Case Reports in Orthopedics The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Managing an Acute and Chronic Periprosthetic Infection Tue, 14 Nov 2017 06:38:00 +0000 A case report of a 65-year-old female with a history of right total hip arthroplasty (THA) in 2007 and left THA in 2009 was presented. She consulted with our institution for the first time, on December 2013, for right hip pain and fistula on the THA incision. It was managed as a chronic infection, so a two-stage revision was performed. First-time intraoperative cultures were positive for Staphylococcus aureus (3/5) and Proteus mirabilis (2/5). Three weeks after the second half of the review, it evolved with acute fever and pain in relation to right hip. No antibiotics were used, arthrocentesis was performed, and a coagulase-negative staphylococci multisensible was isolated at the 5th day. Since the germ was different from the first revision, it was decided to perform a one-stage revision. One year after the first review, the patient has no local signs of infection and presents ESV and RPC in normal limits. The indication and management of periprosthetic infections are discussed. Cristian Barrientos, Maximiliano Barahona, and Rodrigo Olivares Copyright © 2017 Cristian Barrientos et al. All rights reserved. Pseudomonas aeruginosa Septic Arthritis and Osteomyelitis after Closed Reduction and Percutaneous Pinning of a Supracondylar Humerus Fracture: A Case Report and Review of the Literature Tue, 14 Nov 2017 00:00:00 +0000 Infectious complications of closed reduction and percutaneous pinning of supracondylar humerus fractures are exceedingly rare. Although postoperative Pseudomonas infection is a feared complication associated with noncompliance and a wet cast, there are no reports in the literature of this occurring. We present the devastating complication of a pediatric patient who developed Pseudomonas aeruginosa subperiosteal abscess, osteomyelitis, and elbow septic arthritis after presenting to the clinic multiple times with a wet cast after closed reduction and percutaneous pinning of a supracondylar humerus fracture. We describe the treatment course for this patient, followed by the sequelae of posterolateral rotary instability. This case not only confirms that patients can get Pseudomonas infections if they get their cast wet but also stresses the importance of patient communication and compliance in preventing unfortunate complications. Adam M. Wegner, John C. Wuellner, and Brian M. Haus Copyright © 2017 Adam M. Wegner et al. All rights reserved. A Unique Case of Melorheostosis Presenting with Two Radiologically Distinct Lesions in the Shoulder Mon, 06 Nov 2017 10:40:03 +0000 Melorheostosis is a rare, nonhereditary, benign, mesenchymal condition of unknown aetiology affecting the bones and surrounding tissues. A male patient complaining of left shoulder pain, swelling, and mildly limited range of motion has an exclusive combination of the classic dripping wax lesion in the scapula and the myositis ossificans-like lesion in the deltoid muscle; this combination is the first to be reported in the shoulder. Both lesions showed typical findings of melorheostosis in radiographs, CT, MRI, and bone scan. This case has a stationary course over the follow-up period, and no specific treatment is needed in due course. Ahmed A. Elsheikh, Rohan S. Pinto, Alpesh Mistry, and Simon P. Frostick Copyright © 2017 Ahmed A. Elsheikh et al. All rights reserved. Bone Resection for Isolated Ulnar Head Fracture Thu, 26 Oct 2017 00:00:00 +0000 Distal ulnar fractures often occur with distal radius fractures (DRFs), and ulnar styloid fractures commonly occur in the setting of DRF. However, isolated ulnar head fractures are rare. We report a case of isolated ulnar head fracture in which we performed bone resection because the ulnar head bone fragment fractured when internal screw fixation was attempted. His outcome at 18 months postoperatively was considered excellent. However, we do not advocate bone resection other than failure of fixation and the difficult case to perform internal fixation. Longer follow-up would be needed because bone resection might lead to osteoarthritis of the distal radioulnar joint in the future. Hiromasa Akino, Shunpei Hama, Masataka Yasuda, Kenta Minato, and Masahiro Miyashita Copyright © 2017 Hiromasa Akino et al. All rights reserved. Therapeutic Management of a Substantial Pelvic Aneurysmatic Bone Cyst Including the Off-Label Use of Denosumab in a 35-Year-Old Female Patient Tue, 17 Oct 2017 00:00:00 +0000 Aneurysmal bone cysts (ABC) are benign bone tumors, which are highly vascularized. The main course of treatment is curettage followed by bone grafting or cement insertion. Still recurrence remains a main problem for patients. Denosumab is a monoclonal antibody, which acts as an inhibitor of the RANK/RANKL pathway, diminishing bone turnover. Recent case reports have shown that Denosumab can be a promising therapeutic agent for people suffering from therapy-resistant ABC. We report the case of a 35-year-old female patient presenting with a pronounced ABC of the pelvis. Since the tumor was inoperable, Denosumab was administered, leading to a significant shrinkage of the lesion, which allowed surgical intervention. Upon recurrence, Denosumab was restarted putting the patient once more into remission. Follow-up was four years overall with a clinical and radiological stable disease for fifteen months after final discontinuation of the monoclonal antibody. Therefore, our case further underlines the potential of Denosumab in the treatment of ABC. D. Ntalos, M. Priemel, C. Schlickewei, D. M. Thiesen, J. M. Rueger, and A. S. Spiro Copyright © 2017 D. Ntalos et al. All rights reserved. Hyperphosphatemic Tumoral Calcinosis after Total Knee Arthroplasty Mon, 16 Oct 2017 00:00:00 +0000 We report a case of hyperphosphatemic tumoral calcinosis (TC) that occurred after total knee arthroplasty. A 64-year-old Japanese man presented with painful swellings in both shoulders, the left elbow, and the right hip that developed after he underwent total knee arthroplasty (TKA). The pathology of the patient’s bone at the time of TKA included a thick osteoid seam with calcareous deposition at the margin of the trabecular bone, which is not generally seen in osteoarthritis. Computed tomography scans of the swollen joints demonstrated leaflet and amorphous calcification masses around the joints. We diagnosed the patient with TC. The present case highlights that TC lesions are rare but should be considered in the differential diagnosis of subcutaneous soft and hard masses around the joint. Takeshi Mochizuki and Katsunori Ikari Copyright © 2017 Takeshi Mochizuki and Katsunori Ikari. All rights reserved. Lumbar Spondylodiscitis Caused by Burkholderia cepacia in a Previously Healthy Patient Sun, 15 Oct 2017 00:00:00 +0000 Burkholderia cepacia spondylodiscitis is a rare entity that has been reported in only four cases. We hereby report the case of a 43-year-old, previously healthy, woman who was found to have a B. cepacia spondylodiscitis after a cholecystectomy. She was treated with a three-month regimen of ceftazidime and ciprofloxacin with complete clinical, biological, and radiological remission. Danielle Jaafar, Maroun Rizkallah, Firas Atallah, Falah Bachour, Angelique Barakat, Ghassan Maalouf, and Matta Matta Copyright © 2017 Danielle Jaafar et al. All rights reserved. Delayed Tibial Osteomyelitis after Anterior Cruciate Ligament Reconstruction with Hamstrings Autograft and Bioabsorbable Interference Screw: A Case Report and Review of the Literature Sun, 15 Oct 2017 00:00:00 +0000 Osteomyelitis following arthroscopically assisted anterior cruciate ligament (ACL) reconstruction has rarely been reported in the literature. We report a case of a 20-year-old female who had delayed tibial osteomyelitis and a pretibial cyst with culture-positive, oxacillin sensitive Staphylococcus epidermidis 15 months after an ACL reconstruction with hamstring autograft. Soft tissue fixation within the tibial tunnel was with a poly-L-D-lactic acid (PLDLA) bioabsorbable interference screw. The patient underwent surgical treatment with curettage, debridement, hardware removal, and bone grafting of the tibial tunnel followed by a course of intravenous antibiotics. Arthroscopic evaluation demonstrated an intact ACL graft without any evidence of intra-articular infection. The patient returned to collegiate athletics without any complications. While the most common biologic complications include pretibial cysts, granuloma formation, tunnel widening, and inflammatory reactions, infection is exceedingly rare. Late infection and osteomyelitis are also rare but can occur and should be considered in the differential diagnosis. Kevin S. Weiss, Justin M. Weatherall, Jen Eick, and James R. Ross Copyright © 2017 Kevin S. Weiss et al. All rights reserved. Spontaneous Bilateral Sternoclavicular Joint Septic Arthritis and Lumbar Discitis: An Unusual Case in a Healthy Adult Mon, 09 Oct 2017 07:17:33 +0000 Introduction. Septic arthritis of the sternoclavicular (SC) joint is a rare condition. Typically, it presents in patients with risk of infection and is usually unilateral. In this report, we describe a case of spontaneous bilateral sternoclavicular joint infection of an otherwise healthy adult. Case Presentation. A 67-year-old man presented in our hospital complaining of 2-week history of neck and chest pain which was radiating to his shoulders bilaterally. Clinical examination revealed erythema and swelling of the sternoclavicular area. Inflammatory markers were raised. Image investigation with CT and MRI was undertaken and verified the presence of bilateral sternoclavicular joint infection. The patient received prolonged course of intravenous antibiotics since his admission. The patient was discharged in a good condition and followed up in clinic. Conclusion. High index of clinical suspicion of SC joint infection is important for early diagnosis to avoid further complications. Georgios Mamarelis, Mohammad Zain Sohail, Athanasios Mamarelis, Hassan Fawi, and Jehangir Mahaluxmivala Copyright © 2017 Georgios Mamarelis et al. All rights reserved. Successful Pelvic Resection for Acetabular Hydatidosis Mon, 09 Oct 2017 00:00:00 +0000 Background. Hydatidosis of the bone is a rare occurrence (0.9 to 2.5% of all localization of the disease). In those occurrences, the pelvic bone is the second most frequent localization. Curative treatment of pelvic bone hydatidosis is difficult and a consensus is yet to be found. Clinical Case. We report a case of hydatidosis of the ischium, extended to the homolateral hip. The patient was treated through hip resection using patient-specific cutting guides, followed by total hip reconstruction. Albendazole was administered to the patient for two months before the surgery and for three months following the surgery. Conclusions. In a young patient, hydatidosis of the pelvic bone can be treated with satisfying results through wide resection of the hip coupled with an antiparasitic treatment administered before and after the surgery. Prosthetic reconstruction, similar to what is done in cancer surgery, restores good functions. Canoville Daniel, Hannebicque Matthieu, Rochcongar Goulven, Michon Jocelyn, Dumaine Valérie, and Hulet Christophe Copyright © 2017 Canoville Daniel et al. All rights reserved. Radiofrequency-Targeted Vertebral Augmentation: Case Report of a Patient with 7 Osteoporotic Vertebral Fractures in a Variant of Osteogenesis Imperfecta Wed, 04 Oct 2017 07:10:06 +0000 Introduction. Radiofrequency-targeted vertebral augmentation (RF-TVA) is a recognized treatment for painful compression fractures. RF-TVA in a patient with multiple compression fractures due to type I osteogenesis imperfecta (OI) has not been previously reported. Case Presentation. A 54-year-old patient with type I OI is presented with a segmental thoracic hyperkyphosis and 7 recent vertebral compression fractures. Because of persistent severe thoracolumbar back pain despite conservative therapy, RF-TVA was indicated. Nocturnal back pain was almost completely relieved at all postoperative time points evaluated. However, overall pain relief dropped only slightly from 7 to 5 on the numerical rating scale (NRS) at the 6-week follow-up, and there was only a small decrease in the Oswestry Disability Index (ODI) from 72% to 63%. An MRI at the 3-month follow-up revealed hyperintensity at levels T11 and T12, indicating slight recollapsing. At the 6-month follow-up, the ODI improved to 55%, although overall pain had worsened to 6 on the NRS. Pain at rest remained at a very low level. Conclusion. Despite the remaining lumbago, RF-TVA may be a good option for patients with OI who have multiple fractures. However, fractures at multiple levels and segmental thoracic hyperkyphosis may increase the risk for recollapsing and ongoing pain. Leonard Westermann, Peer Eysel, Marvin Simons, and Kourosh Zarghooni Copyright © 2017 Leonard Westermann et al. All rights reserved. Usefulness of Sacral Sublaminar Wire for Low Transverse Sacral Fractures: Two Cases’ Report Wed, 04 Oct 2017 00:00:00 +0000 Low transverse sacral fractures are rare, with only two published reports regarding their surgery. The complication associated with surgery for sacral fractures is the prominence of implants. In addition, screw fixation below S3 is impractical. We performed posterior sacral fixation using S2 alar iliac (S2AI) screws and sacral sublaminar wires for low transverse sacral fractures. Case 1 was 65-year-old male with an S2-3 transverse sacral fracture. We performed laminectomy (S2-3) and passed ultrahigh molecular weight polyethylene (UHMWPE) cables from laminectomy area to the third posterior sacral foramina. We inserted S2AI screws and connected rods. We also tightened the UHMWPE cables. The implants did not protrude into skin. One year after surgery, the sacral fracture healed without any displacement. Case 2 was a 42-year-old female with an S2 transverse sacral fracture. We performed laminectomy (S1–3) and passed UHMWPE cables from laminectomy area to the third and fourth posterior sacral foramina. We inserted S1 pedicular screws and S2AI screws and connected rods. We also tightened UHMWPE cables. The implants did not protrude into skin. One year after surgery, the sacral fracture healed without any displacement. We consider sacral sublaminar wires to be useful bone anchors in lower sacrum. Tatsuro Sasaji, Hideki Imaizumi, and Taishi Murakami Copyright © 2017 Tatsuro Sasaji et al. All rights reserved. Natural Remission of Major Periprosthetic Osteolysis following Total Hip Arthroplasty with Metal-on-Metal Bearings Wed, 04 Oct 2017 00:00:00 +0000 The natural course of adverse events following the use of metal-on-metal (MoM) bearings in total hip arthroplasty (THA) is not well known. In this article, we report the case of a patient with asymptomatic major acetabular osteolysis following MoM THA that diminished gradually without any surgical intervention. A 58-year-old male underwent one-stage bilateral MoM THA for bilateral osteoarthritis. Four years after THA, major acetabular osteolysis developed in his right hip without any local or systemic symptoms. The patient underwent a careful radiographic and clinical observation without any surgical intervention because he did not want to undergo revision surgery. The lesion gradually diminished after 7 years, and most of the osteolytic area was replaced by newly formed bone at 10 years. He continues to be followed with no evidence of cup loosening or migration. Our observation suggests that a periprosthetic osteolytic change related to the use of MoM bearings has the potential for natural remission. Tatsuya Tamaki and Kazuhiro Oinuma Copyright © 2017 Tatsuya Tamaki and Kazuhiro Oinuma. All rights reserved. Sacral Stress Fracture in an Amateur Badminton Player Tue, 03 Oct 2017 00:00:00 +0000 Sacral stress fractures are rare among athletes but have been reported most frequently in long distance runners. We report herein the first case of a sacral stress fracture in an amateur badminton player. A 16-year-old, left-handed adolescent girl, who had just started to play badminton 3 months previously, complained of acute left buttock pain when she received a shuttlecock. Magnetic resonance imaging revealed a linear lesion of the left sacrum with low signal intensity on T1- and high signal intensity on T2-weighted images, which was consistent with a stress fracture. Conservative treatment with rest relieved her symptoms. Her fracture was considered to have occurred due to repetition of an exercise that caused excessive vertical power. Yusuke Yuasa, Naohisa Miyakoshi, Michio Hongo, Kunio Ebata, Tatsuru Tomioka, and Yoichi Shimada Copyright © 2017 Yusuke Yuasa et al. All rights reserved. Compression of the Femoral Vessels by a Pseudotumor after Metal-on-Metal Total Hip Arthroplasty Sun, 01 Oct 2017 07:22:45 +0000 Here we present a case of pseudotumor following total hip arthroplasty (THA) that resulted in a circulatory disturbance caused by compression of the femoral vasculature. A 63-year-old man presented with pain, swelling, and redness of the left leg 5 years after primary metal-on-metal THA using the AML-Plus stem, Pinnacle® acetabular cup, and 36 mm diameter Ultamet™ metal head system (DePuy Orthopaedics, Warsaw, IN). Enhanced computed tomography and magnetic resonance imaging revealed a large cystic lesion extending from the left hip anteriorly to the intrapelvic region and compressing the left femoral vessels. Percutaneous puncture of the lesion yielded a dark red aspirate and the patient was diagnosed to have a pseudotumor causing compression of the femoral vessels. We performed revision surgery to replace the metal head and metal liner with a smaller ceramic head and polyethylene liner without removal of the stem. Corrosion of the head-neck junction was identified intraoperatively with no obvious wear on the bearing surfaces. The left leg swelling and redness improved immediately postoperatively. A large pseudotumor should be kept in mind as a cause of vascular compression with unilateral leg edema in a patient who has undergone metal-on-metal THA. Yasuaki Tamaki, Tomohiro Goto, Takahiko Tsutsui, Tomoya Takasago, Keizo Wada, and Koichi Sairyo Copyright © 2017 Yasuaki Tamaki et al. All rights reserved. Quadriceps Tendon Rupture in an Adolescent Athlete Tue, 26 Sep 2017 00:00:00 +0000 Quadriceps tendon rupture is an uncommon injury that usually occurs in middle-aged and elderly men with a history of chronic illnesses. We report the case of a 17-year-old healthy adolescent male baseball player who sustained this injury as a result of sudden deceleration in his left knee. He initially reported to the emergency department and then presented to our practice, where he was diagnosed with a quadriceps tendon tear. Preoperatively, he was unable to perform a single straight-leg raise. During surgical repair, the free edge of the quadriceps tendon was mobilized and anchored into the superior pole of the patella, followed by sutures to ensure reinforcement of the quadriceps footprint. His postoperative course progressed normally, demonstrating full range of motion at 3 months and return to team training at 5 months. Unlike previously reported quadriceps tendon ruptures in adolescents, to our knowledge, this is the first report of a patient who sustained such an injury without previous trauma to his knee or quadriceps mechanism. It is possible that weakened tendon integrity from repeated microtrauma during training combined with the sudden weight change distribution may have resulted in the injury. As urgent surgical intervention is necessary to ensure efficient recovery and return to sport, the sports medicine practitioner must remain educated and vigilant on caring for these patients. William A. Zuke, Beatrice Go, Alexander E. Weber, and Brian Forsythe Copyright © 2017 William A. Zuke et al. All rights reserved. Complete Resection of a Massive Synovial Osteochondromatosis of the Hip Using an Anterior Approach: A Report of Two Cases Wed, 20 Sep 2017 00:00:00 +0000 Arthroscopic excision of synovial osteochondromatosis of the hip is commonly performed. However, when the lesion extends to the extra-articular space of the hip joint, excision using arthroscopy becomes difficult. Although surgical dislocation of the hip with a trochanteric flip osteotomy is commonly used, manual access to the inferomedial portion of the acetabulum remains difficult. In this case report, we describe arthroscopic resection followed by open surgery using an anterior approach with or without surgical dislocation to excise a synovial osteochondromatosis of the hip that had extended to the extra-articular space and formed a herniation sac. Excision was completed without complications. An anterior approach with or without surgical dislocation should be considered as a surgical option for the treatment of a massive synovial osteochondromatosis of the hip joint. Masanao Kataoka, Koji Goto, Yutaka Kuroda, Toshiyuki Kawai, Ouki Murata, Masayuki Sugimoto, and Shuichi Matsuda Copyright © 2017 Masanao Kataoka et al. All rights reserved. Triplane Fracture of the Proximal Tibia: A Case Report and Literature Review Mon, 18 Sep 2017 00:00:00 +0000 Background. The triplane fracture, a unique transitional physeal injury, is classically described in the distal tibia. A small number of additional anatomic locations are documented in the orthopaedic literature. Methods. Available literature surrounding triplane fractures was reviewed. We describe a rare case of a proximal tibial triplane fracture in a thirteen-year-old girl, suffered during a skiing accident. Results. Using arthroscopically assisted percutaneous reduction techniques an anatomic reduction was achieved. Conclusion. We outline the surgical and postoperative techniques for management of this unique injury. Jason Strelzow, Alexander Aarvold, and Christopher W. Reilly Copyright © 2017 Jason Strelzow et al. All rights reserved. A Case of C5 Vertebral Chordoma in a 73-Year-Old Patient with More Than 8 Years of Follow-Up after Total Piecemeal Spondylectomy Tue, 12 Sep 2017 00:00:00 +0000 Chordoma arising from the cervical spine is rare and the traditional long-term prognosis is typically poor. Total en bloc spondylectomy with a wide margin is generally accepted to be the most appropriate management for thoracic and lumbar malignant tumors. However, this method is still challenging for the cervical spine because of the proximity of the tumor to the vertebral arteries and neural elements. Here, we report a 73-year-old man with a C5 vertebral chordoma treated with total piecemeal spondylectomy. Histological examination revealed pathognomonic physaliphorous cells with mucus-filled cytoplasm in the tumor, and the ratio of Ki-67-positive cells within the tumor was high (19.0%), showing active proliferation rate. Local recurrences were found at 9 months, 4 years and 2 months, and 6 years after the initial surgery. All the recurrences were encapsulated and isolated and treated with an additional en bloc resection successfully at each stage. Eight years after the initial total piecemeal spondylectomy, the patient maintained his intact neurological status without local recurrence or metastasis. The prognosis of cervical chordoma depends on the patient’s age, surgical procedures, and histological features. In this report, we present that piecemeal spondylectomy is an alternative management for aged patients with cervical chordoma, even for those with high MIB-1 index. Keigo Tanaka, Harutoshi Sakakima, Kazutoshi Hida, Kanako Hatanaka, and Kosei Ijiri Copyright © 2017 Keigo Tanaka et al. All rights reserved. Successful Treatment of a 15-Year-Old Nonunion of a Midshaft Clavicle Fracture Causing Brachial Plexus Compression Sun, 10 Sep 2017 00:00:00 +0000 A 49-year-old man with a 15-year-old nonunion of a midshaft clavicle fracture suffered from progressive tingling in his entire arm and fingers for two years, due to irritation of the brachial plexus in the costoclavicular space, especially upon elevation of the arm. After open reduction and internal plate fixation, all symptoms were resolved and complete consolidation of the fracture was achieved at one-year follow-up. This case demonstrates two things: brachial plexus compression can occur even many years after a nonunion of a clavicle fracture and union can be still achieved, even in a longstanding nonunion. Annemarijn Teunis, Rianne M. H. A. Huis In ’t Veld, Vincent E. J. A. de Windt, Sjoerd van Raak, and Anne J. H. Vochteloo Copyright © 2017 Annemarijn Teunis et al. All rights reserved. Ligament Augmentation and Reconstruction System Failures in Repair of Grade V Acromioclavicular Joint Dislocation Wed, 06 Sep 2017 07:20:23 +0000 The Ligament Augmentation and Reconstruction System® (LARS®) represents a popular synthetic anatomical reduction method for acromioclavicular joint dislocation by means of coracoclavicular ligament reconstruction. To our knowledge, no early failure has been documented in the literature. We present two unusual cases of LARS failure, one at four months after implant and the other at three weeks, without obvious causes, requiring re-do reconstruction, and discuss potential contributory factors. Martin K.-H. Li and David Woods Copyright © 2017 Martin K.-H. Li and David Woods. All rights reserved. Reverse Fosbury Flop Tear of the Rotator Cuff Tue, 05 Sep 2017 09:45:20 +0000 Introduction. “Fosbury flop” tear is an avulsion of the posterosuperior rotator cuff from the bone with reversal healing on its medial bursal-side. This case report describes a unique variant of Fosbury flop tear with a lesion of the musculotendinous junction that healed, for its tendon part, on the anterior humerus and coracoid process. Case Presentation. A 62-year-old man developed a posttraumatic painful shoulder with active loss of range of motion. Magnetic resonance arthrography demonstrated a lesion of the musculotendinous junction of the supraspinatus with healing of the tendon on the above-mentioned structures (reverse Fosbury flop). During arthroscopic evaluation, tendon repair was not possible and a debridement to avoid subacromial and anterior impingement associated with a tenotomy of the long head of the biceps were carried out. One year postoperatively, the patient had complete range of motion and was satisfied with the clinical results. Discussion and Conclusion. Different Fosbury flop tears exist. Radiologists and orthopedic surgeons should be aware of these tear patterns as failure to recognize them may lead to inadequate treatment. Jérôme Tirefort, Gregory Cunningham, and Alexandre Lädermann Copyright © 2017 Jérôme Tirefort et al. All rights reserved. Volar Distal Radioulnar Joint Dislocation Associated with Acute Median Nerve Neuropathy and a Distal Radius Fracture Wed, 30 Aug 2017 09:15:57 +0000 Volar distal radioulnar (DRUJ) dislocations are uncommon and can easily be missed. We present a rare case of an irreducible volar DRUJ dislocation associated with a distal radius fracture and acute median nerve neuropathy at the wrist. An attempt to reduce the DRUJ dislocation in the emergency department had failed. The patient was then taken to the operating room requiring a carpal tunnel release, as well as an open reduction and internal fixation of the distal radius fracture and repair of the volar distal radioulnar ligament. We also review some of the volar DRUJ case reports in the literature. Naser Alnusif, Sultan Aldebeyan, and Rudolf Reindl Copyright © 2017 Naser Alnusif et al. All rights reserved. Reverse Total Shoulder Arthroplasty as Treatment for Rotator Cuff-Tear Arthropathy and Shoulder Dislocations in an Elderly Male with Parkinson’s Disease Tue, 29 Aug 2017 07:47:28 +0000 We report the case of a 70-year-old male with Parkinson’s disease (PD) and recurrent traumatic left shoulder dislocations. This case is rare because (1) he had a massive irreparable rotator cuff tear and end-stage arthritis (i.e., rotator cuff-tear arthropathy) of the same shoulder and (2) his shoulder was ultimately reconstructed with a reverse total shoulder arthroplasty (RTSA). His first dislocation occurred after a fall. Recurrent shoulder dislocations occurred despite successful closed reduction and physical therapy. Initial surgical treatment included an open capsular-labral reconstruction; RTSA was not an ideal option because of the presumed risk of failure from PD-related dyskinesias. However, the capsular-labral reconstruction failed after he lost balance and stumbled but did not fall. A RTSA was then done which restored the patient’s shoulder stability and greatly improved his pain. At final follow-up two years later, he reported pain relief and improved function. This was partially attributed to the fact that he had moved to an assisted living center. He also began using an electric wheelchair one year after the RTSA. We report this case because of the unusual set of conditions and circumstances, namely, the implantation of a RTSA in a patient with PD and shoulder instability. John G. Skedros, James S. Smith, Tanner D. Langston, and Micheal G. Adondakis Copyright © 2017 John G. Skedros et al. All rights reserved. Reverse Segond Fracture Associated with Anteromedial Tibial Rim and Tibial Attachment of Anterior Cruciate Ligament Avulsion Fractures Tue, 29 Aug 2017 00:00:00 +0000 Reverse Segond fracture is an uncommon avulsion fracture of the tibial attachment of the deep portion of the medial collateral ligament of the knee. We report a reverse Segond fracture associated with anterior cruciate ligament tibial avulsion fracture and anteromedial tibial rim fracture. Unlike previous reports, the combination of reverse Segond fracture, anteromedial tibial rim fracture, and anterior cruciate ligament avulsion fracture was not associated with posterior cruciate ligament injury, posterolateral corner injury, or tibial plateau fracture. This new combination of injuries provides better understanding of the mechanisms of ligamentous injuries of the knee and highlights the importance of meticulous assessment of these injuries for accurate diagnosis and subsequent management. Yehia H. Bedeir Copyright © 2017 Yehia H. Bedeir. All rights reserved. Fatal Cobalt Toxicity after a Non-Metal-on-Metal Total Hip Arthroplasty Sun, 27 Aug 2017 00:00:00 +0000 This case illustrates the potential for systemic cobalt toxicity in non-metal-on-metal bearings and its potentially devastating consequences. We present a 71-year-old male with grinding sensations in his right hip following ceramic-on-ceramic total hip arthroplasty (THA). After diagnosing a fractured ceramic liner, the hip prosthesis was revised into a metal-on-polyethylene bearing. At one year postoperatively, X-rays and MARS-MRI showed a fixed reversed hybrid THA, with periarticular densities, flattening of the femoral head component, and a pattern of periarticular metal wear debris and pseudotumor formation. Before revision could take place, the patient was admitted with the clinical picture of systemic cobalt toxicity, supported by excessively high serum cobalt and chromium levels, and ultimately died. At autopsy dilated cardiomyopathy as cause of death was hypothesized. A third body wear reaction between ceramic remnants and the metal femoral head very likely led to excessive metal wear, which contributed systemic cobalt toxicity leading to neurotoxicity and heart failure. This case emphasizes that fractured ceramic-on-ceramic bearings should be revised to ceramic-on-ceramic or ceramic-on-polyethylene bearings, but not to metal-on-polyethylene bearings. We aim to increase awareness among orthopedic surgeons for clinical clues for systemic cobalt intoxication, even when there is no metal-on-metal bearing surface. Rinne M. Peters, Pax Willemse, Paul C. Rijk, Mels Hoogendoorn, and Wierd P. Zijlstra Copyright © 2017 Rinne M. Peters et al. All rights reserved. Chronic Osteomyelitis of the Distal Femur Treated with Resection and Delayed Endoprosthetic Reconstruction: A Report of Three Cases Tue, 15 Aug 2017 00:00:00 +0000 Chronic osteomyelitis involving the distal femur often results in amputation or arthrodesis. This article presents three cases of chronic osteomyelitis treated with a staged approach culminating in endoprosthetic reconstruction. Stage one involved resection of infected bone and placement of an intramedullary nail spanning the bony defect between proximal femur and tibia, with antibiotic cement packed around the nail. Patients were then placed on long-term IV +/− oral antibiotics to clear the infection. A “cooldown” period was then used between stages where patients were off antibiotics and inflammatory markers were monitored for signs of remaining infection. Stage two then involved reconstruction of the distal femur and knee with an endoprosthesis. In the appropriate patient, this treatment strategy offers another option in this challenging population. Sean Ryan, William Eward, Brian Brigman, and Robert Zura Copyright © 2017 Sean Ryan et al. All rights reserved. Acute Traumatic Patellar Tendon Rupture at the Tibial Tuberosity Attachment without Avulsion Fracture Thu, 10 Aug 2017 09:34:18 +0000 Patellar tendon rupture in children is especially rare. The fact that the area of traumatic rupture has wide variations makes surgical treatment difficult. We present an 11-year-old boy with acute traumatic patellar tendon rupture at the tibial tuberosity attachment without avulsion fracture. Primary end-to-end repair and reinforcement using 1.5 mm stainless steel wires as a surgical strategy were undertaken. Early range of motion began with a functional knee brace and the reinforced stainless wire was removed 3 months after surgery. Knee function at the final follow-up was satisfactory. We suggest that this strategy may provide a useful option for surgical treatment. Shuichi Miyamoto, Makoto Otsuka, Fumio Hasue, Takayuki Fujiyoshi, Koushirou Kamiya, Hitoshi Kiuchi, Ken Ohara, Atsushi Yunde, Yasunori Toki, Tadashi Tanaka, Junichi Nakamura, and Seiji Ohtori Copyright © 2017 Shuichi Miyamoto et al. All rights reserved. The Training Effect of Early Intervention with a Hybrid Assistive Limb after Total Knee Arthroplasty Thu, 10 Aug 2017 00:00:00 +0000 After total knee arthroplasty (TKA), it is important for patients to show early improvements in knee joint function and walking to regain independence in performing the activities of daily life. We conducted for 4 weeks an intervention one week after TKA using a hybrid assistive limb (HAL: unilateral leg type) as an exoskeleton robotic device to facilitate knee joint function and walking. The intervention improved the range of knee extension movement safely and without pain compared to preoperation. In addition, we found that training with the HAL improved walking ability, speed, and rate, as well as the time taken to perform the timed up and go (TUG) test compared to preoperation. The strength of the quadriceps muscle did not improve with training; however, the patient was able to induce a knee extensor moment during the initial stance phase, as measured by kinetics and kinematics, and these actions could be performed without pain. HAL training soon after TKA improved knee joint function in a 76-year-old patient who presented with OA of the knee. The improvements in knee extension lag and knee extensor moment allowed the patient to walk without pain and regain ADL in comparison with preoperation. Takashi Fukaya, Hirotaka Mutsuzaki, Kenichi Yoshikawa, Ayumu Sano, Masafumi Mizukami, and Masashi Yamazaki Copyright © 2017 Takashi Fukaya et al. All rights reserved. Recalcitrant Lateral Premalleolar Bursitis of the Ankle Associated with Lateral Ankle Instability Thu, 03 Aug 2017 00:00:00 +0000 Lateral premalleolar bursitis of the ankle is a rarely reported disorder in the English literature although it is not uncommon in Asian countries where people commonly sit on their feet. Here, we present the case of a 66-year-old woman with recalcitrant lateral premalleolar bursitis associated with lateral ankle instability which was successfully treated with surgical resection of the bursa and repair of the anterior talofibular ligament. Operative findings revealed a communication between the bursa and articular cavity of the ankle joint via the sheath of the extensor digitorum longus tendon, which was considered to act as a check valve leading to a large and recalcitrant bursitis. This report provides a novel concept about the etiology of recalcitrant lateral premalleolar bursitis of the ankle. Masashi Naito, Takumi Matsumoto, Song Ho Chang, Masachika Ikegami, Jun Hirose, and Sakae Tanaka Copyright © 2017 Masashi Naito et al. All rights reserved.