Case Reports in Orthopedics The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Weber B Fracture of the Lateral Malleolus with Concomitant Anterior Talofibular Ligament Injury following an Ankle Supination Injury Sun, 29 May 2016 13:40:16 +0000 The Lauge-Hansen (LH) classification attempts to predict patterns of ankle injuries based upon the preceding mechanism of injury. Although it is widely used in clinical practice, it has been criticized mainly due to numerous reports of cases conflicting the prediction system. Here, we report a case of a 32-year-old male who sustained a Weber B fracture of the lateral malleolus following a supination ankle injury, which was treated conservatively, following which the patient presented with ankle instability and was found to have concurrent anterior talofibular ligament tear. Critical review of the LH classification along with its shortcomings is discussed. Mohammed Khalid Faqi, Abdulla AlJawder, Fahad Alkhalifa, and Ali H. Almajed Copyright © 2016 Mohammed Khalid Faqi et al. All rights reserved. A Case Report of Isolated Cuboid Nutcracker Fracture Thu, 26 May 2016 09:38:00 +0000 Isolated cuboid fractures are very rare, since they typically occur in combination with midfoot fractures or dislocations. A 61-year-old man presented at our hospital with pain and swelling on the outside of his right foot. The lateral column of his right foot was shortened by approximately 6.5 mm on X-ray. CT showed displacement of the joint surface between the cuboid and the fourth metatarsal, with a 3.5 mm depression. An MRI revealed no other injuries. Based on these findings, we diagnosed the patient with an isolated nutcracker fracture of the cuboid. Using a 1.9 mm arthroscope, we examined the Lisfranc joint. Then the depressed fragments were elevated until the regular joint line was restored. A bone biopsy needle was then used to fill in the large defect with artificial bone. In this case, we did not plate the fracture. Six months after surgery, patient could walk without pain. We report a very rare case of isolated nutcracker fracture of the cuboid. In addition, we suggest our new treatment plan of this fracture. Takaaki Ohmori, Shinichi Katsuo, Chiaki Sunayama, Katsunori Mizuno, Tomohiro Ojima, Kotaro Yamakado, Tomonari Ando, Shin Watanabe, Seigaku Hayashi, and Hiroyuki Tsuchiya Copyright © 2016 Takaaki Ohmori et al. All rights reserved. Late Occurring Medial Migration of a Lag Screw in Gamma Nailing Mon, 23 May 2016 11:52:39 +0000 An 81-year-old female was treated for a pertrochanteric multifragmentary fracture of the proximal femur with a third-generation Gamma nail. After 3 months she presented herself again with acute pain and inability to bear weight on the leg. Radiographs showed medial migration of the lag screw. She was treated with a total hip arthroplasty, after which she was successfully discharged. In this case report the possible causes of this late and unusual complication are discussed. S. van Hoef, M. C. H. W. Fuchs, and R. H. M. ten Broeke Copyright © 2016 S. van Hoef et al. All rights reserved. Hemodynamic Instability after Low-Energy Thigh Contusion Caused by Injury to the Femoral Artery: A Case Report and Literature Review Wed, 18 May 2016 12:28:31 +0000 Acute vascular injuries have been described in relation to high-energy trauma accidents or in patients undergoing surgery in the femoral area. We describe a healthy patient who sustained a direct, low-energy contusion in the thigh and presented haemodynamic instability. Arteriography was used to locate the point of bleeding, and embolisation and vessel occlusion were carried out to stop the haemorrhage. The genetic study identified the COL3A1 gene mutation; accordingly, the patient was diagnosed with the Ehlers-Danlos syndrome type IV (vascular type). Juan Miguel Rodríguez-Roiz, José Ballesteros-Betancourt, Raquel García-Tarriño, Victor Antonio Rodríguez-Roiz, and Manuel Llusa Copyright © 2016 Juan Miguel Rodríguez-Roiz et al. All rights reserved. Lipoma Arborescens: Review of an Uncommon Cause for Swelling of the Knee Mon, 16 May 2016 13:41:20 +0000 Lipoma arborescens is a rare cause of chronic monoarticular arthritis, with only a few cases reported in the literature. It is most commonly seen in the knee, but cases in other joints such as the wrist, shoulder, and elbow have also been described. It is a benign condition, in which the subsynovial tissue is replaced diffusely by mature fat cells. We describe a case involving the knee and discuss the symptoms, diagnosis, and treatment. M. De Vleeschhouwer, E. Van Den Steen, G. Vanderstraeten, W. Huysse, J. De Neve, and L. Vanden Bossche Copyright © 2016 M. De Vleeschhouwer et al. All rights reserved. Femoral Varus Osteotomy for Hip Instability after Traumatic Fracture Dislocations of the Hip Associated with Femoral Head Fractures: A Report of Two Cases Mon, 16 May 2016 12:52:12 +0000 Fracture of the femoral head and the acetabulum with traumatic dislocation of the hip is a severe injury representing various types and unfavorable outcome. We showed a 45-year-old man with Pipkin type-IV fracture and coxa valga. An immediate closed reduction was achieved followed by open reduction and internal fixation via a posterior approach 6 days later. However, dislocation occurred three times without traumatic events after three weeks. CT demonstrated no displacement of posterior fragments or implant failure. Femoral intertrochanteric varus osteotomy was performed to gain concentric stability and successfully resolved recurrent dislocation. Another 45-year-old woman with Pipkin type-IV fracture and coxa valga also underwent closed reduction initially and then continued conservative treatment. After eight weeks, when she started gait training, progressive pain became symptomatic. Persistent hip pain at weight bearing was not improved in spite of arthroscopic synovectomy and osteochondroplasty. Two years after injury, femoral intertrochanteric varus osteotomy was indicated and her refractory pain was resolved gradually. We suggest that femoral varus osteotomy should be considered for superolateral subluxation associated fracture dislocation of the hip in Pipkin type-IV and coxa valga. Shuichi Miyamoto, Junichi Nakamura, Satoshi Iida, Chiho Suzuki, Seiji Ohtori, Sumihisa Orita, and Kazuhisa Takahashi Copyright © 2016 Shuichi Miyamoto et al. All rights reserved. Black Colouration of the Knee Articular Cartilage after Spontaneously Recurrent Haemarthrosis Thu, 12 May 2016 08:16:36 +0000 Mild discolouration of the articular cartilage is known to gradually occur during aging. However, pathological tissue pigmentation is occasionally induced under several specific conditions. In the present case, we performed total knee replacement in a patient with recurrent haemarthrosis. However, during the operation, we observed severe black colouration of the knee articular cartilage, due to the deposition of hemosiderin and lipofuscin. To our knowledge, this is the first report of severe cartilage pigmentation, due to hemosiderin and lipofuscin deposition in articular cartilage. Kazu Matsumoto, Daichi Ishimaru, Hiroyasu Ogawa, and Haruhiko Akiyama Copyright © 2016 Kazu Matsumoto et al. All rights reserved. Subchondral Insufficiency Fracture of the Femoral Head Caused by Excessive Lateralization of the Acetabular Rim Wed, 11 May 2016 14:03:39 +0000 We present a case of a 53-year-old woman with subchondral insufficiency fracture (SIF) of the femoral head without history of severe osteoporosis or overexertion. Plain radiographs showed acetabular overcoverage with excessive lateralization of the acetabular rim. A diagnosis of SIF was made by typical MRI findings of SIF. The lesion occurred at the antipodes of the extended rim. Increased mechanical stress over the femoral head due to impingement against the excess bone was suspected as a cause of SIF. The distinct femoral head deformity is consistent with this hypothesis. This is the first report of SIF associated with acetabular overcoverage. Tetsuya Kimura, Tomohiro Goto, Daisuke Hamada, Takahiko Tsutsui, Keizo Wada, Shoji Fukuta, Akihiro Nagamachi, and Koichi Sairyo Copyright © 2016 Tetsuya Kimura et al. All rights reserved. Cam Femoroacetabular Impingement as a Possible Explanation of Recalcitrant Anterior Knee Pain Tue, 10 May 2016 14:16:39 +0000 We present a case of a patient with chronic anterior knee pain (AKP) recalcitrant to conservative treatment who returned to our office for severe hip pain secondary to Cam femoroacetabular impingement (Cam FAI) at 10 months after the onset of knee pain. This case highlights the fact that the main problem is not in the patella but in the hip in some patients with AKP. We hypothesize that there is an external femoral rotation in order to avoid the impingement and therefore the hip pain in patients with Cam FAI. This functional femoral rotation could provoke a patellofemoral imbalance that may be, in theory, responsible for patellofemoral pain in this particular patient. In our case, Cam FAI resolution was related to the resolution of AKP. Vicente Sanchis-Alfonso, Marc Tey, and Joan Carles Monllau Copyright © 2016 Vicente Sanchis-Alfonso et al. All rights reserved. Acute Achilles Paratendinopathy following Major Injury of the Crural Fascia in a Professional Soccer Player: A Possible Correlation? Sun, 08 May 2016 11:18:20 +0000 Background. The anatomy and mechanical properties of the Crural Fascia (CF), the ubiquitous connective tissue of the posterior region of the leg, have recently been investigated. The most important findings are that (i) the CF may suffer structural damage from indirect trauma, (ii) structural changes of the CF may affect the biomechanics of tissues connected to it, causing myofascial pain syndromes, and (iii) the CF is in anatomical continuity with the Achilles paratenon. Consistent with these points, the authors hypothesize that the onset of acute Achilles paratendinopathy may be related to histological and biomechanical changes of the CF. Case Presentation. A professional male football player suffered an isolated injury of the CF, interposed between the soleus and medial gastrocnemius (an atypical site of injury) with structural connective integrity of the muscles. After participating in the first official match, two and a half months after the trauma, he has unexpectedly demonstrated the clinical picture of acute Achilles paratendinopathy in the previously injured limb. Conclusions. Analysis of this case suggests that the acute Achilles paratendinopathy may be a muscle injury complication from indirect trauma of the calf muscle, if a frank and extensive involvement of the CF were to be ascertained. Gabriele Mattiussi, Michele Turloni, Pietro Tobia Baldassi, and Carlos Moreno Copyright © 2016 Gabriele Mattiussi et al. All rights reserved. A Case of Spontaneous Osteonecrosis of the Knee with Early and Simultaneous Involvement of the Medial Femoral Condyle and Medial Tibial Plateau Tue, 03 May 2016 15:15:26 +0000 Spontaneous osteonecrosis of the knee (SPONK) usually involves a single condyle, most often the medial femoral condyle (MFC). Involvement of the medial tibial plateau (MTP) is less common, occurring in about 2% of knees with SPONK. Early onset SPONK on the ipsilateral side of the medial compartment is very rare, with, to our knowledge, only four cases reported to date. We describe a very rare case of SPONK with early simultaneous development in the MFC and MTP. Serial plain radiographs and magnetic resonance imaging showed that SPONK in both condyles followed a similar progressive course. The pathological findings in these lesions were similar to those observed in subchondral insufficiency fractures. Shinya Fujita, Yuji Arai, Kuniaki Honjo, Shuji Nakagawa, and Toshikazu Kubo Copyright © 2016 Shinya Fujita et al. 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.