A rare case of extensive neurogenic heterotopic ossification: a case report.

INTRODUCTION: Neurogenic Heterotopic ossification (NHO) is a potential sequalae and a detrimental complication following neurological insult. It is characterized by formation of localized gradually progressive, peri-articular lamellar bone formation in extra-skeletal tissues. We would like to report a rare case of heterotopic ossification involving all 4 limbs, in which we tried to restore joint mobility to improve his functional status so that he could perform his daily tasks. CASE PRESENTATION: We present a case of a 33-year-old bed ridden male, diagnosed with NHO involving all 4 limbs (bilateral hip, right knee, right shoulder, left elbow). The patient had a crippled posture, significant pain and impaired range of motion hampering movement of all four limbs which prevented him from lying down supine, sitting, walking and performing activities of daily living. After three surgeries, the patient achieved wheelchair mobilization and upright posture with the assistance of calipers. CONCLUSION: The management of NHO requires a multidisciplinary approach involving orthopaedic surgeons, neurologists & rehabilitation specialists. Prognosis of NHO depends on factors such as extent of ossification, underlying neurological condition & patients overall health.

Unusual Mechanism of Injury during a Wedding Tradition Leading to a Metacarpal Shaft Fracture - A Case Report.

Introduction: "Joota Chori" is a traditional Indian wedding ritual which involves playful competition between the bride's and the groom's friends, with the aim of hiding and retrieving the groom's shoes. Case Report: We describe a rare case scenario wherein an orthopedic surgeon sustained a metacarpal shaft fracture while gripping the shoe and engaging in a tussle with the groom's friends. Despite feeling a sudden snap and experiencing pain, the surgeon held onto the shoe. The subsequent diagnosis revealed a 4th metacarpal long oblique shaft fracture. Conclusion: This case highlights the uncommon mechanism of injury involving forceful hyperextension of the MCP joint and the potential risks associated with physically intense wedding rituals. It also emphasizes the importance of adequate first aid resources and medical attention at wedding venues to promptly address musculoskeletal injuries.

Bilateral Spontaneous Osteonecrosis of Knee with Concomitant Medial Femoral and Tibial Condyle Involvement - A Rare Presentation and Short Review.

INTRODUCTION: Osteonecrosis of knee is classified as primary spontaneous osteonecrosis of knee (SPONK) and secondary osteonecrosis of knee. Primary SPONK usually involves medial femoral condyle (MFC). Incidence of medial tibial plateau (MTP) is only 2% among the patients with SPONK and simultaneous involvement of MFC and MTP is very rare. CASE REPORT: We report a very rare case of 45-year-old female with SPONK affecting both MFC and MTP simultaneously with subchondral insufficiency fractures. She presented with pain in both the knees and difficulty in walking since 1 year. Physical examination revealed decreased range of motion and local tenderness over MFC and medial tibial condyle. Subchondral fracture with articular surface collapse of MFC with joint space narrowing and varus deformity was seen on X-ray in both the knees. Sclerosis was seen in the medial tibial condyle bilaterally. Magnetic resonance imaging showed characteristic focal hyperintense areas surrounded by band like hypointense areas in both MFC and MTP which was suggestive of subchondral collapse with ill-defined bone marrow changes. X-ray of both knees revealed SPONK in Koshino's Stage IV and Carpintero's Stage IV. Bilateral total knee replacement (TKR) was planned. First left knee was operated. A cruciate retaining type of TKR was done. Two weeks, later right side TKR was operated. MFC of right side also had a large osteochondral fragment which was excised to leave defect with depth more than 2 cm. Defect was reconstructed with bone graft obtained from posterior condylar cuts. Posterior stabilized type of knee replacement component was used along with femoral extender stem. Histopathological examination revealed necrotic bone surrounded by an area of fibrovascular granulation tissue on both the femoral and tibial sides. Patient has good functional outcome at 2 years follow-up. CONCLUSION: Concomitant SPONK of MFC and MTP in bilateral knee is very rare and in advanced stages TKR can provide good radiological and functional outcome. Furthermore, pre-operative assessment of bone defects is necessary and appropriate use of augments (extender stem or metal wedges) is crucial.

Prevalence of metal hypersensitivity in total knee replacement.

BACKGROUND: Cutaneous and local reactions to metals used in orthopaedic implants have been well documented. The prevalence of metal sensitivity in general population is 10%-15%. Nickel, Cobalt and Chromium are the most common allergen. The association between cutaneous reactions and implants has been less understood. Hence, this study was taken up with the aim to assess the prevalence of metal hypersensitivity in Total Knee Replacement (TKR) patients and find the most prevalent allergen. MATERIALS & METHODS: Longitudinal study conducted during January-December 2017. We enrolled 233 subjects who were at least three months postoperative. Radiological assessment was done. CREDISOL® kit was used for patch test. Results were recorded using ICDRG grading at 48 hours and five days. RESULTS: Mean age was 59.59 years; 12.01% were symptomatic. Pain followed by loss of function were the most common symptoms. However, loss of function and patient dissatisfaction towards procedure were significantly associated with metal hypersensitivity (χ2 value > 3.84; p value < 0.05). In 66% subjects, pre-operative diagnosis was severe osteoarthritis, followed by rheumatoid arthritis (23%). None of the subjects had evidence of loosening on X-ray. Prevalence of Metal Hypersensitivity was found to be 15.87% (patch test positive). Chromium (11.58%) was found to be most common allergen followed by Nickel (8.58%) and then Cobalt (6.43%). CONCLUSIONS: Significant prevalence of metal hypersensitivity was found. Therefore, we recommend pre-operative patch test for detecting allergic reactions to implants. Alternatives like Titanium or Zirconium can be used to avoid complications.

Complete Extra-articular Ankylosis of Hip and Stiff Elbow in a Case of Extensive Myositis Ossificans: A Rare Presentation.

INTRODUCTION: Myositis ossificans (MO) is a benign ossifying lesion. It is also known as heterotopic ossification of muscle, in which lamellar bone is formed in the muscle most commonly due to trauma or neurological injury. Complete extra-articular ankylosis due to extensive MO is rare. CASE REPORT: We report a case of 22-year-old female with post-traumatic MO following head injury. The patient developed extensive MO in iliopsoas and brachialis muscle leading to complete extra-articular ankylosis of hip and stiffness of elbow which lead to severe functional disability to the patient. Hematological parameters were normal. Surgical excision of the bony mass was done in two stages- hip followed by an elbow. The patient had marked functional improvement in hip and elbow. CONCLUSION: Complete extra-articular ankylosis of hip is rare in the case of MO. The massive size of bony mass connecting the femur to pubis is not common and computed tomography angiography is beneficial if bony mass is in the vicinity of neurovascular bundle. Good functional results can be obtained with excision of bony mass after ruling out bony malignancy.

SubcapitalNeck of Femur Fracture in a Case of Osteonecrosis of Femoral Head - Rare Presentation.

INTRODUCTION: Osteonecrosis of femoral head is a common debilitating condition affecting young males most commonly. It is endpoint of a series of events leading to disturbance in the blood supply of femoral head. Rarely, these cases present with acute pain following trivial trauma due to pathological fracture in the neck of femur. We present a rare case of pathological subcapital neck of femur fracture in a case of osteonecrosis of femoral head. These cases should not be confused with post-traumatic neck of femur fracture. CASE REPORT: A 28-year-old male student presented with history of acute pain in right hip and inability to walk after a squatting event. He was diagnosed to have osteonecrosis of bilateral femoral head 1 year back, for which he denied further treatment. On clinical examination, right hip examination was painful with flexion, adduction, and external rotation deformity. Radiological examination revealed fracture at subcapital region in neck of right femur with osteonecrosis of femoral head. After discussing treatment options with the patient, we performed total hip arthroplasty (THA). Harris hip scores improved from 17.1 to 83.5. CONCLUSION: The presentation of osteonecrosis of femoral head with pathological fractures is rare. Furthermore, it is not included in the commonly used classifications. Osteosynthesis of pathological fracture of neck of femur with osteonecrosis of femoral head rarely has good results.THAcan be a good option in these cases with good functional results.

Digging Deeper into the Patello - Femoral Joint: Patello - Femoral Composite - A New Dimension for Overstuffing of Patello - Femoral Joint.

INTRODUCTION: Patello-femoral complications are the most common complications in postoperative Total Knee Arthroplasty (TKA) patients especially overstuffing of Patello - Femoral Joint (PFJ). So, to study the effects of overstuffing of PFJ in postoperative TKA patients we put forth a new dimension - "PATELLO - FEMORAL COMPOSITE (PFC)". This is the maximum distance between anterior cortical line of femur shaft and the anterior cortex of patella with knee in full extension. AIM: To calculate chances of overstuffing of PFJ in postoperative TKA patients and document the effect of overstuffing of PFJ on the passive knee Range of Motion (ROM) in post- op TKA patients. MATERIALS AND METHODS: This was a prospective observational study which included 51 consecutive primary TKAs. Preoperative and postoperative (24 weeks) passive knee ROM was measured. Preoperative and postoperative radiological parameters {PFC, Anterior Femur Offset (AFO), Patellar thickness (PT)} was recorded using Computed Tomography (CT) Scanogram image of patient in lateral view with knee in full extension and perfect overlap of both femur condyles, using DICOM format of the CT Scanogram image on the DICOM viewer. RESULTS: The postoperative PFC was more than its preoperative-value in 80.39% TKAs. Patients who had increased postoperative PFC had significantly less preoperative AFO. Female patients in our study had significantly less preoperative AFO compared to males. Thus, we deduced that female patients with lesser preoperative AFO undergoing TKA had increased postoperative PFC than male patients. PFC not only accounted for the overstuffing of the PFJ because of the patellar component, but also because of the femoral component; thus was a better measure of PFJ overstuffing compared to isolated PT. Passive knee ROM in the postoperative TKA patients approximately decreased by 2 degrees for every 1 mm increase in PFC compared to its preoperative-value in the patients with PFJ overstuffing. CONCLUSION: We conclude that overstuffing of the PFJ in postoperative TKA is present in 80.39% patients. Higher chances of postoperative PFJ over stuffing are present in female patients and those with thinner anterior cortex of distal femur. Postoperative passive knee ROM decreases significantly in patients with postoperative PFJ overstuffing (Every 1 mm increase in the postoperative PFC, passive knee ROM decreased by approximately 2 degrees).

Expect the Unexpected: Mycobacterial Infection in Post Total Knee Arthroplasty Patients.

Orthopaedic Surgeons rarely encounter mycobacterial infections in Post Total Knee Arthroplasty (TKA) patients. We present series of two cases to create awareness among clinicians to expect the unexpected. Tuberculosis typical/ atypical is a hidden culprit in catch clinical situations when chronic infection is Suspected, but the lab investigations are negative in persistently symptomatic patients. In such situations clinicians should suspect atypical or complex mycobacterial infections and evaluate the patients accordingly. Clinical suspicion, evaluation, isolation and treatment of atypical or complex mycobacterial infections with sensitive chemotherapy, leads to complete resolution of infection and full functional rehabilitation.