Case Reports in Orthopedics

Varicella is a common viral infection in children and most of them recover without sequelae, but serious complications can follow this infection and 6% have been reported to be musculoskeletal. A previously healthy 3-year-old Caucasian male presented with odynophagia, anorexy, fever, refusal to bear weight, and vesicular exanthema. Varicella was diagnosed, but he sustained fever around 39°C and local tenderness on the proximal lateral portion of the right leg maintaining an antalgic position. Ultrasonography and plain radiography were performed, but the magnetic resonance imaging (MRI) was performed due to the clinically worsening diagnosed pyomyositis. He was subjected to surgical debridement, and we started intravenous antibiotherapy. Streptococcus pyogenes grew in the microbiologic culture. At a 6-month follow-up, the boy did not suffer from any sequelae. The regular course of varicella is benign; however, it can occasionally develop into a more serious illness. The initial presentation of pyomyositis is often subacute, and the first symptoms may be vague. The awareness of musculoskeletal complications is imperative, and the combination of varicella’s exanthema and fever followed by some limb complaint should lead to an alert attitude.

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Till date, there are no clear guidelines regarding the treatment of multiple ligament knee injuries. Ligament repair is advantageous as it preserves proprioception and does not involve grafting. Many studies have reported the use of open repair and reconstruction for multiple ligament knee injuries; however, reports on arthroscopic-combined single-stage anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) repairs are scarce. In this report, we describe a case of type III knee dislocation (ACL, PCL, and medial collateral ligament (MCL) injuries) in a 43-year-old man, caused by contact while playing futsal. On the sixth day after injury, arthroscopic ACL and PCL repairs were performed with open MCL repair. The proximal lesions in the three ligaments that were injured were sutured using no. 2 strong surgical sutures. The ACL was pulled out to the lateral condyle of the femur and fixed using a suspensory fixation device. The PCL was pulled out to the medial condyle of the femur, and the MCL was pulled towards the proximal end of the femur; both were fixed using suture anchors. Early mobilization was performed, and both, clinical and imaging outcomes, were good two years after surgery.

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This report presents an unusual case of instrumentation failure after posterior fixation of a C2 fracture and reviews currently available treatment alternatives. The patient, a 53-year-old female, initially presented to the emergency department at an outside facility with acute alcohol intoxication and acute neck pain following a fall from a ladder. CT demonstrated bilateral C2 pars fractures and unstable posteroinferior displacement of the posterior elements. She underwent an emergent C2 open-reduction internal fixation (ORIF) at the outside facility with 3.5 mm polyaxial synapse pedicle screws (DePuy Synthes, Switzerland). There were no known complications and the patient was discharged. Two years after the index operation, cervical CT scan at a different facility revealed that although the fracture was fully healed, bilateral tulip caps had detached from the pedicle screw heads at C2. All implants were removed without postoperative complications. Industry review of alternate lag screws approved for the cervical spine demonstrated that there is not currently an ideal implant for fixation of C2 fractures without fusion. Cannulated trauma screws, which are low profile and would have avoided the instrumentation failure seen here, are not currently FDA approved for the cervical spine.

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Spinal subdural abscesses are rare lesions. We report the case of surgical site infection complicated with meningitis and rapidly progressive spinal subdural abscess caused by P. aeruginosa following transforaminal lumbar interbody fusion (TLIF). A 72-year-old woman was admitted to our hospital complaining of drop foot syndrome and sciatica caused by stenosis of the L5/6 intervertebral foramen accompanied by L5 lumbar vertebral fracture. Accordingly, TLIF of L5-L6 and balloon kyphoplasty of L5 were performed. On the 3rd postoperative day (POD), she was diagnosed with surgical site infection complicated with bacterial meningitis. Subcutaneous fluid, blood, and cerebrospinal fluid cultures indicated P. aeruginosa. On the 7^th POD, a repeat MRI showed a large dorsal fluid collection consistent with a subdural infection and massive cauda equina compression. We performed debridement and instrument removal and found a dural laceration that was not observed during the first operation. An intraoperative insensible dural laceration may cause bacteria intrusion into the subdural space.

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Robotic arm-assisted arthroplasty was introduced in 2006 and has expanded its applications into unicompartmental knee, total knee, and total hip replacement. The first case of a revision surgery from conventional unicompartmental to total knee arthroplasty with the utilization of the robotic arm-assisted MAKO system is presented. An 87-year-old female presented with deteriorating left knee pain due to failure of medial unicompartmental knee arthroplasty at the outpatient clinic. The patient was advised to undergo revision surgery. Through medial parapatellar arthrotomy, the joint was exposed. With the use of the MAKO system, the estimated depth of the medial plateau according to CT planning was found to be 10 mm more distal than the lateral. The resection line of the remaining plateau was placed deliberately 2 mm more distal in order to achieve satisfactory replacement of the bony gap of the medial tibial condyle by a 10 mm augment. The patient had an uneventful recovery. A plethora of additional applications in the future, such as total shoulder or reverse total shoulder arthroplasty, megaprosthesis placement in oncological patients, and total hip or knee revision surgeries, may improve patient-related outcomes.

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A 50-year-old man presented to the clinic with severe neck pain, fever, and difficulty breathing and was subsequently admitted to the local orthopedics department with possible retropharyngeal abscess and pyogenic spondylitis. Antibiotic therapy was initiated; however, due to poor oxygenation, he was referred and transferred to our department and admitted. Magnetic resonance imaging showed signal changes at the left C1/2 lateral atlantoaxial joint, posterior pharynx, longus colli muscle, carotid space, and medial deep cervical region, predominantly on the left side. In addition, despite lymph node enlargement from the posterior pharynx to the deep cervical region, there was no abscess formation. There were no signs of a space-occupying lesion or signal changes in the jugular foramen. One day postadmission, the patient’s temperature had risen to 39.1°C and his SpO₂ had fallen. His neck pain had also worsened, and emergency surgery was decided. Preoperatively, we suspected retropharyngeal abscess and pyogenic spondylitis. On day 13 postadmission, the patient exhibited dysphagia, deviated tongue protrusion, and the curtain sign. Glossopharyngeal and hypoglossal nerve paralysis were diagnosed. The patient’s swallowing functions recovered and he was discharged on day 36. We experienced a case of glossopharyngeal and hypoglossal nerve paralysis secondary to pyogenic cervical facet joint arthritis.

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