Journal of Orthopaedic Case Reports最新文献

Introduction: Tibial pseudoarthrosis is an uncommon but serious complication following high-energy trauma, particularly in complex distal tibial fractures such as pilon fractures. Atrophic pseudoarthrosis, characterized by avascular bone ends and a lack of biological activity, is often associated with risk factors such as smoking, soft-tissue damage, and multiple surgical interventions. Its management is particularly challenging, requiring a tailored approach that restores both mechanical stability and the biological environment for bone healing. Orthoplastic strategies have emerged as essential in cases with significant bone loss and compromised soft-tissue coverage.

Case report: We present the case of a 42-year-old male, a chronic smoker, who sustained a comminuted pilon fracture and fibular shaft fracture following a fall. Initial management included external fixation, followed by open reduction and internal fixation, and subsequent application of a hexapod fixator due to delayed healing. Persistent non-union and soft tissue compromise led to multiple reconstructive procedures, including autologous bone grafting and an anterolateral thigh free flap. Eleven months after the initial injury, the patient was referred to our orthoplastic unit. Diagnostic studies confirmed atrophic pseudoarthrosis of the distal tibia. A two-stage surgical approach was undertaken: First, debridement and placement of an antibiotic-impregnated cement spacer; second, tibiocalcaneal arthrodesis with an intramedullary nail and reconstruction using a contralateral free fibular flap. Post-operative recovery was favorable, with early signs of consolidation and good functional outcomes.

Conclusion: This case underscores the importance of a multidisciplinary, staged approach in managing complex tibial pseudoarthrosis. Orthoplastic collaboration enables successful limb salvage by addressing both osseous and soft tissue challenges, optimizing conditions for definitive bone healing and functional restoration.

Introduction: Lipomas arising from the muscle and bone are uncommon and remain unnoticed till giant size. Major concern is to differentiate from atypical lipomatous tumors (ALTs) which have propensity to recur or differentiate to liposarcomas. Through this case report, we review the intramuscular lipomas involving muscles of shoulder girdle and the current concepts in imaging and histopathological examination to differentiate deeply seated lipomas from ALTs.

Case report: A 47-year-old female was evaluated for a painless swelling that gradually increased in size in the right shoulder and upper arm for 8 months. Magnetic resonance imaging (MRI) showed lipomatous lesions in the biceps tendon of size 7 × 5 cm but expressed heterogeneous fat signals on suppression sequence. The biopsy revealed mature adipocytes with occasional fibrous septa that contained mixed inflammatory cells. Due to equivocal findings with ALT, immunohistochemical staining for murine double minute 2 (MDM2) homolog expression was performed but negative. There was no recurrence of the lesion and patient had no functional impairment.

Conclusion: Intramuscular lipomas that grow to giant size can exhibit heterogeneous fat signals in MRI and need to be looked for ALTs or well-differentiated liposarcoma through histopathological examination. Staining for MDM2 homolog and cyclin-dependent kinase-4 expression that are typical for ALTs is necessary when histopathological findings are indeterminate.

Introduction: Windswept deformity of the elbow, defined as cubitus varus on one side and cubitus valgus on the contralateral side, is exceptionally rare, particularly in post-traumatic settings. The majority of published literature focuses on windswept deformities of the lower limbs, with almost no evidence-based guidelines for upper limb deformities.

Case report: An 8-year-old male sustained bilateral elbow injuries in separate falls, leading to an untreated cubitus varus deformity of the left elbow (carrying angle -15°, Baumann's angle 82°) and a cubitus valgus deformity of the right elbow (carrying angle +20°). The child presented 18 months after the initial trauma due to pandemic-imposed restrictions, with parental concern primarily for cosmesis of the left elbow. Dome osteotomy was performed on the left humerus using a posterior approach with crossed K-wire fixation. The right elbow was managed conservatively due to preserved function and accepted cosmesis. Rehabilitation commenced at 3 weeks, and follow-up over 18 months demonstrated excellent cosmesis and function (Mayo Elbow Performance Score 95, Disabilities of Arm, Shoulder, and Hand score 8). No lateral condylar prominence or recurrent deformity was observed.

Conclusion: This is a rare report of a bilateral windswept elbow deformity. Dome osteotomy offers multiplanar correction with superior cosmesis and biomechanical restoration. Population-based carrying angle norms provide valuable guidance in planning correction when contralateral anatomy is unavailable. This case highlights the importance of individualized surgical decision-making, meticulous planning, and patient-centered care. Furthermore, it highlights the acceptance of a valgus deformity at the elbow as opposed to a varus deformity.

Introduction: Meniscal tears are among the most frequent knee injuries requiring surgical intervention. Arthroscopic repair has largely supplanted open repair due to its minimally invasive nature, yet long-term comparative outcomes remain poorly characterized. This study compared clinical outcomes of arthroscopic versus open meniscus repair using a large multicenter electronic health record database.

Materials and methods: We performed a retrospective cohort analysis using the TriNetX US Collaborative Network, including adult patients (18-60 years) who underwent meniscus repair between 2010 and 2025. Cohorts were defined by surgical approach: Open repair (CPT 27427-27429) and arthroscopic repair (CPT 29882-29883). Outcomes assessed within two years post-surgery were meniscal repair failure/re-tear, revision meniscus surgery, knee osteoarthritis (OA) progression, and venous thromboembolism (VTE). Propensity score matching (1:1) balanced demographics and comorbidities, yielding 17,925 patients per group. Risk ratios (RR), hazard ratios (HR), and Kaplan-Meier analyses were calculated.

Results: Before matching, the arthroscopic cohort (n = 48,101) was older and more frequently male compared with the open cohort (n = 17,966). After matching (n = 17,925 each), groups were well balanced across demographics and comorbidities (Table 1). Median follow-up was 22 months in both groups.Meniscal failure was significantly higher after arthroscopic repair (51.4%) than open repair (16.2%) (RR 0.32, 95% confidence interval [CI] 0.30-0.33; HR 0.24, 95% CI 0.23-0.25; P < 0.001). Revision surgery occurred in 3.4% of arthroscopic versus 1.0% of open repairs (RR 0.30, 95% CI 0.25-0.35; HR 0.29, 95% CI 0.25-0.35; P < 0.001). Conversely, OA progression was slightly more frequent in open repair patients (6.1% vs. 4.9%; RR 1.23, 95% CI 1.12-1.34; HR 1.23, 95% CI 1.12-1.34; log-rank P < 0.001). VTE incidence was low overall but higher after open repair (1.9% vs. 1.4%; RR 1.42, 95% CI 1.20-1.67; HR 1.41, 95% CI 1.20-1.66; P < 0.001).

Conclusions: In this large matched cohort, open meniscus repair was associated with markedly lower risks of meniscal failure and revision surgery compared with arthroscopic repair. However, open repair carried modestly higher risks of knee OA progression and VTE. These findings suggest open repair offers superior meniscal durability but at the expense of slightly increased long-term joint degeneration and thromboembolic risk. Shared decision-making should incorporate both durability and complication profiles, and prospective studies with longer follow-up are warranted.

Introduction: Effective post-operative pain control after total hip arthroplasty (THA) is essential for early mobilization, faster rehabilitation, and improved patient satisfaction. The present study was to compare the analgesic effectiveness and safety of a 5 mg transdermal buprenorphine patch versus an intraoperative periarticular cocktail injection for post-operative pain relief in THA patients, by assessing pain intensity and rescue analgesia use.

Materials and methods: This observational analytical study was carried out in the Department of Orthopedics at Gandhi Medical College and Hamidia Hospital, Bhopal, between May 2023 and April 2024. A total of 44 adult patients scheduled for THA were enrolled and divided into two equal groups. Group 1 (n = 22) received a 5 mg transdermal buprenorphine patch applied 12 h before surgery. At the same time, Group 2 (n = 22) received an intraoperative periarticular cocktail injection composed of 0.2% ropivacaine, cefuroxime, triamcinolone, ketorolac, adrenaline, and normal saline (45 mL). Post-operative pain was assessed using the visual analog scale (VAS), with scores recorded preoperatively and at 4, 8, 12, 24, 48, 72, and 120 h after surgery. The requirement and timing of rescue analgesia, as well as any adverse events, were monitored throughout the study period.

Results: Baseline demographic and surgical variables were comparable between the two groups. VAS scores were similar preoperatively (P = 0.763) and at 4 h postoperatively (P = 0.853). From 8 to 72 h postoperatively, the intraoperative cocktail group reported significantly lower VAS scores (e.g., at 8 h: 5.45 ± 1.63 vs. 7.73 ± 1.42; P < 0.001) and required fewer rescue analgesic doses (mean 1.91 vs. 3.73; P = 0.008). After 120 h, pain levels converged (3.55 ± 1.26 vs. 2.95 ± 1.62; P = 0.194), suggesting more sustained pain relief in the buprenorphine patch group. Both methods were safe, with only minor and non-significant adverse events.

Conclusion: Intraoperative cocktail infiltration provided superior early post-operative analgesia and reduced the need for rescue analgesia, while transdermal buprenorphine patches offered comparable and possibly more sustained pain relief by post-operative day 5. Both modalities were well tolerated. Tailoring the choice of analgesic strategy to patient-specific needs and surgical context may optimize pain management in hip arthroplasty. To the best of our knowledge, this is the first study directly comparing transdermal buprenorphine patches with periarticular cocktail infiltration for post-operative pain management in THA.

Introduction: Schwannomas are benign, encapsulated peripheral nerve sheath tumors derived from Schwann cells. They are rarely seen around the knee, accounting for <1% of all schwannomas, and can mimic other benign swellings such as ganglion cysts or bursae.

Case report: We report a 32-year-old female who presented with anteromedial right knee pain and a tender swelling for 2 years. Radiographs were normal, and a provisional diagnosis of a ganglion cyst was made. The lesion was excised under local anesthesia through a vertical incision and found to be a well-encapsulated mass measuring approximately 1 × 1 × 1 cm, located superficial to the joint capsule. Based on its location, the swelling was suspected to arise from a branch of the saphenous nerve, most likely the infrapatellar branch. Histopathological examination confirmed the diagnosis of schwannoma.

Conclusion: Schwannomas, though benign and uncommon around the knee, should be included in the differential diagnosis of localized knee pain with soft-tissue swelling and normal radiographs.

Introduction: Complex intra-articular proximal tibia fractures (Schatzker types V and VI) are difficult to manage due to articular involvement, malalignment, and soft-tissue compromise. Conventional plating techniques carry risks of infection and soft-tissue morbidity. Suprapatellar intramedullary nailing (IMN), combined with condylar screws, offers a minimally invasive option with potential biomechanical and clinical advantages.

Materials and methods: A prospective case series was conducted at a tertiary trauma center in Chennai, India, including 10 consecutive adults with Schatzker type V (n = 6) and VI (n = 4) fractures. All patients underwent Suprapatellar IMN in the semi-extended position, reinforced with two lateral-to-medial condylar screws. Patients were followed for 12 months. Radiological union, fracture alignment, and complications were documented. Functional recovery was assessed using the lower extremity functional scale (LEFS) and knee range of motion (ROM).

Results: The mean patient age was 46.9 years (range 29-73), with 8 males and 2 females. The mean operative time was 104.3 ± 14.2 min. All fractures united radiologically at a mean of 14.3 ± 1.8 weeks. At 12 months, the mean LEFS score was 66.6 ± 7.5; 70% of patients achieved minimal limitation (LEFS ≥64). The mean knee ROM was 125° ± 7.8°. No cases of infection, non-union, implant failure, or neurovascular injury were recorded.

Conclusion: Suprapatellar IMN supplemented with condylar screws appears to be a reliable minimally invasive technique for complex proximal tibia fractures, allowing stable fixation, early mobilization, and good functional outcomes. Larger studies are warranted to validate these findings.

Introduction: Glomus tumors are benign vascular tumors that are rare and most usually located in the nail bed. They may go undetected when they are found in unusual places, such as the forearm, and hence, cause a delay in diagnosis and treatment. In this report, we have discussed a 34-year-old man with a history of forearm pain, which was diagnosed as a glomus tumor, thus illustrating the importance of a high index of suspicion about unusual sites of such a tumor in cases of persistent pain to make an early diagnosis and enable faster treatment.

Case report: A 34-year-old man presented with a history of local forearm pain over a long period, with a tender purplish subcutaneous swelling over the medial aspect of the upper forearm. The pain was chronic and exaggerated even on light touch, with no history of trauma or family history. The clinical observation showed a non-indurated, solitary and non-inflammatory lesion, without any inflammation. Ultrasound and magnetic resonance imaging showed a clearly defined, superficial, subcutaneous lesion, with homogeneous post-contrast enhancement, directly over the basilic vein. The patient was surgically treated by wide local excision with an elliptical incision. In the course of surgery, a well-circumscribed dark red mass was found and excised in its entirety. A histopathological analysis of a well-circumscribed dermal and subcutaneous tumor of glomus cells in the form of a nest confirmed the diagnosis of glomangioma. At 1-year follow-up, the patient had no symptoms. This case illustrates the possibility of extradigital glomus tumors in individuals who present with chronic localized unexplained forearm pain.

Conclusion: The case highlights the importance of diagnosing extradigital glomus tumors as a potential cause of chronic and localized pain in the limbs. Their abnormal location and insidious presentation often lead to neglect of such tumors, and therefore, their diagnosis becomes late and causes the patient undue discomfort. Even though clinical suspicion and appropriate imaging are useful in the early diagnosis, surgical excision is the treatment of choice, which offers complete relief. This report highlights the fact that early diagnosis can enhance the outcome of such cases.

Introduction: Perioperative blood loss is a significant challenge in total hip arthroplasty (THA), and it often necessitates blood transfusion. Tranexamic acid (TXA), an antifibrinolytic agent, is widely used to reduce surgical blood loss, but to date; there is no clear consensus on the optimal and most efficacious route of administration of TXA. Therefore, this study was planned to evaluate and compare the efficacy of different routes of administration of TXA in reducing perioperative blood loss through a prospective comparative study.

Materials and methods: A total of 102 patients undergoing elective unilateral THA were enrolled and randomized into three cases and their three control groups of 17 patients each. The patients in group A (intravenous [IV]-TXA group) received IV-TXA while its control Group D received an equivalent amount of IV normal saline (NS). Group B (Topical-TXA group), received topical TXA, while its control Group E received an equivalent amount of NS at similar stages in a similar fashion. Group C (combined-TXA group) received IV as well as topical TXA, while its control Group F received an equivalent amount of NS at similar stages. Perioperative blood loss was measured from suction cylinders, mop weight and drain output. Statistical analysis included analysis of variance, post hoc Tukey tests, and independent t-tests.

Results: All TXA groups showed reduced blood loss as compared to their controls. Among these, the combined-TXA group demonstrated the lowest total mean blood loss (629.29 ± 26.33 mL), followed by the IV-TXA and topical-TXA group. These differences were statistically significant (P < 0.05). No adverse events were reported in the case or control groups.

Conclusion: The route of TXA administration plays a significant role in its efficacy in reducing perioperative blood loss. The combined (IV+ Topical) route is more effective in reducing intraoperative and post-operative blood loss as compared to IV or topical routes.

Introduction: Bertolotti syndrome (BS) is an underdiagnosed cause of chronic low back pain associated with lumbosacral transitional vertebrae (LTV). Although conservative management is usually the first-line approach, a subset of patients remains refractory and may benefit from surgical intervention. Reports on surgical outcomes remain scarce, and evidence is predominantly limited to isolated case reports. We present a case series of three patients with symptomatic BS who did not respond to conservative management and underwent surgical treatment.

Case report: Three patients (two females, one male; age range 21-32 years) presented with chronic low back pain and radicular symptoms. All had imaging findings consistent with Castellvi Type II or Type III LTV. Prior management included physical therapy, non-steroidal anti-inflammatory drugs, image-guided injections, and activity modification, with inadequate symptom relief. Surgical management consisted of resection of the anomalous transverse process articulation in all cases. Clinical follow-up evaluated pain Visual Analog Scale, function, and return to activity. All patients reported significant improvement in pain and functional outcomes, with sustained benefit at final follow-up (6-24 months). No neurological complications or reoperations occurred.

Conclusion: Surgical resection may be considered in carefully selected patients with symptomatic BS who fail conservative management. This case series reinforces the importance of appropriate diagnosis, patient selection, and surgical expertise in addressing this uncommon but impactful cause of persistent low back pain. Further studies with larger cohorts are needed to better define indications and outcomes.