Journal of Orthopaedic Case Reports最新文献

Introduction: With improved survival rates and functional outcomes, amputees are increasingly presenting with degenerative hip pathology requiring total hip arthroplasty (THA). However, THA in patients with ipsilateral lower limb amputation poses unique anatomical, biomechanical and technical challenges, and current surgical training often lacks specific technical insights for these complex cases. The literature remains limited, with few reports detailing technical strategies and rehabilitative measures in this patient population. This report aims to contribute to the existing knowledge by highlighting key pre-operative, operative and rehabilitative considerations in THA following transfemoral amputation.

Case report: A male in his early 30s, with left above-knee amputation following trauma 3 years prior, developed progressive left hip pain impairing prosthetic ambulation. Radiographs revealed advanced osteoarthritis with femoral head collapse and retained internal fixation hardware. Pre-operative assessment included full-length femur imaging and bone density evaluation, confirming adequate bone stock. An uncemented total hip replacement was performed via a modified lateral approach. Intraoperative control of the femoral stump was achieved with a Steinmann pin inserted in the distal femur, facilitating dislocation and stem positioning without compromising fixation. Post-operatively, rehabilitation emphasized strengthening hip flexors, extensors, abductors, and adductors, with weight-bearing deferred until soft tissue healing permitted prosthetic fitting. By 3 months, the patient resumed independent ambulation with the prosthesis. Follow-up imaging at 6 months showed stable implant integration. The Harris Hip Score improved from 30 pre-operatively to 70 post-operatively.

Conclusion: THA in above-knee amputees requires meticulous preoperative planning, including detailed imaging and bone quality evaluation, alongside tailored intraoperative techniques, such as traction pin use for stump control. Implant fixation strategy must consider residual femur morphology, and rehabilitation should be customized to overcome specific muscular deficits. With comprehensive management, favorable functional outcomes and prosthetic gait restoration can be achieved in this challenging patient population.

Background: Avulsion fracture of the tibial tuberosity is a rare orthopedic injury, predominantly affecting adolescents but seldom seen in the adult population. Lateral tibial plateau fractures, while more common, infrequently present combined with tibial tuberosity avulsion. No established classification system currently describes or guides management for cases featuring both lateral tibial plateau split fracture and tibial tuberosity avulsion.

Case report: This report describes a 30-year-old male presenting with acute knee pain and swelling following a road traffic accident. Radiographic evaluation revealed a unique combination of lateral tibial plateau split fracture and displaced tibial tuberosity avulsion. The patient underwent surgical fixation through an anterolateral approach, utilizing a lateral proximal tibial plate for the plateau fracture and lag screws with tension band wiring for the tuberosity avulsion. Early post-operative mobilization was implemented to mitigate the risk of stiffness.

Discussion: While tibial tuberosity fractures are historically documented in pediatric populations, their occurrence with isolated split lateral tibial plateau fractures in adults is exceptionally rare. A thorough review of the literature yielded only isolated reports of similar injury patterns, often within multi-fragmentary or bicondylar fractures. Proper radiological assessment and targeted internal fixation are crucial for optimal outcomes. Addressing the tuberosity avulsion is essential to restore extensor mechanism integrity and prevent non-union.

Conclusion: Simultaneous isolated split lateral tibial plateau fracture and tibial tuberosity avulsion highlight an uncommon injury pattern, warranting vigilance during diagnosis and treatment. Early surgical intervention and rehabilitation achieve favorable functional results.

Introduction: Anatomical variations of the sciatic nerve are of significant clinical importance due to their implications in hip surgery, regional anesthesia, and the evaluation of sciatic neuropathies. The most widely accepted description of sciatic nerve-piriformis muscle relationships is the Beaton and Anson classification, which encompasses six recognized patterns. However, rare anatomical variants exist that do not conform to this classification and may predispose patients to nerve injury or diagnostic challenges.

Case report: We report a rare, unclassified anatomical variation of the sciatic nerve encountered intraoperatively during open reduction and internal fixation of a posterior wall acetabular fracture in a 32-year-old male following a road traffic accident. The sciatic nerve was observed to divide into its tibial and common peroneal components below the piriformis muscle; a pattern not described in existing classification systems.

Conclusion: Awareness of such atypical anatomy is essential for orthopedic surgeons to prevent iatrogenic nerve injury and highlights the need for further anatomical and radiological studies to expand current classification systems.

Introduction: Clavicle fractures are common in children, representing 7-15% of pediatric fractures, typically healing with conservative management. Non-union is exceedingly rare, especially in children under 3 years of age.

Case report: We report a case of a 3-year-old male with traumatic midshaft clavicle fracture non-union, presenting 2 years post-injury with persistent pain, swelling, deformity, and restricted shoulder function. Radiographs revealed a hypertrophic non-union with significant displacement and 2 cm shortening. The patient was managed surgically with open reduction, internal fixation using a mini-fragment plate and screws, and autogenous bone grafting.

Outcome: Progressive callus formation and complete osseous union were confirmed radiologically by 12 weeks. At final follow-up, the child had a full, pain-free range of motion and no residual deformity, returning to normal activities.

Conclusion: This case highlights that clavicle non-union, although rare, can occur even in toddlers. Surgical management with plate fixation and bone grafting can yield excellent outcomes. Vigilant follow-up of displaced pediatric clavicle fractures is essential to detect and manage this uncommon complication.

Introduction: Malignant peripheral nerve sheath tumors (MPNST) are uncommon soft-tissue sarcomas that typically arise in proximal segments of the extremities or pelvis. Their management requires precise biopsy planning, careful surgical assessment, and coordinated multidisciplinary care. Tumors involving multiple longitudinal levels of the leg are rare and pose significant challenges for limb salvage.

Case report: We report the case of a 79-year-old male presenting with a rapidly progressive mass extending along the posterior cruris, in the setting of a prior hip hemiarthroplasty and a revision total knee arthroplasty with long femoral and tibial stems. Magnetic resonance imaging demonstrated two heterogeneous solid masses in the posterolateral proximal right cruris and biopsy revealed a high-grade MPNST (Fédération Nationale des Centres de Lutte Contre le Cancer grade 3). The tumor board concluded that limb-sparing resection was unsafe due to tumor extent, limited soft-tissue envelope, and anticipated difficulty achieving durable wound closure. The presence of existing long-stem implants further complicated determination of a safe osteotomy level. Above-knee amputation was therefore selected as the most reliable method for achieving oncologic control while minimizing post-operative complications.

Discussion/results: The amputation was performed with fluoroscopy-guided planning of the osteotomy level to avoid stem interference, followed by myoplasty and myodesis for stable stump reconstruction. Histopathology confirmed a high-grade MPNST with diffuse S100 and SOX10 positivity, extensive necrosis, high mitotic activity, and a Ki-67 index of 50%.

Conclusion: This case illustrates the critical importance of methodical biopsy planning and multidisciplinary coordination in managing sarcomas of the lower extremity. The unusual longitudinal distribution of the tumor, combined with the constraints imposed by pre-existing long-stem implants, made limb salvage infeasible. Individualized surgical planning, incorporating both oncologic and reconstructive considerations, is essential when managing complex MPNSTs in reconstructively compromised limbs.

Introduction: Combined anterior cruciate ligament (ACL) and meniscus injuries are common in active individuals. This study evaluates the outcomes of arthroscopic ACL reconstruction with simultaneous meniscus repair.

Materials and methods: A prospective study of 14 patients undergoing ACL reconstruction with meniscus repair was conducted. Lysholm Knee Score and Visual Analog scale (VAS) were used for outcome assessment. Intraoperative and post-operative complications were recorded.

Results: All 14 patients had poor pre-operative Lysholm Scores (mean 25.2). At 6 months, 71.4% achieved excellent outcomes, with the mean score improving to 92 (P < 1.54 × 10^-17). Mean VAS scores decreased from 4 pre-operatively to 0.8 at 6 months (P < 1.98 × 10^-12), indicating significant functional recovery and pain relief.

Conclusion: Arthroscopic ACL reconstruction with meniscus repair provides excellent functional outcomes with minimal complications.

Introduction: Airgun or air-rifle injuries are often perceived as minor injuries; however, they can cause significant morbidity, particularly in children. The cervical spine, with its vital neurovascular and airway structures around, is vulnerable to any penetrating injury, even to low-velocity projectiles.

Case report: We report the case of a 9-year-old boy who sustained an accidental posterior cervical airgun injury at home. The child was neurologically intact, and imaging revealed a retained metallic pellet deeply embedded in the posterior aspect of the neck impacted within the edge of the right lateral mass of the C7 vertebra without involvement of the spinal canal or injury to major vessels. Multiple unsuccessful retrieval attempts were performed at the district hospital before the pellet was successfully removed surgically at our tertiary care institute. The post-operative course was uneventful, and the child remained asymptomatic on follow-up.

Conclusion: Pediatric cervical airgun injuries, though often considered minor, can endanger vital cervical structures. Even in neurologically intact patients, retained projectiles may warrant surgical removal when safely accessible to prevent delayed complications such as infection or migration. This case underscores the principle of decision-making beyond deficits, where management is guided by anatomical risk, long-term safety, and the imperative to raise public awareness about the potential dangers of airguns in children.

Introduction: Hand fractures of the metacarpals and phalanges account for up to 10% of all skeletal injuries and can lead to significant functional impairment if not managed appropriately. Retrograde intramedullary headless screw (IMHS) fixation is a minimally invasive technique that promises stable fixation and early mobilization, but its clinical efficacy in a prospective setting warrants evaluation.

Materials and methods: A prospective interventional study was conducted at tertiary care center from May 2023 to October 2024. Forty adult patients with simple, extra-articular metacarpal or phalanx fractures were enrolled; six were lost to follow-up, leaving 34 for analysis. Fractures were stabilized using retrograde IMHS fixation. Functional recovery was assessed at 3 weeks, 3 months, and 6 months postoperatively using the disabilities of the arm, shoulder and hand (DASH) score, hand grip strength, and total active motion (TAM) per American Society for Surgery of the Hand criteria.

Results: The mean patient age was 29.29 ± 8.52 years; 82.4% were male, and 52.9% had injuries in the dominant hand. Shaft fractures predominated (83.8%). (1) DASH score improved from 47.07 ± 7.29 at 3 weeks to 27.30 ± 2.59 at 3 months and 1.32 ± 1.51 at 6 months (all P < 0.001). (2) Grip strength increased from 11.09 ± 1.75 kg at 3 weeks to 24.38 ± 3.46 kg at 3 months and 39.74 ± 4.69 kg at 6 months (all P < 0.001). (3) TAM rose from 116.18 ± 11.81° at 3 weeks to 154.71 ± 14.61° at 3 months and 268.53 ± 17.78° at 6 months (all P < 0.001).

Conclusion: Retrograde IMHS fixation offers stable fracture stabilization with minimal soft-tissue disruption, enabling early mobilization and resulting in excellent functional recovery for metacarpal and phalangeal fractures.

Introduction: Charcot neuroarthropathy (CN) commonly affects the foot in diabetic patients but can also occur in patients with other conditions, such as myelopathy. It is important to recognize as it can occur and progress rapidly and is associated with significant long-term morbidity. CN can affect the forefoot although this is much rarer, and it can occur after surgery. The combination of CN affecting the forefoot following forefoot surgery in a non-diabetic patient has never been described before. We present a case report of a patient to highlight the importance of including CN in the differential diagnosis of a post-operative inflamed foot in patients with myelopathy.

Case report: A 51-year-old non-diabetic man sustained an intra-articular fracture to his second toe. It did not heal despite appropriate non-operative management over 3 months. He was discovered to have myelopathy arising from his cervical and thoracic spine. He underwent reconstructive forefoot surgery to address an arthritic bunion and the fracture but had a persistently inflamed foot post-operatively. Initially, this was suspected to be an infection, but the wounds healed well, and inflammatory markers were normal. The swelling was noted to improve on elevation and there was a significant side-to-side temperature variation. Radiographs revealed early failure of fixation and following subsequent magnetic resonance imaging scan, he was diagnosed with forefoot CN. He was treated in a total contact cast and rapidly improved. At 6 weeks, he was transitioned to a boot and underwent staged spinal surgery to address the myelopathy. By 5 months post-operatively, his foot had recovered and there was no longer a side-to-side temperature difference. By 10-month post-operatively, he was able to return to light jogging with a pain-free, well-corrected foot.

Conclusion: CN affecting the forefoot is rare, particularly in the setting of myelopathy in the non-diabetic patient. It can, however, be triggered by forefoot surgery. It is important to be aware of this potential diagnosis as if it is diagnosed and treated early, rapid resolution can occur, but if missed, it could potentially result in long-term complications.