Case Reports in Orthopedics The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. An Unusual Presentation of Right-Sided Sciatica with Foot Drop Wed, 27 Apr 2016 07:14:27 +0000 Rarely, sciatica is of extraspinal aetiology. By compressing the sciatic nerve, swelling of the short external rotators of the hip can cause sciatica. Uncommon anatomical relationships between the sciatic nerve and local muscles may potentiate this compressive effect. In this report, we describe the presentation of right sciatica and foot drop resulting from both extreme local constriction and unusual anatomical variation of the right sciatic nerve. Fergus J. McCabe and John P. McCabe Copyright © 2016 Fergus J. McCabe and John P. McCabe. All rights reserved. A Rare Case of Bilateral Patellar Tendon Ruptures: A Case Report and Literature Review Wed, 20 Apr 2016 09:36:53 +0000 Bilateral patellar tendon ruptures are rare. The majority of case reports describing bilateral patellar tendon ruptures have occurred in patients with predisposing factors to tendinopathy. We describe a case of bilateral patellar tendon rupture sustained following minimal trauma by a patient with no systemic disease or history of steroid use. Due to the rarity of this injury, clinical suspicion is low. It is reported that 38% of patellar tendon ruptures are misdiagnosed initially. Therefore careful history taking and physical examination is integral in ensuring a diagnosis is achieved for early primary repair. We discuss the aetiology of spontaneous tendon rupture and report a literature review of bilateral patellar tendon ruptures. Nadim Tarazi, Padhraig O’loughlin, Amin Amin, and Peter Keogh Copyright © 2016 Nadim Tarazi et al. All rights reserved. N-Acetyl-Cysteine as Effective and Safe Chelating Agent in Metal-on-Metal Hip-Implanted Patients: Two Cases Mon, 11 Apr 2016 14:02:29 +0000 Systemic toxicity associated with cobalt (Co) and chromium (Cr) containing metal hip alloy may result in neuropathy, cardiomyopathy, and hypothyroidism. However clinical management concerning chelating therapy is still debated in literature. Here are described two metal-on-metal hip-implanted patients in which N-acetyl-cysteine decreased elevated blood metal levels. A 67-year-old male who underwent Co/Cr hip implant in September 2009 referred to our Poison Control Centre for persisting elevated Co/Cr blood levels (from March 2012 to November 2014). After receiving oral high-dose N-acetyl-cysteine, Co/Cr blood concentrations dropped by 86% and 87% of the prechelation levels, respectively, and persisted at these latter concentrations during the following 6 months of follow-up. An 81-year-old female who underwent Co/Cr hip implant in January 2007 referred to our Centre for detection of high Co and Cr blood levels in June 2012. No hip revision was indicated. After a therapy with oral high-dose N-acetyl-cysteine Co/Cr blood concentrations decreased of 45% and 24% of the prechelation levels. Chelating agents reported in hip-implanted patients (EDTA, DMPS, and BAL) are described in few cases. N-acetyl-cysteine may provide chelating sites for metals and in our cases reduced Co and Cr blood levels and resulted well tolerable. Andrea Giampreti, Davide Lonati, Benedetta Ragghianti, Anna Ronchi, Valeria Margherita Petrolini, Sarah Vecchio, and Carlo Alessandro Locatelli Copyright © 2016 Andrea Giampreti et al. All rights reserved. Total Hip Arthroplasty Using a Polished Tapered Cemented Stem in Hereditary Multiple Exostosis Tue, 05 Apr 2016 11:44:01 +0000 A 61-year-old Japanese man underwent right total hip arthroplasty for hereditary multiple exostosis. At first presentation, he had suffered from coxalgia for a long time. On radiographic images, there was a gigantic femoral head, increased shaft angle, and large diameter of the femoral neck. He had also developed coxarthrosis and severe pain of the hip joint. The transformation of the proximal femur bone causes difficulty in setting a cementless total hip prosthesis. Therefore, total hip arthroplasty using a cemented polished tapered stem was performed via a direct lateral approach. Using a cemented polished tapered stem allowed us to deal with the femoral bone transformation and bone substance defectiveness due to exostosis and also minimized the invasiveness of the operation. Akio Kanda, Kazuo Kaneko, Osamu Obayashi, and Atsuhiko Mogami Copyright © 2016 Akio Kanda et al. All rights reserved. An Undescribed Monteggia Type 3 Equivalent Lesion: Lateral Dislocation of Radial Head with Both-Bone Forearm Fracture Sun, 03 Apr 2016 12:43:20 +0000 Monteggia fractures are accepted as hard-to-recognize and easy-to-handle fractures. Adequate radiographic investigations and clinical examinations are necessities. This case holds unique features involving diagnosis and treatment. In this case, the radial head was dislocated laterally while both bones were fractured in the proximal diaphysis, being the first to be mentioned in the literature. Closed reduction of the ulna is the preferred method of handling and almost always results in reduction of the radial head. Literature obligates ulnar reduction as a preliminary to reduce and stabilize the radial head. Closed reduction reduced the ulna but the radial head was not reduced. Hence an intramedullary K-wire was used to reduce the radial head and a long arm cast was used to stabilize the reduction. The operation was successful and follow-up showed no complications. Adnan Kara, Mahmut Enes Kayaalp, Mehmet İşyar, Cem Sever, Melih Malkoç, and Mahir Mahiroğulları Copyright © 2016 Adnan Kara et al. All rights reserved. A Thickened Coracohumeral Ligament and Superomedial Capsule Limit Internal Rotation of the Shoulder Joint: Report of Three Cases Wed, 30 Mar 2016 06:30:05 +0000 Adhesive capsulitis of the shoulder (also known as frozen shoulder) is a painful and disabling disorder with an estimated prevalence ranging from 2% to 5% in the general population. Although the precise pathogenesis of frozen shoulder is unclear, thickened capsule and coracohumeral ligament (CHL) have been documented to be one of the most specific manifestations. The thickened CHL has been understood to limit external rotation of the shoulder, and restriction of internal rotation of the shoulder has been believed to be related to posterior capsular tightness. In this paper, three cases of refractory frozen shoulder treated through arthroscopic release of a contracted capsule including CHL were reported. Two cases in which there is recalcitrant severe restriction of internal rotation after manipulation under anesthesia (MUA) were finally treated with arthroscopic surgery. Although MUA could release the posterior capsule, internal rotation did not improve in our cases. After release of the thickened CHL, range of motion of internal rotation was significantly improved. This report demonstrates the role of the thickened CHL in limiting the internal rotation of the shoulder. We highlight the importance of release of thickened CHL in addition to the pancapsular release, in case of severe limitation of internal rotation of shoulder. Masashi Koide, Junichiro Hamada, Yoshihiro Hagiwara, Kenji Kanazawa, and Kazuaki Suzuki Copyright © 2016 Masashi Koide et al. All rights reserved. Spontaneous Knee Ankylosis through Heterotopic Ossification after Total Knee Arthroplasty Tue, 29 Mar 2016 14:14:13 +0000 This paper reports on a case of total ankylosis of the knee after a cruciate-sacrificing cemented total knee arthroplasty (TKA). An 82-year-old female patient previously underwent primary TKA for osteoarthritis twenty years ago in our institution. She had recovered uneventfully and returned to her regular activities. There was no history of postsurgical trauma; however, she progressively lost knee range of motion. Radiographs revealed severe bridging heterotopic ossification. Samuel Boulezaz, Emmanuel Gibon, Philippe Loriaut, Laurent Casabianca, Romain Rousseau, Benjamin Dallaudiere, and Hugues Pascal-Moussellard Copyright © 2016 Samuel Boulezaz et al. All rights reserved. A Case of Nonunion Avulsion Fracture of the Anterior Tibial Eminence Tue, 29 Mar 2016 12:32:15 +0000 Avulsion fracture of the anterior tibial eminence is an uncommon injury. If bone union does not occur, knee extension will be limited by impingement of the avulsed fragment and knee instability will be induced by dysfunction of the anterior cruciate ligament (ACL). This report describes a 55-year-old woman who experienced an avulsion fracture of the right anterior tibial eminence during recreational skiing. Sixteen months later, she presented at our hospital with limitation of right knee extension. Plain radiography showed nonunion of the avulsion fracture region, and arthroscopy showed that the avulsed fragment impinged the femoral intercondylar notch during knee extension. The anterior region of the bony fragment was debrided arthroscopically until the knee could be extended completely. There was no subsequent instability, and the patient was able to climb a mountain 6 months after surgery. These findings indicate that arthroscopic debridement of an avulsed fragment for nonunion of an avulsion fracture of the anterior tibial eminence is a minimally invasive and effective treatment for middle-aged and elderly patients with a low level of sports activity. Satoru Atsumi, Yuji Arai, Shuji Nakagawa, Hiroaki Inoue, Kazuya Ikoma, Hiroyoshi Fujiwara, and Toshikazu Kubo Copyright © 2016 Satoru Atsumi et al. All rights reserved. Case Report of a Traumatic Atlantoaxial Rotatory Subluxation with Bilateral Locked Cervical Facets: Management, Treatment, and Outcome Mon, 28 Mar 2016 06:39:43 +0000 The aim was to report a rare case of isolated traumatic atlantoaxial rotatory subluxation without ligamentous injury. Management consisted of analgesia, sedation, and application of a halo skull traction device. After removing halo skull traction, full reduction and recovery were achieved without instability. Nael Hawi, Dirk Alfke, Emmanouil Liodakis, Mohamed Omar, Christian Krettek, Christian Walter Müller, and Rupert Meller Copyright © 2016 Nael Hawi et al. All rights reserved. Traumatic Isolated Trapezium Dislocation without Fracture: A Case Report and Review of the Literature Wed, 23 Mar 2016 12:03:18 +0000 Isolated dislocation of the trapezium is an uncommon injury. There are sixteen cases to date reported in the literature. The management of these cases has varied from complete excision to open or closed reduction, with or without percutaneous wiring. This paper presents a case of an isolated dislocation of the trapezium without fracture, managed with closed reduction and percutaneous wiring, resulting in a good functional outcome. Robert M. Kenyon, Enda G. Kelly, and Benny Padinjarathala Copyright © 2016 Robert M. Kenyon et al. All rights reserved. Lipoma of the Thumb: Spindle Cell Subtype Mon, 21 Mar 2016 07:47:45 +0000 We report hereby the case of a 61-year-old man who presented with a soft-tissue swelling on the palmar aspect of the thumb. A detailed clinical examination followed by ultrasonography and excisional biopsy confirmed a spindle cell lipoma. Lipomas are rare in the hand and exceptional in the fingers, and we report, to our knowledge, the first spindle cell lipoma in the thumb to help in the differential diagnosis of a similar swelling. Johnny El Rayes, Roula Bou Sader, and Elie Saliba Copyright © 2016 Johnny El Rayes et al. All rights reserved. Surgical Treatment of an Infected Nonunion of the Middle Third of the Femur Associated with Femoral Shortening in a Hemophilia Patient Thu, 17 Mar 2016 13:06:13 +0000 The management of nonunion and limb length discrepancy has remained a constant challenge in hemophilic patients. In this study, we aimed to present the treatment of femur infected nonunion and limb length discrepancy in a twenty-seven-year-old patient with hemophilia type A. A 27-year-old male patient with hemophilia type A referred to our institution for the treatment of right femur infected nonunion and 10 cm shortness of the femur. Resection of the nonunion site and bone-to-bone fixation with autologous bone grafting were performed. Compression to the pseudoarthrosis site and distraction from new osteotomy site were applied with the unilateral external fixator. Union was achieved, and 6 cm lengthening was obtained according to the initial length. Patient was followed up for 7 years. After this treatment, the patient is able to walk with full weight bearing on the affected extremity with 4 cm shortening which is compensated by the heel lift. The results of this case indicate that limb lengthening and treatment of nonunion with the external fixation could be reliable and effective method for hemophilic patients. Ahmet Salduz, Özcan Kaya, Halil İbrahim Balci, Turgut Akgul, Fatih Dikici, Bülent Zülfikar, and Mehmet Kocaoğlu Copyright © 2016 Ahmet Salduz et al. All rights reserved. Delayed Presentation of Gluteal Compartment Syndrome: The Argument for Fasciotomy Thu, 17 Mar 2016 12:00:48 +0000 A male patient in his fifties presented to his local hospital with numbness and weakness of the right leg which left him unable to mobilise. He reported injecting heroin the previous morning. Following an initial diagnosis of acute limb ischaemia the patient was transferred to a tertiary centre where Computed Tomography Angiography was reported as normal. Detailed neurological examination revealed weakness in hip flexion and extension (1/5 on the Medical Research Council scale) with complete paralysis of muscle groups distal to this. Sensation to pinprick and light touch was globally reduced. Blood tests revealed acute kidney injury with raised creatinine kinase and the patient was treated for rhabdomyolysis. Orthopaedic referral was made the following day and a diagnosis of gluteal compartment syndrome (GCS) was made. Emergency fasciotomy was performed 56 hours after the onset of symptoms. There was immediate neurological improvement following decompression and the patient was rehabilitated with complete nerve recovery and function at eight-week follow-up. This is the first documented case of full functional recovery following a delayed presentation of GCS with sciatic nerve palsy. We discuss the arguments for and against fasciotomy in cases of compartment syndrome with significant delay in presentation or diagnosis. John E. Lawrence, Duncan J. Cundall-Curry, and Kuldeep K. Stohr Copyright © 2016 John E. Lawrence et al. All rights reserved. Unusual MRI Findings in a Polio Survivor Wed, 16 Mar 2016 11:58:57 +0000 A 63-year-old male consulted our institution due to worsening of right hip pain for approximately one month. The patient had no apparent functional disorders besides rigidity of the right ankle secondary to childhood poliomyelitis. Plain radiographs demonstrated narrowing of the right hip joint space. Magnetic resonance imaging (MRI) showed unusual findings in the right gluteus medius muscle, suspecting a malignant musculoskeletal tumor. Further examinations clarified acute inflammation caused by Staphylococcus aureus with no atypia. After treatment, serum inflammatory markers normalized and MRI showed homogeneous fat signal intensity in the muscle, which was consistent with poliomyelitis. Total hip arthroplasty was performed due to progression of osteoarthritis. Intraoperative findings showed flaccidity of the gluteus medius muscle, and histological examination of the specimen also was compatible with poliomyelitis. Postoperatively there was no hip instability and the patient has been able to resume his previous physical activity. To our knowledge, this is the first report regarding polio survivors combined with septic arthritis, and sole MRI examination was unable to lead to the diagnosis. The current patient demonstrates the possibility that the involved muscles in poliomyelitis exist even in asymptomatic regions, which will be helpful for accurate diagnosis and life guidance in polio survivors. Masaaki Sakamoto, Hitoshi Watanabe, Hitoshi Kubosawa, and Takeshi Ishii Copyright © 2016 Masaaki Sakamoto et al. All rights reserved. Unusual Spinal Epidural Lipomatosis and Lumbosacral Instability Wed, 16 Mar 2016 11:57:52 +0000 Introduction. Epidural lipomatosis is most frequently observed in patients on chronic steroid treatment. Only a few idiopathic epidural lipomatosis cases have been described. Material and Methods. 64-year-old male patient presented with low back pain and left leg pain. Later, the patient experienced neurogenic claudication and radicular pain in the left leg without urinary dysfunction. Plain radiography and magnetic resonance imaging demonstrated an abnormal fat tissue overgrowth in the epidural space with compression of the dural sac, degenerative disc disease at L4-L5 level, and instability at L5-S1. Endocrinopathic diseases and chronic steroid therapy were excluded. If conservative treatment failed, surgical treatment can be indicated. Results. After surgery, there was a gradual improvement in symptoms and signs, and six months later the patient returned to daily activities and was neurologically normal. Conclusion. In the absence of common causes of neurogenic claudication, epidural lipomatosis should be considered. The standard test for the diagnosis of epidural lipomatosis is magnetic resonance (MR). At first, conservative treatment must be considered; weight loss and the suspension of prior corticosteroid therapy are indicated. In the presence of neurological impairment, the operative treatment of wide surgical decompression must be performed soon after diagnosis. David Ruiz Picazo and José Ramírez Villaescusa Copyright © 2016 David Ruiz Picazo and José Ramírez Villaescusa. All rights reserved. Optimization Correction Strength Using Contra Bending Technique without Anterior Release Procedure to Achieve Maximum Correction on Severe Adult Idiopathic Scoliosis Tue, 15 Mar 2016 12:02:32 +0000 Adult scoliosis is defined as a spinal deformity in a skeletally mature patient with a Cobb angle of more than 10 degrees in the coronal plain. Posterior-only approach with rod and screw corrective manipulation to add strength of contra bending manipulation has correction achievement similar to that obtained by conventional combined anterior release and posterior approach. It also avoids the complications related to the thoracic approach. We reported a case of 25-year-old male adult idiopathic scoliosis with double curve. It consists of main thoracic curve of 150 degrees and lumbar curve of 89 degrees. His curve underwent direct contra bending posterior approach using rod and screw corrective manipulation technique to achieve optimal correction. After surgery the main thoracic Cobb angle becomes 83 degrees and lumbar Cobb angle becomes 40 degrees, with 5 days length of stay and less than 800 mL blood loss during surgery. There is no complaint at two months after surgery; he has already come back to normal activity with good functional activity. Ahmad Jabir Rahyussalim, Ifran Saleh, Dyah Purnaning, and Tri Kurniawati Copyright © 2016 Ahmad Jabir Rahyussalim et al. All rights reserved. Treatment of a Femur Nonunion with Microsurgical Corticoperiosteal Pedicled Flap from the Medial Femoral Condyle Tue, 15 Mar 2016 09:36:56 +0000 Introduction. The vascularized corticoperiosteal flap is harvested from the medial femoral condyle and it is nourished by the articular branch of the descending genicular artery and the superomedial genicular artery. This flap is usually harvested as a free flap for the reconstruction of bone defects at forearm, distal radius, carpus, hand, and recently at lower limb too. Case Report. A 50-year-old Caucasian man referred to our department for hypertrophic nonunion of the distal femur, refractory to the conservative treatments. The first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle. We considered union to have occurred 3.5 months after surgery when radiographs showed bridging of at least three of the four bony cortices and clinically the patient was able to walk with full weight bearing without any pain. At the last follow-up (25 months), the patient was completely satisfied with the procedure. Discussion. The corticoperiosteal flap allows a faster healing of fractures with a minimal morbidity at the donor site. We suggest that the corticoperiosteal pedicled flap graft is a reliable and effective treatment for distal femur nonunion. Matteo Guzzini, Cosma Calderaro, Marco Guidi, Carolina Civitenga, Germano Ferri, and Andrea Ferretti Copyright © 2016 Matteo Guzzini et al. All rights reserved. An Unexpected Complication after Headless Compression Screw Fixation of an Osteochondral Fracture of Patella Mon, 14 Mar 2016 09:17:20 +0000 This study evaluated complications associated with implant depth in headless compression screw treatment of an osteochondral fracture associated with a traumatic patellar dislocation in a 21-year-old woman. Computed tomography and X-rays showed one lateral fracture fragment measuring 25 × 16 mm. Osteosynthesis was performed with two headless compression screws. Five months later, the screws were removed because of patella-femoral implant friction. We recommend that the screw heads be embedded to a depth of at least 3 mm below the cartilage surface. Further clinical studies need to examine the variation in cartilage thickness in the fracture fragment. Suavi Aydoğmuş, Tahir Mutlu Duymuş, and Tolga Keçeci Copyright © 2016 Suavi Aydoğmuş et al. All rights reserved. Cervical Spondylotic Myelopathy Secondary to Dropped Head Syndrome: Report of a Case and Review of the Literature Sun, 13 Mar 2016 11:05:14 +0000 The dropped head syndrome (DHS) is a disabling condition caused by severe weakness of the neck extensor muscles causing progressive reducible kyphosis of the cervical spine and the inability to hold the head up. Weakness can occur in isolation or in association with a generalized neuromuscular disorder. Isolated cases are owed to the late onset of noninflammatory myopathy designated as INEM, where persistent chin to chest deformity may gradually cause or aggravate preexisting degenerative changes of the cervical spine and ultimately result in myelopathy. In review of the literature, we could find only 5 cases, with no unique guidelines to address the management of these two concomitant pathologies. Herein, a 69-year-old man who had developed cervical myelopathy 2 years after being affected by isolated dropped head syndrome is presented. Chin to chest deformity and cervical myelopathy were managed through three-level anterior cervical discectomy and fusion (ACDF) combined with decompressive cervical laminectomy and stabilization with C2 to C7 pedicle screw-rod construct. At 4-month follow-up, despite recovery in patient’s neurological status, flexion deformity reappeared with recurrence of dropped head due to C7 pedicle screws pull-out. However, this was successfully managed with extension of the construct to the upper thoracic levels. Abolfazl Rahimizadeh, Housain F. Soufiani, and Saghayegh Rahimizadeh Copyright © 2016 Abolfazl Rahimizadeh et al. All rights reserved. Salmonella Typhi Vertebral Osteomyelitis and Epidural Abscess Thu, 10 Mar 2016 06:24:21 +0000 Salmonella vertebral osteomyelitis is an uncommon complication of Salmonella infection. We report a case of a 57-year-old transgender male who presented with lower back pain for a period of one month following a fall. Physical examination only revealed tenderness over the lower back with no neurological deficits. MRI of the thoracic and lumbar spine revealed a spondylodiscitis at T10-T11 and T12-L1 and right posterior epidural collection at the T9-T10 level. He underwent decompression laminectomy with segmental instrumentation and fusion of T8 to L3 vertebrae. Intraoperatively, he was found to have acute-on-chronic osteomyelitis in T10 and T11, epidural abscess, and discitis in T12-L1. Tissue and wound culture grew Salmonella Typhi and with antibiotics susceptibility guidance he was treated with intravenous ceftriaxone for a period of six weeks. He recovered well with no neurological deficits. Hau Wei Khoo, Ying Ying Chua, and John L. T. Chen Copyright © 2016 Hau Wei Khoo et al. All rights reserved. A Rare Case of Bipolar Clavicle Fracture Wed, 09 Mar 2016 11:07:08 +0000 Segmental or bipolar fractures of the clavicle generally refer to a concomitant ipsilateral distal clavicle and midshaft clavicle fracture. These injuries are exceedingly rare and are generally secondary to higher energy injuries. We report a case of a 38-year-old male who sustained a left bipolar clavicle fracture after falling from a push bike while riding recreationally which unusually involved the medial and lateral ends of the clavicle and not the midshaft as previously reported in other patients. The patient’s exact fracture configuration was not immediately apparent highlighting the need for careful examination of the whole clavicle in order to not miss a bipolar fracture. Matthew A. Yalizis, Gregory A. Hoy, and Eugene T. H. Ek Copyright © 2016 Matthew A. Yalizis et al. All rights reserved. Oblique Axis Body Fracture: An Unstable Subtype of Anderson Type III Odontoid Fractures—Apropos of Two Cases Sun, 06 Mar 2016 12:27:48 +0000 Purpose. Anderson type III odontoid fractures have traditionally been considered stable and treated conservatively. However, unstable cases with unfavorable results following conservative treatment have been reported. Methods. We present the cases of two patients who sustained minimally displaced Anderson type III fractures with a characteristic fracture pattern that we refer to as “oblique type axis body fracture.” Results. The female patients aged 90 and 72 years, respectively, were both diagnosed with minimally displaced Anderson type III fractures. Both fractures had a characteristic “oblique type” fracture pattern. The first patient was treated conservatively with cervical spine immobilization in a semirigid collar. However, gross displacement was noted at the 6-week follow-up visit. The second patient was therefore treated operatively by C1–C3/4 posterior fusion and the course was uneventful. Conclusions. Oblique type axis body fractures resemble a highly unstable subtype of Anderson type III fractures with the potential of severe secondary deformity following conservative treatment, irrespective of initial grade of displacement. The authors therefore warrant a high index of suspicion for this injury and suggest early operative stabilization. Hirokazu Takai, Lukas Konstantinidis, Hagen Schmal, Peter Helwig, Stefan Knöller, Norbert Südkamp, and Oliver Hauschild Copyright © 2016 Hirokazu Takai et al. All rights reserved. Acute Traumatic Musculotendinous Avulsion of the Flexor Pollicis Longus Tendon Treated with Primary Flexor Digitorum Superficialis Transfer: A Novel Technique of Management Thu, 25 Feb 2016 10:41:36 +0000 Traumatic musculotendinous junction avulsions are rare injuries except in avulsion amputations. They pose a significant challenge to the treating surgeon. We present a 24-year-old male who sustained an open musculotendinous avulsion of the flexor pollicis longus tendon. He was treated with primary tendon transfer using the flexor digitorum superficialis of ring finger, in flexor zone 3. The functional result at 10 months following surgery was excellent. P. Kiran Sasi, Swagath Mahapatra, Samuel C. Raj Pallapati, and Binu P. Thomas Copyright © 2016 P. Kiran Sasi et al. All rights reserved. Lesser Trochanter Migration following Intramedullary Fixation of an Intertrochanteric Femur Fracture Wed, 24 Feb 2016 06:34:52 +0000 Intertrochanteric femur fractures are commonly observed in the elderly and may be associated with a complete fracture of the lesser trochanter in over 50% of cases. The migration of the lesser trochanter secondary to the psoas muscle contracture is a rare event. This case report presents a rare case of sudden groin pain three-week status after intramedullary fixation of a intertrochanteric femur fracture. Carlo Montoli, Cecilia Pasquali, Elia Paiusco, Vincenzo Pellecchia, and Ettore Vulcano Copyright © 2016 Carlo Montoli et al. All rights reserved. Spinal Epidural Hematoma after Thoracolumbar Posterior Fusion Surgery without Decompression for Thoracic Vertebral Fracture Thu, 18 Feb 2016 11:21:51 +0000 We present a rare case of spinal epidural hematoma (SEH) after thoracolumbar posterior fusion without decompression surgery for a thoracic vertebral fracture. A 42-year-old man was hospitalized for a thoracic vertebral fracture caused by being sandwiched against his back on broken concrete block. Computed tomography revealed a T12 dislocation fracture of AO type B2, multiple bilateral rib fractures, and a right hemopneumothorax. Four days after the injury, in order to promote early orthostasis and to improve respiratory status, we performed thoracolumbar posterior fusion surgery without decompression; the patient had back pain but no neurological deficits. Three hours after surgery, he complained of acute pain and severe weakness of his bilateral lower extremities; with allodynia below the level of his umbilicus, postoperative SEH was diagnosed. We performed immediate revision surgery. After removal of the hematoma, his symptoms improved gradually, and he was discharged ambulatory one month after revision surgery. Through experience of this case, we should strongly consider the possibility of preexisting SEH before surgery, even in patients with no neurological deficits. We should also consider perioperative coagulopathy in patients with multiple trauma, as in this case. Tsuyoki Minato, Masayuki Miyagi, Wataru Saito, Shintaro Shoji, Toshiyuki Nakazawa, Gen Inoue, Takayuki Imura, Hiroaki Minehara, Terumasa Matsuura, Tadashi Kawamura, Takanori Namba, Naonobu Takahira, and Masashi Takaso Copyright © 2016 Tsuyoki Minato et al. All rights reserved. Inflammatory Neuropathy of the Lumbosacral Plexus following Periacetabular Osteotomy Tue, 16 Feb 2016 16:18:10 +0000 Introduction. During periacetabular osteotomy (PAO), the sciatic, femoral, and obturator nerves are at risk. Most frequently nerve lesions can be attributed to a mechanical cause; however, in the absence of a clear mechanical cause surgeons are faced with a diagnostic problem and in many cases no diagnosis will be established. We report a case of inflammatory neuropathy of the lumbosacral plexus following a PAO. Case Presentation. A 31-year-old female developed weakness of ankle and knee flexion and extension 6 months after a PAO. Electrophysiological studies revealed damage to the obturator, femoral, and sciatic nerve consistent with an inflammatory lumbosacral plexopathy. MRI of the lumbosacral plexus was normal. The patient was treated with multimodal pain therapy and prolonged physiotherapy; nevertheless, symptoms worsened over time. At 2-year follow-up, there were no signs of recovery. Discussion. Inflammatory neuropathy of the lumbosacral plexus is a potential cause of pain and weakness after ipsilateral orthopaedic procedures. It should be distinguished from more frequently encountered mechanical causes of postsurgical neuropathy based on clinical suspicion, electrophysiological studies, MRI, and nerve biopsy. It is important that the orthopaedic community is aware of this complication since there is some evidence that early recognition and initiation of immunosuppressive therapy can lead to improved clinical outcome. Stijn Ghijselings, Frans Bruyninckx, Hendrik Delport, and Kristoff Corten Copyright © 2016 Stijn Ghijselings et al. All rights reserved. Group B Streptococcal Septic Arthritis of the Shoulder and Potential Association with Pelvic Examination and PAP Smear Sun, 14 Feb 2016 11:26:11 +0000 Group B streptococcal (GBS) infection of a native joint in a nonpregnant adult is uncommon. While many women are colonized with this flora, it rarely becomes pathogenic in its adult host. GBS associated joint infections have been reported, most of which have been related to hematogenous seeding from unknown sources. To our knowledge, there are no published case reports of a GBS joint infection in association with a pelvic exam and Papanicolaou (PAP) smear. In this case report, we present a case of GBS sepsis of a native shoulder, possibly resulting from a routine pelvic exam and PAP smear. William E. Daner III, Brett D. Meeks, William C. Foster, and Norman D. Boardman III Copyright © 2016 William E. Daner III et al. All rights reserved. A Woman with Rheumatoid Arthritis and a Bilateral Fracture of the Proximal Tibia Thu, 11 Feb 2016 12:19:38 +0000 A 52-year-old woman presented herself with pain on the medial sides of the proximal tibia after a minimal trauma. Conventional X-rays did not show any pathology. However, the MRI showed a bilateral fracture of the proximal tibia. Since the patient was treated with methotrexate due to rheumatoid arthritis, methotrexate osteopathy was considered. Long term treatment with low doses of methotrexate proved to inhibit osteoblast proliferation and may eventually lead to decreased bone formation and osteopenia. On the other hand, immobilization, joint deformities, and steroid treatment are associated with rheumatoid arthritis and are also known risk factors for fractures. The clinical relevance of methotrexate osteopathy still has to be established. However, if a patient treated with methotrexate localizes pain in the tibia, methotrexate osteopathy should be considered. Withdrawal of the drug may improve symptoms. J. Th. (Arjan) Hooghof, Joris J. Mellema, Marcel D. Posthumus, and Jos J. A. M. van Raaij Copyright © 2016 J. Th. (Arjan) Hooghof et al. All rights reserved. Surgical Treatment of Posttraumatic Radioulnar Synostosis Mon, 08 Feb 2016 14:01:20 +0000 Radioulnar synostosis is a rare complication of forearm fractures. The formation of a bony bridge induces functional disability due to limitation of the pronosupination. Although the etiology of posttraumatic synostosis is unknown, it seems that the incidence is higher in patients who have suffered a concomitant neurological or burn trauma, and extensive soft tissue injury, mainly due to high-energy impact. Surgical treatment, such as reinsertion of distal biceps tendon into the radius, seems to be another possible factor. The aim of the surgical treatment is to remove the bony bridge and restore complete range of movement (ROM), thus preventing recurrence. Literature does not indicate a preferred type of surgical procedure for the aforementioned complication; however, it has been shown that surgical interposition of inert material reduces the formation rate of recurrent bony bridge. We describe a surgical technique in two cases in which the radius and ulna were wrapped with allogenic, cadaver fascia lata graft to prevent bony bridge formation. The data from 2 years of follow-up are reported, indicating full restoration of ROM and no recurrence of synostosis. S. Pfanner, P. Bigazzi, C. Casini, C. De Angelis, and M. Ceruso Copyright © 2016 S. Pfanner et al. All rights reserved. A Bilateral Traumatic Hip Obturator Dislocation Mon, 08 Feb 2016 08:59:58 +0000 A case of a bilateral simultaneous traumatic obturator dislocation of both hip joints in an 18-year-old young man following a traffic accident is presented. We reduced the dislocated femoral heads immediately under general anesthesia followed by passive and active exercises and early full-weight bearing mobilization. After 5 years, the result was excellent. Ahmet Adnan Karaarslan, Nihat Acar, Tolga Karci, and Erhan Sesli Copyright © 2016 Ahmet Adnan Karaarslan et al. All rights reserved.