Case Reports in Orthopedics The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. Atlantoaxial Subluxation after Pyogenic Spondylitis around the Odontoid Process Sun, 24 May 2015 12:40:08 +0000 Study Design. A case report and review of the literature. Objective. The aim of this study was to describe the conservative management of pyogenic spondylitis around the odontoid process. Summary of Background Data. Atlantoaxial subluxation after pyogenic spondylitis is rare. The therapeutic approach to infection of the upper cervical spine is controversial. Methods. Medical chart and radiological images of a 76-year-old male patient were retrospectively reviewed. Radiography revealed atlantoaxial subluxation, and an abscess was seen around the odontoid process on magnetic resonance images. Intravenous antibiotics and a halo vest were used to treat the patient. We then observed the patient’s conservative treatment course. Results. C-reactive protein levels returned to normal 4 weeks after administration of the intravenous antibiotics. The patient’s muscle weakness also completely recovered 8 weeks after administration of the intravenous antibiotics. Because the patient was able to walk without any support, surgical treatment was not necessary. Conclusions. Pyogenic spondylitis of the upper cervical spine is a rare manifestation. Surgical or conservative treatment must be selected carefully based on the patient’s symptoms. If early diagnosis and treatment can be provided to the patients, conservative treatment can be achieved. Atsushi Hasegawa, Mitsuru Yagi, Masakazu Takemitsu, Masafumi Machida, Takashi Asazuma, and Shoichi Ichimura Copyright © 2015 Atsushi Hasegawa et al. All rights reserved. A Case Report of Implant Fracture of Extensively Porous-Coated, Distally Fixated Cementless Long Stem: Detailed Course of Stem Bending Development Thu, 21 May 2015 12:54:19 +0000 We report the fracture of a cementless long stem in a distally fixated, extensively porous-coated femoral prosthesis used for revisional total hip arthroplasty (THA) 9 years previously in a 48-year-old woman, measuring 58 kg in weight and 155 cm in height. Following resolution of an infection 7 years after the revisional THA, a series of posterior dislocations occurred up until 7 months before sudden stem fracture. Extensive radiographic imaging evidence indicated a gradual progression of bending in the stem, and scanning electron microscope energy dispersive X-ray spectroscopy revealed oxygen in the medial and lateral sections, suspecting in vivo corrosion. We retrospectively examined the detailed course of stem bending development prior to stem fracture. The stem bending immediately after the revisional THA, at the first dislocation, and immediately before the stem fracture was 0°, 1.9°, and 5.2°, respectively. We consider that the cyclic loading with poor proximal bone support, distal fixation, and small diameter were the potential risk of this implant fracture. However, the course of stem bending development suggested that repeated operations and several dislocations might have aggravated the implant fatigue in the present case. Tomohiro Mimura Copyright © 2015 Tomohiro Mimura. All rights reserved. Simultaneous Disruption of the Pubic Symphysis and Sacroiliac Joint during Vaginal Birth Wed, 20 May 2015 08:37:29 +0000 Background. Puerperal diastasis of the pubic symphysis is a rare intrapartum complication. This report presents the case of a woman who experienced synchronous pubic symphysis and sacroiliac joint separations induced by vaginal delivery. Case. A 32-year-old woman (gravida 2, parity 2) with an uncomplicated prenatal course developed acute-onset anterior pubic pain during vaginal delivery. The pain persisted postpartum and was exacerbated by leg movement. Physical and radiographic examinations showed a pubic symphyseal separation of 2.4 cm, accompanied by a 10 mm disruption of the left sacroiliac joint. The patient was treated conservatively with pain-relief medication; bed rest, mostly in the left lateral decubitus position; closed reduction and application of a pelvic binder; use of a walker; and physical therapy. Conclusion. The patient responded to conservative management. She was essentially pain-free and regained movement and ambulation by 12 weeks postpartum. Hakan Çıçek, H. Levent Keskın, Ümit Tuhanıoğlu, Kasım Kiliçarslan, and Hasan Ulaş Oğur Copyright © 2015 Hakan Çıçek et al. All rights reserved. Myxoinflammatory Fibroblastic Sarcoma: A Radiographical, Pathological, and Immunohistochemical Report of Rare Malignancy Mon, 18 May 2015 12:47:41 +0000 Myxoinflammatory fibroblastic sarcoma (MIFS) is a rare, painless, and intermediate (rarely metastasizing) fibroblastic tumor, which commonly occurs in the extremities, with an equal sex predilection. This sarcoma is composed of a mixed inflammatory infiltrate along with spindled, epithelioid, and bizarre tumor cells in a background of hyaline and myxoid areas. In spite of such a distinctive morphology, the tumor can be a diagnostic challenge, simulating inflammatory conditions as well as neoplastic nature. For accurate diagnosis, the tumor requires extensive clinical, radiological, and pathological investigations. We present a case of MIFS in a 19-year-old female who presented with a mass in the left ankle. After appropriate excision and postoperative radiation therapy, she is free of disease, including recurrence and metastasis, at 12 years postoperatively. Michitaka Kato, Takuji Tanaka, and Takatoshi Ohno Copyright © 2015 Michitaka Kato et al. All rights reserved. Expandable Total Humeral Replacement in a Child with Osteosarcoma Mon, 18 May 2015 12:11:38 +0000 Case. A right-handed 8-year-old female patient presented with a conventional, high-grade osteosarcoma involving her right humerus; through-shoulder amputation was recommended. After consultation, total humerus resection with expandable, total humeral endoprosthesis reconstruction was performed with a sleeve to encourage soft-tissue ingrowth. At three-year follow-up she has received one lengthening procedure and her functional scores are excellent. Conclusion. Total humeral resection and replacement in the pediatric population are rare and although early reports of expandable total humeral endoprosthesis outcomes demonstrate high failure rates, this patient’s success indicates that expandable total humeral replacement is a viable option. Eric R. Henderson, Jidi Gao, John Groundland, Odion Binitie, and G. Douglas Letson Copyright © 2015 Eric R. Henderson et al. All rights reserved. Double-Layered Lateral Meniscus Accompanied by Meniscocapsular Separation Mon, 18 May 2015 07:20:53 +0000 We report an extremely rare case of double-layered lateral meniscus accompanied by meniscocapsular separation. The upper accessory meniscus was connected with the posterior horn and middle segment of the lower normal meniscus and was more mobile than the lower normal meniscus. A meniscocapsular separation was evident at the overlapping middle segment. Clinical symptoms were significantly improved by the resection of the upper accessory meniscus and the repair of the meniscocapsular separation. Careful arthroscopic analysis of other associated pathologies together with this rare abnormality was needed to achieve clinical improvement. Aki Fukuda, Akinobu Nishimura, Shigeto Nakazora, Ko Kato, and Akihiro Sudo Copyright © 2015 Aki Fukuda et al. All rights reserved. Iliopsoas Abscess (together with Bullet) Resulting from a Firearms Injury Thu, 14 May 2015 14:18:04 +0000 Psoas abscess, which is a rarely encountered infection, is defined as the accumulation of suppurative fluid within the fascia surrounding the psoas and iliac muscles. It is categorised as being primary or secondary. Although there are reports in the literature of secondary psoas abscess from foreign bodies, to the best of our knowledge, this is the first reported case of psoas abscess developing due to a bullet, following a firearms injury. The patient was first seen in the Emergency Department following a firearms injury in the posterolateral lumbar region and as the neurovascular examination was normal, the patient was discharged after 24 hours of observation. One month later, the patient presented again to the polyclinic with a high temperature and back pain. As a result of physical examination and tests, a diagnosis was made of psoas abscess and percutaneous drainage was applied under ultrasonography guidance. The complaints improved but, 10 days later with an increase in pain and indications of infection, open abscess drainage was applied and the bullet was removed. At the 6-month follow-up examination, the patient had no complaints. Yunus Güzel, Sadettin Çiftçi, Ali Özdemir, and Mehmet Ali Acar Copyright © 2015 Yunus Güzel et al. All rights reserved.