphylococcus aureus PASA with concomitant epidural abscess in an immunocompetent adult. Annelise Miller, Fahad Abduljabbar, and Peter Jarzem Copyright © 2015 Annelise Miller et al. All rights reserved. External Iliac Artery-Appendicular Fistula due to Antegrade Unusual Migration of K-Wire from Hip to Pelvis: An Unreported Complication Wed, 03 Jun 2015 09:26:26 +0000 Background. K-wires are thought to be extremely safe implants and complications as a result of direct insertion or migration are very rare. Complications may be life-threatening in some instances where migration results in injury to vital organs. We report one such case where antegrade migration of K-wire from the hip resulted in injury to external iliac artery and formation of external iliac artery-appendicular fistula. No such complication due to migration has ever been reported in the literature. Case Description. A 15-year-old boy presented with lower abdominal pain, right lower limb swelling and pain, inability to walk, and rectal bleeding for 1 month after 2 K-wires had been inserted in his right hip joint for treatment of slipped capital femoral epiphysis the previous year. On investigation, he was diagnosed to have external iliac artery-appendicular fistula for which he was surgically treated. Clinical Relevance. Antegrade migration of K-wire from hip joint may lead to life-threatening injuries which can be minimized by bending the end of the K-wire, keeping the tip protruding outside the skin wherever possible and by early removal of K-wire once its purpose has been achieved. Nagmani Singh, Chakra Raj Pandey, Bhaskar Raj Pant, Uttam Krishna Shrestha, and Biraj Bista Copyright © 2015 Nagmani Singh et al. All rights reserved. Combined Effect of a Locking Plate and Teriparatide for Incomplete Atypical Femoral Fracture: Two Case Reports of Curved Femurs Tue, 26 May 2015 09:27:04 +0000 In surgical treatment for atypical femoral fractures (AFFs), reconstruction nail fixation is recommended for both complete and incomplete fractures. Although it has been reported that AFF is affected by many factors, The ASBMR Task Force 2013 Revised Case Definition of AFFs states that a curved femur is often seen in Asian patients. It is sometimes difficult to insert a nail into a femur in incomplete AFF patients with severely curved femurs. We report two incomplete bisphosphonate-related AFF patients with marked femoral curvatures treated by locking plates and teriparatide, showing early bone unions and favorable long-term outcomes. Hiroyuki Tsuchie, Naohisa Miyakoshi, Tomio Nishi, Hidekazu Abe, Toyohito Segawa, and Yoichi Shimada Copyright © 2015 Hiroyuki Tsuchie et al. All rights reserved. Simultaneous Bilateral Femoral Neck Stress Fracture in a Young Stone Mason Tue, 26 May 2015 08:37:21 +0000 Unilateral stress fractures of the femoral neck are very uncommon and bilateral involvement is even rarer. They commonly occur in athletes, military recruits, older persons, or individuals with underlying metabolic disorders and very seldom in normal individuals. We present a rare case of simultaneous bilateral fracture neck of femur in a 25-year-old man who came with complaints of pain in bilateral groin for 1 month. There was no history of trauma or history suggestive of excessive activity prior to the onset of pain, but there was history of lifting heavy weights daily. On evaluation with MRI scan bilateral fracture of the femur neck was diagnosed and patient was operated on bilaterally with internal fixation done using dynamic hip screw. Patient then regained his routine activity over a period of 6 months and on follow-up at 1 year no avascular necrosis changes were seen in the femur head. We presented this case because of its unusual presentation and the diagnostic challenge it poses. Nikhil A. Khadabadi and Kiran S. Patil Copyright © 2015 Nikhil A. Khadabadi and Kiran S. Patil. All rights reserved.