Giant Cell Tumor of the Second Metatarsal Managed with Ray Amputation: A Rare Case Report and Review of Literature.

Introduction: The giant cell tumor of bone (GCTB), also known as an osteoclastoma or a myeloid sarcoma, is a benign local aggressive osteolytic bone tumor that primarily affects skeletally mature young adults typically 20-40 years of age. Giant cell tumors (GCTs) are usually solitary tumors and very rarely are found in the metatarsal bones. The characteristic histological appearance of GCT displays a high number of osteoclast-like multinucleated giant cells, which resulted in the classification "osteoclastoma" or "giant cell tumor." Case Report: A 38-year-old male presented to the hospital with a firm swelling over the 2nd metatarsal slowly progressing over a period of 4 months, initial screening radiological investigations included X-rays, X-rays showed a tumorous growth involving the shaft of the 2nd metatarsal of the right foot, and the X-rays showed a characteristic soap bubble appearance. Magnetic resonance imaging. On gross assessment, the intraoperative sample showed that the GCTB has a dark brown-to-reddish appearance that is friable in texture. The gold standard for diagnosing a GCT is based on biopsy histopathological findings. The key histomorphologic feature is multinucleated giant cells. Conclusion: Giant cell tumors are frequently locally aggressive with high recurrence percentage, hence, excision was done. Nowadays, early radiological screening techniques help early detection of such rare occurrence of tumors such as the GCT and appropriate management. In conclusion, the giant cell tumor of the bone is a unique presentation of stromal cell and hematopoietic interaction in the bone.

Morel-Lavallee Lesion Associated with Subtrochanteric Femur Fracture in a Young Female Resulting in Extensive Soft-Tissue Necrosis and Hypertrophic Non-union Managed with Staged Surgeries and Exchange Nailing: A Rare Injury Pattern and Review of Literature.

Introduction: Morel-Lavallee lesion is a closed degloving soft-tissue injury which occurs as a result of acute traumatic separation of skin and subcutaneous tissue from the underlying fascia and muscle layer. The most common sites include thigh (peritrochanteric region), abdomen, scapula, and paraspinal area. Early diagnosis and management of the lesion is essential so as to prevent complications such as infections or extensive skin necrosis. The management options include conservative or operative depends on extent, location of lesion, and duration since injury. For the management of underlying fracture, one should take into the consideration, the soft tissue compromises which can occur if lesion is large at presentation and plan accordingly for either primary definitive fixation or staged surgeries as necessary. Case Report: A 25-year-old female patient presented with pain and swelling over the anterolateral aspect of the right thigh after a traumatic road traffic accident 2 days back. On radiological investigation, there was subtrochanteric femur fracture with a butterfly fragment. The patient also had Morel-Lavallee lesion on local ultrasound. Emergency management was done for Morel-Lavallee lesion in the form of percutaneous drainage and compression bandage; fixation was done in the form of external fixator. The wound progressed into complete skin necrosis so external fixator was removed and thorough wound debridement was done. Fracture stabilized with four TENS nails (titanium elastic nail). Removal of the TENS nail and exchange nailing in the form of intramedullary interlocking nail was performed after complete soft-tissue healing. Bony union seen at the fracture site clinically and radiologically at 3-month follow-up. Conclusion: Initial screening of lesion is very important at time of presentation. Early definitive fixation should not be done if the lesion is large and one should fix the bone once the lesion is resolved.

Management of Neglected Developmental Dysplasia of the Left Hip in a 14-Year-Old Child with Staged Osteotomies Planned with 3D-Printed Model - A Case Report.

Introduction: Developmental dysplasia of hip (DDH) is abnormal development of hip joint causing mild subluxation to complete dislocation of femoral head from acetabulum. Incidence in India is 1-9.2/1000 . Typical risk factors for DDH are said to be female child, first born, breech position, positive family history, left hip, and unilateral involvement. Femoral head and acetabular compressive forces are mutually important stimulators for normal growth (both shape and depth). Deviation from above normal process due to subluxated or dislocated head since birth can lead to abnormal development of both acetabulum and femoral head. Diagnosis of the DDH is made at birth using clinical test and radiologically using ultrasound of hip joint. Management is based on the age of presentation and severity of the instability. Most hips are managed conservatively management depends on the age and symptoms of the patient. Case Report: A 14-year-old female child presented with the complaints of pain in the left hip and difficulty in walking. On clinical and radiological examination, she was diagnosed to have developmental dysplasia of the left hip with partial subluxation of the left hip. Thorough investigation and planning were done using CT PBH and 3D reconstruction of the pelvis to plan the osteotomy. Stages surgery was planned, first, triple innominate osteotomy was performed and later femoral varus derotation osteotomy 6 weeks later. At 3-year follow-up, the patient is pain free and is having no difficulty in doing day-to-day activities. X-ray showing complete coverage of the femoral head with no changes of arthritis in hip. Conclusion: Late presentations of neglected developmental dysplasia poses difficult challenges in management. It can be addressed with osteotomies for improving range of motion and preventing future early arthritis. In our case, good functional range of motion was restored at 3 years follow-up.

A Case of Calcaneal Intraosseous Lipoma along with Haglund Deformity and Chronic Tendoachilles Tear Managed using Double Row Suture Anchor Repair Augmented with FHL Graft and Curettage of Lipoma with Filling the Cavity Using Hydroxyapatite Bone Substitute.

Introduction: Achilles' tendon is the largest tendon in the body, Tendon is an anatomical structure with inherent less blood supply and so more prone to injury and notorious healing outcomes. The management options for tendoachilles injury depend on the location of the tear, degree of retraction of the torn ends, and patient-related factors. Intraosseous lipoma is very rare benign tumor of bone accounting for 0.1% of all bone tumors. Most common site being proximal femur involvement of calcaneum is very rare presentation. Symptomatic patients with significant heel pain need operative intervention in the form of curettage alone or in combination with filling cavity with bone graft or bone graft substitutes. Many people use PMMA bone cement to fill the void. Case Report: A 65-year-old male presented with chronic heal pain and difficulty in walking. On clinical examination and radiological investigation, calcaneal intraosseous lipoma was confirmed along with insertional tendinopathy of tendoachilles and haglund syndrome causing tear at insertion into calcaneal tuberosity. We managed this patient in single-stage surgery using tendoachilles split approach for removing haglund deformity and double row anchor suturing for tendon reattachment. Repair was augmented with flexor hallucis longus (FHL) graft fixed using interference screw in the calcaneum. Lipoma was approached with separate medial approach. Cortical window created, lipoma curettage was done, and cavity filled with hydroxyapatite bone graft substitute. Conclusion: Tendoachilles split approach with double row suture anchor repair along with FHL graft gives good clinical outcome in insertional tendinopathy of tendoachilles with haglund syndrome. Curettage of intraosseous lipoma with filling the void using bone graft substitute such as hydroxyapatite gives good results and pain relief.

A Case Report on Surgical Excision of Intracapsular Osteochondroma of Femur Neck using Mini-Arthrotomy without Hip Dislocation in a Young Female with Hereditary Multiple Exostoses.

Introduction: Osteochondromas are the most common benign bone tumors. They probably are developmental malformations rather than true neoplasms and are thought to originate within the periosteum as small cartilaginous nodules. The lesions consist of a bony mass produced by progressive endochondral ossification of a growing cartilaginous cap. Osteochondromas usually are found on the metaphysis of a long bone near the physis such as distal femur, proximal tibia, and proximal humerus. Surgical treatment for femur neck osteochondroma is difficult due to the high risk of avascular necrosis following excision. These lesions in femur are in close proximity to important neurovascular bundle and can cause symptoms related to their compression. Furthermore, the symptoms related to labral tear and hip impingement are common. Recurrence is rare and is caused by failure to remove the entire cartilaginous cap. Case Report: A 25-year-old female presented with the complaints of pain in the right hip and difficulty in walking and running for 1 year. On radiological examination, the right femur neck osteochondroma was diagnosed, it was located along the posteroinferior margin of the femur neck. Surgical removal of the lesion was done in lateral decubitus position using posterolateral approach to hip without dislocation of the femur. Conclusion: Osteochondroma at femur neck can be safely removed without surgical hip dislocation. It's necessary to remove it completely to avoid recurrence.

Management of a Gap Non-union Patella Fracture Using Encirclage Wire and Tension Band Wiring with Quadriceps V-Y Plasty in an Elderly Patient: A Rare Case Report and Review of Literature.

Introduction: The management of gap non-union patella fractures continues to be a challenge in orthopedics. The incidence of these cases ranges between 2.7% and 12.5%. The quadriceps muscle attached to the proximal fractured fragment pulls it proximally leading to the gap at fracture site. If the gap is too large, there won't be any fibrous union resulting in failure of quadriceps mechanism and extension lag. The primary aim is to bring the fracture fragments together and restore the extensor mechanism. Most of the surgeons prefer single-stage procedure, in which mobilization of the proximal fragment, followed by fixing with the lower fragment is done using V-Y plasty or x lengthening with or without pie Crusting. Others use of pre-operative traction to the proximal fragment using pins or ilizarov method. In our case, we used single-stage procedure whose results were encouraging. Case Report: A 60-year-old male patient presented with pain in the left knee with difficulty in walking since 3 months. The patient had road traffic accident 3 months back and sustained trauma to left knee. On clinical examination, there was palpable gap of more than 5 cm between the fracture fragments, anterior surface of femur and condyles was palpated through fracture site and knee range of motion was between 30° and 90° of flexion, and X-ray suggests of patella fracture. Midline 15 cm longitudinal incision was taken. The insertion of the quadriceps tendon over proximal pole of patella was exposed and pie crusting was done on medial and lateral side and V-Y plasty was done. SS wire was used to hold the reduction of the fragments by encirclage wiring and anterior tension band wiring done. Retinaculum was repaired and wound closed in layers. Postoperatively, long rigid knee brace was given for 2 weeks and walking with partial weight-bearing started. After suture removal at 2 weeks, full weight-bearing initiated. At 3 weeks, knee range of motion started and continued till 8 weeks. At 3 months post-operative, the patient is able to do flexion up to 90° and no extension lag is present. Conclusion: Adequate quadriceps mobilization during the surgery along with pie crusting and V-Y plasty with TBW and encirclage combined gives good functional outcome in patella gap non-unions.

Bilateral Traumatic Nightstick Fracture of the Ulna - A Rare Case Report and Review of the Literature.

INTRODUCTION: Unilateral isolated ulna fracture secondary to trauma are common but the bilateral nightstick fractures are quite rare in the clinical scenario. These are managed conservatively or surgically depending upon the degree of displacement, location of the fracture, fracture pattern and associated injury to other bones. Proper management of these fractures helps in getting a better outcome. The purpose of the study was to present a case of bilateral traumatic isolated ulna fracture and its management. CASE REPORT: A 33-year-old male presented to the emergency department with complaints of pain and swelling over the dorsum of both forearms with a history of assault with a bamboo stick. The mechanism of the injury was, the patient placed his both the forearms in front of the face as a defense during the assault and sustained injury to both forearms. On examination, the patient had bilateral forearm swelling with tenderness. Bony crepitus was present over both the ulna on palpation. X-ray of both forearms (radius and ulna) revealed the fracture of both right and left ulna without any associated fractures/injuries. The patient was managed surgically with open reduction and internal fixation using a 3.5 mm locking compression plate. At present, 1-year follow-up, the patient is having complete wrist, elbow ROM and supination, pronation without any pain. CONCLUSION: Bilateral traumatic Nightstick fractures of the ulna are rare and this is the first reported case of traumatic bilateral isolated ulna fracture according to author's best knowledge and literature review. Open reduction and stable internal fixation using the principles of fracture fixation along with early mobilization helps in getting better functional outcome and prevents further complications and secondary procedures. This case is unique as it helps in identifying the mode of trauma in medico legal cases like assault in cases of bilateral ulna fracture. The mode and the mechanism of injury are different in this case.

Femur Neck Osteoid Osteoma Managed with Radiofrequency Ablation - A Case Report.

INTRODUCTION: Osteoid osteoma is a benign tumor of bones involving mainly the tubular bones and rarely axial skeletons. The patient mainly complains of night pain in the affected region or the joint nearby. Pain always subsides with analgesics and gradually increased over the period of time. It is mostly missed on the plain radiograph so magnetic resonance imaging or computed tomography (CT) scan are preferred for accurate and early diagnosis of the tumor. CASE REPORT: A 20-year-old male presented with pain in the left hip region which was gradually increased over the period of 6 months and was experiencing pain more in the night, used to relieve on medications. CT scan of the left hip showed the presence of osteoid osteoma of 0.5 cm diameter, which was managed with radiofrequency ablation. Moreover, the patient had pain relief immediately after the procedure. At present 1-year follow-up, the patient is symptomless with no recurrence. CONCLUSION: The neck of femur osteoid osteomas is best managed with radiofrequency ablation as it causes less morbidity to the patient and helps in early return to normal activities with fewer complications as compared to open procedures.

Giant Cell Tumor (GCT) of the Third Metatarsal in an Elderly Patient: A Rare Case Report.

INTRODUCTION: Giant cell tumour (GCT) is a benign osteolytic, locally aggressive lesion. Seen in young adults at the epiphysis. The most common site is long bones (85-90%). GCT of the metatarsal in elderly patients is very rare. CASE REPORT: A 60-year-old male came with complaints of pain and swelling over right foot dorsal aspect since for the last past one 1 year. There was no history of trauma. X-ray foot showed an osteolytic lesion in the right third metatarsal with thinning of the cortex. MRI and fine-needle aspiration cytology confirmed the diagnosis of GCT. The patient was managed by excision with the 3rd ray amputation. At present, 1.5 years follow-up, the patient is having no pain, difficulty in walking and no evidence of clinical and radiological recurrence . CONCLUSION: Giant cell tumours could also present at uncommon sites, and they should be considered in the differential diagnosis of lytic lesions of the metatarsals. Excision with ray amputation of the involved metatarsal helps in complete removal of the lesion and helps in early weight-bearing. This is the viable alternative treatment option in managing the metatarsal GCT in elderly patients.

Subtrochanteric Femur Fracture in Monostotic Pagets Disease and its Management - A Case Report and Review of Literature.

INTRODUCTION: Paget disease of bone is a chronic progressive disease of the bone of uncertain etiology, characterized initially by an increase in bone resorption, followed by a disorganized and excessive formation of bone, leading to pain, fractures, and deformities. It can manifest as a monostotic or polyostotic disease. Pathological fracture secondary to Paget's disease requires surgical management. CASE REPORT: A 60-year-old male patient came with complaint of pain and swelling over the left hip for 30 days. The patient had a history of a trivial fall. Radiological investigations were suggestive of pathological subtrochanteric femur fracture with Paget's disease of the left femur. We managed with the long proximal femoral nail (PFN). Histopathological examination confirmed the diagnosis of Paget's disease. At present 1-year follow-up, the patient is having good radiological and functional outcome with no implant failure. CONCLUSION: Subtrochanteric pathological femur fractures in Paget's disease are best managed with the long PFN with good outcome and fewer complications, which help in early mobilization and weight-bearing. Long PFN spans the entire pathologic femur and prevents the secondary fractures.

Non -Union of Lateral Hoffa Fracture - A Case Report.

INTRODUCTION: Hoffa is a coronal fracture of the femoral condyle. It is an uncommon injury easily missed on X-rays, which later presents as a non-union. Computed tomography (CT) scan knee helps in diagnosing undisplaced fractures and planning the management. CASE REPORT: A 24-year-old male patient presented to us with complaints of pain, decreased range of knee movements, difficulty in walking and clicking sound at the left knee for 9 years. The patient had a history of trauma 9 years back. X-ray of the left knee showed the non-union of left lateral Hoffa fracture, which was managed with open reduction and internal fixation with CC screws using the lateral para patellar approach. At present 1.5 years follow-up, the patient is comfortable with no pain and having a complete knee range of motion. CONCLUSION: Although Hoffa fracture is rare, clinical suspicion, along with radiological investigations, is essential to diagnose Hoffa fracture. A missed diagnosis can lead to malunion or non-union, which predisposes to knee arthritis. Timely and proper management of Hoffa non-union with open reduction, stable internal fixation and early knee mobilization help in getting a better outcome.

Surgical Management of Chronic Tendoachilles Tear in Elderly Patients - A Case Series.

INTRODUCTION: Chronic tendoachilles (TA) tears are commonly missed injuries in elderly population with associated comorbidities and they usually occur as low-energy injuries. Appropriate surgical management helps in getting a better functional outcome in elderly patients. CASE SERIES: We present a series of three cases of chronic TA tear in elderly patients managed surgically. Two patients had an insertional tear and they were managed with flexor hallucis longus (FHL) transfer and fixed with interference screw in the calcaneum. Another patient was managed with end-to-end suturing using fiber wire. All the patients are having good functional outcome without any wound complication or re rupture. CONCLUSION: Early diagnosis, meticulous repair, and handling of soft tissues and TA tear help in getting a better outcome in elderly patients. The final functional outcome depends on intraoperative stability of the repair, ankle physiotherapy, and wisely selection of the treatment method, which mainly depends on the location of the tear. Reconstruction with FHL tendon using interference screw in calcaneum helps to repair the insertional tears in elderly patients.

Management of Distal Femur Periprosthetic Fracture in an Elderly Patient by Open Reduction and Internal Fixation With Locking Plate Osteosynthesis -: A Case Report.

INTRODUCTION: Distal femur periprosthetic fractures are rare entityies and difficult to manage. Supracondylar femur fractures are most common amongst periprosthetic fractures. They can be managed by various modalities. These fractures are often difficult to treat because of various factors likesuch as osteoporosis, communication, female gender, and poor bone stock. Fixation of supracondylar femur fracture by locking plate provides excellent results in terms of radiological and clinical outcomes. CASE REPORT: We report a case of a 70 year -year-old female with pain and swelling in the right knee since for 1 day. She had a history of fall in bathroom 1 day back. The patient was operated with total knee replacement 6 years back for grade Grade 3 osteoarthritis of the knee. The patient was known case of hypertension and was on medication for the same. We operated the patient by open reduction and internal fixation with distal femur locking plate and it provided excellent clinical outcome. CONCLUSION: Periprosthetic supracondylar femur fractures are rare entity entities and generally difficult to manage, especially in elderly patient, due to poor bone quality. The choice of implant used to treat such fractures depends on the surgeon's choice and patient's compliance. Open reduction and internal fixation with a locking plate is a good entity as it provides excellent clinical and radiological outcome.

A Case Report of Humerus Shaft Osteomyelitis Secondary to Local Skin Infection Treated with Saucerization.

Introduction: Osteomyelitis of the humerus shaft after local skin infection is rare clinical entity, all the principles of tibia and femur osteomyelitis are used in the humerus osteomyelitis. Early detection is best done by the magnetic resonance imaging. Surgical debridement and curettage with IV antibiotics gives good clinical outcome in the patient. Case Report: A 35-year-old female presented with discharging sinus over posterior aspect of the humerus for 1 year. Diagnosis done based on X-ray and clinical examination. The patient managed with local debridement and saucerization, on follow-up patient is doing all the daily activities and no sign of recurrence at 18 months post-operative. Conclusion: Local debridement saucerization and course of IV antibiotics according to culture sensitivity give good clinical outcome in cases of humerus osteomyelitis.

Segmental Fibulectomy to Excise the Adherent Distal Tibia Osteochondroma in a Case of Hereditary Multiple Exostosis - A Rare Case Report.

INTRODUCTION: Hereditary multiple exostosis (HME) is an autosomal dominant disorder affecting the skeletal system, which is characterized by multiple osteochondromas in bones arising from osteochondral ossification and leading to skeletal deformities, short stature, soft tissue, and neurovascular compressive symptoms. CASE REPORT: A 10-year-old female a case of HME presented with painless multiple swelling around knees, wrist, and painful varus deformity in the lower third of the right leg. The large exostosis of the right distal tibia was symptomatic and indenting the fibula which required excision along with the segment of the fibula of about 2.5 cm above the syndesmosis adjacent to the exostosis as the mass was adherent to the fibula. CONCLUSION: Although distal tibia osteochondromas are rare, they can lead to deformity of the ankle and loss of function if not managed early and properly. Hence, early detection, proper planning, and management of periarticular distal tibia osteochondromas are essential to prevent the development or progression of the deformity. Segmental fibulectomy is required to remove the adherent osteochondromas completely and to prevent the recurrence and secondary surgical procedures. It is very essential to follow up the patient till the skeletal maturity to identify the delayed presentation and late progression of the ankle deformities.