Case Reports in Orthopedics The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Traumatic Periprosthetic Acetabular Fracture Treated with One-Stage Exchange and Bone Reconstruction Using a Synthetic Bone Graft Substitute Thu, 30 Jun 2016 11:29:40 +0000 A case of a traumatic periprosthetic acetabular fracture in an elderly patient, which was treated by one-stage hip exchange with implantation of an antiprotrusio cage and reconstruction of the acetabular bone loss with an injectable calcium sulphate/hydroxyapatite bone graft substitute, is reported. The paste-like bone graft substitute was injected through the holes of the antiprotrusio cage. After a setting time of 15 minutes, a low-profile cup was cemented onto the cage using polymethylmethacrylate and a new stem was inserted. The patient was encouraged to ambulate three days postoperatively weight-bearing as tolerated. At the one-year follow-up visit the patient was ambulatory and full weight-bearing without any walking aids. The follow-up radiographs demonstrated stable position and articulation of the revision hip arthroplasty with no signs of loosening of the antiprotrusio cage. However, the most interesting finding was that the bone graft substitute had remodelled to a great extent into bone. This calcium sulphate/hydroxyapatite composite shows high osteoconductive potential and can be used to regenerate bone stock in revision arthroplasty. Jan Svacina Copyright © 2016 Jan Svacina. All rights reserved. Surgical Management of Intracanal Rib Head Dislocation in Neurofibromatosis Type 1 Dystrophic Kyphoscoliosis: Report of Two Cases and Literature Review Thu, 30 Jun 2016 08:11:45 +0000 There is still no consensus on the management of severe intracanal RH dislocation in neurofibromatosis type 1 dystrophic kyphoscoliosis. This study notes the early cord function impairment signs, reports a serious complication in a susceptible cord, identifies possible mechanisms of injury, and discusses the management of intracanal RH dislocation presented in the literature. First report is as follows: a 12-year-old female with cord compromise and preoperative neurology that underwent thoracotomy and anterior release. The RH was left in situ following a rib excision. During the posterior stage of the procedure she presented with complete loss of all IOM traces prior to any correction manoeuvres. The neurology recovered 72 h postop and the final correction and instrumented fusion were uneventfully completed 15 days postop. Second report is as follows: a 10-year-old male, whose only neurology was a provoked shock-like sensation to the lower limbs following direct pressure on the rib cage. He underwent an uneventful posterior RH excision and instrumented correction and posterior spinal fusion. In conclusion, any possible cord dysfunction sign should be sought during examination. Decompression of the spinal cord by resecting the impinging bony part, even in the absence of neurological symptoms, is advised before any attempt to release or correct the deformity. George I. Mataliotakis, Nikolaos Bounakis, and Enrique Garrido-Stratenwerth Copyright © 2016 George I. Mataliotakis et al. All rights reserved. Nontraumatic Myositis Ossificans of Hip: A Case Presentation Wed, 29 Jun 2016 10:44:56 +0000 In most of the cases trauma is the leading etiology and the nontraumatic myositis ossificans (MO) is a very rare condition. We present an MO case without any trauma occurring. A 36-year-old female patient with a history of pain and restriction of range of motion of the left hip was admitted. Hip motions were restricted with 10–60° of flexion, 10° of internal rotation, 20° of external rotation, 10° of abduction, and 10° of adduction. There was no history of trauma and familial involvement. The biopsy of the lesion revealed mature bone tissue confirming our diagnosis of MO. The mass was removed surgically and postoperatively the patient was treated with a single dose radiotherapy with 800 gyc. MO is a benign and well differentiated bone formation or in other words heterotopic ossification of the muscle tissue. It has a prevalence of less than 1/1 million. Trauma is the most frequent etiological factor seen in almost 60–75% of the cases. Nontraumatic MO is very rare in the literature. Our patient had no history of trauma or familial involvement. Combination of the surgical excision with radiotherapy in the treatment of the MO of the hip may give satisfactory results. Yunus Oc, Muhammed Sefa Ozcan, Hasan Basri Sezer, Bekir Eray Kilinc, and Osman Tugrul Eren Copyright © 2016 Yunus Oc et al. All rights reserved. Spontaneous Regression of Herniated Lumbar Disc with New Disc Protrusion in the Adjacent Level Sun, 26 Jun 2016 10:11:04 +0000 Spontaneous regression of herniated lumbar discs was reported occasionally. The mechanisms proposed for regression of disc herniation are still incomplete. This paper describes and discusses a case of spontaneous regression of herniated lumbar discs with a new disc protrusion in the adjacent level. A 41-year-old man was admitted with radiating pain and numbness in the left lower extremity with a left posterolateral disc extrusion at L5-S1 level. He was admitted to hospital with low back pain due to disc herniation caudally immigrating at L4-5 level three years ago. He refused the surgical intervention that was offered and was treated conservatively at that time. He had no neurological deficit and a history of spontaneous regression of the extruded lumbar disc; so, a conservative therapy, including bed rest, physical therapy, nonsteroidal anti-inflammatory drugs, and analgesics, was advised. In conclusion, herniated lumbar disc fragments may regress spontaneously. Reports are prone to advise conservative treatment for extruded or sequestrated lumbar disc herniations. However, these patients should be followed up closely; new herniation at adjacent/different level may occur. Furthermore, it is important to know which herniated disk should be removed and which should be treated conservatively, because disc herniation may cause serious complications as muscle weakness and cauda equine syndrome. Tayfun Hakan and Serkan Gürcan Copyright © 2016 Tayfun Hakan and Serkan Gürcan. All rights reserved. Stress Fracture and Nonunion of Coronoid Process in a Gymnast Thu, 23 Jun 2016 14:59:13 +0000 Background. Gymnasts have high mechanical loading forces of up to 14 times body weight. Overuse lesions are typical in wrists and stress fractures in the olecranon, while isolated fractures of the coronoid process are uncommon. We present a case of retraumatized nonunion stress fracture of the ulnar coronoid process. Case Description. A 19-year-old gymnast presented with elbow pain after training. Imaging confirmed an old fracture of the coronoid process. We describe a 6-month multiphase return to competition rehabilitation program, which allowed him to compete pain-freely. Literature Review. Acute and overuse injuries in gymnasts are known but no nonunion of the coronoid process has been described before. Only one case of stress fracture of coronoid process in a gymnast was reported. Purpose and Clinical Relevance. We could successfully and conservatively return to sport a reactivated nonunion of a stress fracture of the coronoid process. T. Hetling, P. Bourban, and B. Gojanovic Copyright © 2016 T. Hetling et al. All rights reserved. A Ruptured Digital Epidermal Inclusion Cyst: A Sinister Presentation Wed, 22 Jun 2016 13:13:25 +0000 Epidermal inclusion cysts are benign cutaneous lesions caused by dermal or subdermal implantation and proliferation of epidermal squamous epithelium as a result of trauma or surgery. They are typically located on the scalp, face, trunk, neck, or back; however they can be found anywhere on the body. Lesions are asymptomatic unless complicated by rupture, malignant transformation to squamous cell carcinoma, or infection at which point they can clinically appear as more sinister pathologies. We present the case of a 45-year-old laborer with a ruptured epidermal inclusion cyst, manifesting clinically and radiographically as a malignancy. Following MRI, definitive surgical management may appear to be a logical progression in management of the patient. This case however is a good example of why meticulously following surgical protocol when evaluating an unknown soft tissue mass is imperative. By following protocol, an alternate diagnosis was made and the patient has since gone on to a make a full recovery without life transforming surgery. Iain Bohler, Phillip Fletcher, Amanda Ragg, and Andrew Vane Copyright © 2016 Iain Bohler et al. All rights reserved. Fabella Syndrome as an Uncommon Cause of Posterolateral Knee Pain after Total Knee Arthroplasty: A Case Report and Review of the Literature Tue, 21 Jun 2016 09:18:02 +0000 The fabella is a sesamoid bone that is located in the lateral head of the gastrocnemius muscle and has been identified on magnetic resonance imaging in 31% of Japanese people. In the present case, a 65-year-old woman experienced posterolateral knee pain, accompanied by a clicking “sound” during active knee flexion, after undergoing total knee arthroplasty for knee osteoarthritis. Eight months of conservative therapy failed to produce an improvement, with progressive osteoarthritic change of the fabella identified on plain radiography. Based on this evidence, a diagnosis of fabella syndrome was made and the patient underwent a fabellectomy. Fabellectomy provided immediate resolution of posterolateral knee pain and the clicking sound with knee flexion, with the patient remaining symptom-free 18 months after fabellectomy and with no limitations in knee function. Fabellectomy eliminated symptoms in all of five case reports that have been previously published and is regarded as an effective first choice for treating fabella syndrome after total knee arthroplasty. Eriko Okano, Tomokazu Yoshioka, Takaji Yanai, Sho Kohyama, Akihiro Kanamori, Masashi Yamazaki, and Toshikazu Tanaka Copyright © 2016 Eriko Okano et al. All rights reserved. Lower Limb Reconstruction with Tibia Allograft after Resection of Giant Aneurysmal Bone Cyst Mon, 20 Jun 2016 16:01:53 +0000 Aneurysmal bone cysts (ABCs) are benign, expansible, nonneoplastic lesions of the bone, characterized by channels of blood and spaces separated by fibrous septa, which occur in young patients and, occasionally, with aggressive behavior. Giant ABC is an uncommon pathological lesion and can be challenging because of the destructive effect of the cyst on the bones and the pressure on the nearby structures, especially on weight-bearing bones. In this scenario, en bloc resection is the mainstay treatment and often demands complex reconstructions. This paper reports a difficult case of an unusual giant aneurysmal bone cyst, which required extensive resection and a knee fusion like reconstruction with tibia allograft. Joaquim Soares do Brito, Joana Teixeira, and José Portela Copyright © 2016 Joaquim Soares do Brito et al. All rights reserved. Scoliosis Surgery in Cystic Fibrosis: Surgical Considerations and the Multidisciplinary Approach of a Rare Case Sun, 19 Jun 2016 10:39:53 +0000 Spinal deformity in patients with cystic fibrosis (CF) is usually mild requiring no treatment. These patients are rarely considered as surgical candidates for scoliosis correction, as the pulmonary condition and other comorbidities increase the risk of general anaesthesia and recovery. This paper reviews all the literature up to date with regard to scoliosis in patients with CF and reports this unique case of a 14-year-old Caucasian girl with progressive scoliosis, who was treated surgically at the age of 17. She underwent a posterior spinal fusion T2-L3 with the use of unilateral segmental instrumentation. Preoperative workup included respiratory, cardiac, anaesthetic, endocrine, and dietician reviews, as well as bone density optimisation with zoledronic acid and prophylactic antibiotics. Surgical time was 150 minutes and intraoperative blood loss was 47% of total blood volume. Postoperative intensive care included noninvasive ventilation, antibiotic cover, pain management, chest physiotherapy, pancreatic enzyme supplementation, and nutritional support. She was discharged on day 9. At follow-up she had a good cosmetic outcome, no complaints of her back, and stable respiratory function. Multidisciplinary perioperative care and meticulous surgical technique may reduce the associated risks of major surgery in CF patients, while achieving adequate deformity correction and a good functional outcome. George I. Mataliotakis, Athanasios I. Tsirikos, Karen Pearson, Don S. Urquhart, Carolyn Smith, and Andrew Fall Copyright © 2016 George I. Mataliotakis et al. All rights reserved. Anatomic Locking Plate Fixation for Scaphoid Nonunion Mon, 06 Jun 2016 09:48:10 +0000 Nonunion can occur relatively frequently after scaphoid fracture and appears to be associated with severity of injury. There have been a number of techniques described for bone grafting with or without screw fixation to facilitate fracture healing. However, even with operative fixation of scaphoid fractures with bone grafting nonunion or malunion rates of 5 to 10 percent are still reported. This is the first report of an anatomic locking plate for scaphoid fracture repair in a 25-year-old right hand dominant healthy male. Joshua Mirrer, Just Yeung, and Anthony Sapienza Copyright © 2016 Joshua Mirrer et al. All rights reserved. Occult Cranial Cervical Dislocation: A Case Report and Brief Literature Review Sun, 05 Jun 2016 09:26:59 +0000 Study Design. Retrospective case report and review. Objective. Cranial cervical dislocation (CCD) is commonly a devastating injury. Delay in diagnosis has been found to lead to worse outcomes. Our purpose is to describe a rare case of occult cranial cervical dislocation (CCD) and use it to highlight key clinical and radiographic findings to ensure expedited diagnosis and proper management avoiding delays and subsequent neurologic deterioration. Method. Case report with literature review. Results. We describe a unique case of occult cranial cervical dislocation where initial imaging of the cervical spine failed to illustrate displacement of the occipital-cervical (O-C1) articulation or C1-C2 articulation. Careful evaluation of subtle radiographic clues suggested a more severe injury than initial review. Additional imaging was obtained due to these subtle clues confirming true cranial cervical dislocation allowing subsequent treatment with no neurologic sequelae. Conclusion. A high index of suspicion of CCD may prevent injury in select patients who present without gross cord compromise. Careful consideration of associated fractures, soft tissue injuries, and mechanism of injury are essential clues to the correct diagnosis and management of injuries to the craniocervical junction (CCJ). Joshua B. Shatsky, Timothy B. Alton, Carlo Bellabarba, and Richard J. Bransford Copyright © 2016 Joshua B. Shatsky et al. All rights reserved. Fabella Fractures after Total Knee Arthroplasty with Correction of Valgus Malalignment Wed, 01 Jun 2016 07:28:48 +0000 The incidence of fabella fractures is considered to be extremely low. This report presents two patients with femorotibial osteoarthritis and considerable preoperative valgus malalignment, who developed a fracture of the fabella (as demonstrated by radiography) after total knee arthroplasty with intraoperative correction of the valgus malalignment. Special attention should be paid to the fabella for not missing a fabella fracture in these patients. Thomas Christian Kwee, Ben Heggelman, Robert Gaasbeek, and Maarten Nix Copyright © 2016 Thomas Christian Kwee et al. All rights reserved. Tuberculous Spondylitis following Intravesical Bacillus Calmette-Guerin for Bladder Cancer Mon, 30 May 2016 12:55:39 +0000 We present a rare case of tuberculous spondylitis following intravesical Bacillus Calmette-Guerin (BCG) therapy for bladder cancer. An 82-year-old man presented with low back pain. Past medical history revealed bladder cancer diagnosed and treated 16 months previously by intravesical BCG. Magnetic resonance imaging of the thoracic spine showed destruction of the T5 and T6 vertebrae and an epidural soft tissue mass with anterior dural sac compression. Due to the progression of vertebral destruction, posterior spinal segmental fusion was performed. Mycobacterium bovis (M. bovis) was identified using multiplex polymerase chain reaction of surgical tissue specimens. The patient was started on an antituberculosis treatment regimen including isoniazid, rifampicin, and ethambutol. After surgery, his back pain resolved completely. At the latest examination, the patient was pain-free with no functional limitations or recurrent infection in clinical or imaging findings. Patients undergoing BCG therapy should be monitored for possible hematogenous spread of mycobacteria to the spine for months or even years after treatment. Masashi Miyazaki, Toyomi Yoshiiwa, Toshinobu Ishihara, Masanori Kawano, and Hiroshi Tsumura Copyright © 2016 Masashi Miyazaki et al. All rights reserved. Weber B Fracture of the Lateral Malleolus with Concomitant Anterior Talofibular Ligament Injury following an Ankle Supination Injury Sun, 29 May 2016 13:40:16 +0000 The Lauge-Hansen (LH) classification attempts to predict patterns of ankle injuries based upon the preceding mechanism of injury. Although it is widely used in clinical practice, it has been criticized mainly due to numerous reports of cases conflicting the prediction system. Here, we report a case of a 32-year-old male who sustained a Weber B fracture of the lateral malleolus following a supination ankle injury, which was treated conservatively, following which the patient presented with ankle instability and was found to have concurrent anterior talofibular ligament tear. Critical review of the LH classification along with its shortcomings is discussed. Mohammed Khalid Faqi, Abdulla AlJawder, Fahad Alkhalifa, and Ali H. Almajed Copyright © 2016 Mohammed Khalid Faqi et al. All rights reserved. A Case Report of Isolated Cuboid Nutcracker Fracture Thu, 26 May 2016 09:38:00 +0000 Isolated cuboid fractures are very rare, since they typically occur in combination with midfoot fractures or dislocations. A 61-year-old man presented at our hospital with pain and swelling on the outside of his right foot. The lateral column of his right foot was shortened by approximately 6.5 mm on X-ray. CT showed displacement of the joint surface between the cuboid and the fourth metatarsal, with a 3.5 mm depression. An MRI revealed no other injuries. Based on these findings, we diagnosed the patient with an isolated nutcracker fracture of the cuboid. Using a 1.9 mm arthroscope, we examined the Lisfranc joint. Then the depressed fragments were elevated until the regular joint line was restored. A bone biopsy needle was then used to fill in the large defect with artificial bone. In this case, we did not plate the fracture. Six months after surgery, patient could walk without pain. We report a very rare case of isolated nutcracker fracture of the cuboid. In addition, we suggest our new treatment plan of this fracture. Takaaki Ohmori, Shinichi Katsuo, Chiaki Sunayama, Katsunori Mizuno, Tomohiro Ojima, Kotaro Yamakado, Tomonari Ando, Shin Watanabe, Seigaku Hayashi, and Hiroyuki Tsuchiya Copyright © 2016 Takaaki Ohmori et al. All rights reserved. Late Occurring Medial Migration of a Lag Screw in Gamma Nailing Mon, 23 May 2016 11:52:39 +0000 An 81-year-old female was treated for a pertrochanteric multifragmentary fracture of the proximal femur with a third-generation Gamma nail. After 3 months she presented herself again with acute pain and inability to bear weight on the leg. Radiographs showed medial migration of the lag screw. She was treated with a total hip arthroplasty, after which she was successfully discharged. In this case report the possible causes of this late and unusual complication are discussed. S. van Hoef, M. C. H. W. Fuchs, and R. H. M. ten Broeke Copyright © 2016 S. van Hoef et al. All rights reserved. Hemodynamic Instability after Low-Energy Thigh Contusion Caused by Injury to the Femoral Artery: A Case Report and Literature Review Wed, 18 May 2016 12:28:31 +0000 Acute vascular injuries have been described in relation to high-energy trauma accidents or in patients undergoing surgery in the femoral area. We describe a healthy patient who sustained a direct, low-energy contusion in the thigh and presented haemodynamic instability. Arteriography was used to locate the point of bleeding, and embolisation and vessel occlusion were carried out to stop the haemorrhage. The genetic study identified the COL3A1 gene mutation; accordingly, the patient was diagnosed with the Ehlers-Danlos syndrome type IV (vascular type). Juan Miguel Rodríguez-Roiz, José Ballesteros-Betancourt, Raquel García-Tarriño, Victor Antonio Rodríguez-Roiz, and Manuel Llusa Copyright © 2016 Juan Miguel Rodríguez-Roiz et al. All rights reserved. Lipoma Arborescens: Review of an Uncommon Cause for Swelling of the Knee Mon, 16 May 2016 13:41:20 +0000 Lipoma arborescens is a rare cause of chronic monoarticular arthritis, with only a few cases reported in the literature. It is most commonly seen in the knee, but cases in other joints such as the wrist, shoulder, and elbow have also been described. It is a benign condition, in which the subsynovial tissue is replaced diffusely by mature fat cells. We describe a case involving the knee and discuss the symptoms, diagnosis, and treatment. M. De Vleeschhouwer, E. Van Den Steen, G. Vanderstraeten, W. Huysse, J. De Neve, and L. Vanden Bossche Copyright © 2016 M. De Vleeschhouwer et al. All rights reserved. Femoral Varus Osteotomy for Hip Instability after Traumatic Fracture Dislocations of the Hip Associated with Femoral Head Fractures: A Report of Two Cases Mon, 16 May 2016 12:52:12 +0000 Fracture of the femoral head and the acetabulum with traumatic dislocation of the hip is a severe injury representing various types and unfavorable outcome. We showed a 45-year-old man with Pipkin type-IV fracture and coxa valga. An immediate closed reduction was achieved followed by open reduction and internal fixation via a posterior approach 6 days later. However, dislocation occurred three times without traumatic events after three weeks. CT demonstrated no displacement of posterior fragments or implant failure. Femoral intertrochanteric varus osteotomy was performed to gain concentric stability and successfully resolved recurrent dislocation. Another 45-year-old woman with Pipkin type-IV fracture and coxa valga also underwent closed reduction initially and then continued conservative treatment. After eight weeks, when she started gait training, progressive pain became symptomatic. Persistent hip pain at weight bearing was not improved in spite of arthroscopic synovectomy and osteochondroplasty. Two years after injury, femoral intertrochanteric varus osteotomy was indicated and her refractory pain was resolved gradually. We suggest that femoral varus osteotomy should be considered for superolateral subluxation associated fracture dislocation of the hip in Pipkin type-IV and coxa valga. Shuichi Miyamoto, Junichi Nakamura, Satoshi Iida, Chiho Suzuki, Seiji Ohtori, Sumihisa Orita, and Kazuhisa Takahashi Copyright © 2016 Shuichi Miyamoto et al. All rights reserved. Black Colouration of the Knee Articular Cartilage after Spontaneously Recurrent Haemarthrosis Thu, 12 May 2016 08:16:36 +0000 Mild discolouration of the articular cartilage is known to gradually occur during aging. However, pathological tissue pigmentation is occasionally induced under several specific conditions. In the present case, we performed total knee replacement in a patient with recurrent haemarthrosis. However, during the operation, we observed severe black colouration of the knee articular cartilage, due to the deposition of hemosiderin and lipofuscin. To our knowledge, this is the first report of severe cartilage pigmentation, due to hemosiderin and lipofuscin deposition in articular cartilage. Kazu Matsumoto, Daichi Ishimaru, Hiroyasu Ogawa, and Haruhiko Akiyama Copyright © 2016 Kazu Matsumoto et al. All rights reserved. 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.