Missed Monteggia Fracture Dislocation in a 10-year-old Child - A Step-by-Step Approach to Properly Solving a Complex Problem: A Case Report.

Introduction: Monteggia injuries are relatively rare in the pediatric population. They can be missed leading to complications arising from a chronic radial head dislocation. There is limited information about their proper management in the literature. Thus, their treatment remains controversial. Case Report: We present a case of a 10-year-old boy who was examined in the orthopedic outpatient clinic of our hospital, due to limited range of motion of his left elbow and difficulty in extending his left thumb, after a forearm injury which occurred 9 months before and was initially treated conservatively. After appropriate imaging was obtained, a Bado type I Monteggia lesion was diagnosed. This was treated by open reduction of the head of radius, osteotomy of the ulna and lengthening using an external fixator, as well as annular ligament reconstruction by the use of synthetic tendon graft. The patient was followed up for 18 months after surgery and during his last examination showed very good clinical and functional results. Conclusion: Missed Monteggia injuries in children are complex problems warranting a step-by-step approach. Their management with ulnar osteotomy, bone lengthening, and reconstruction of the annular ligament presents a viable option with excellent clinical, functional, and radiological outcomes.

A Rare Case of an Intertrochanteric Hip Fracture Combined with an Ipsilateral Incomplete Atypical Femoral Fracture Treated with a Long Gamma Intramedullary Nail.

Introduction: Osteoporotic hip fractures can occur at the femoral neck and intertrochanteric area, with the peritrochanteric fracture being responsible for half of these fractures in the geriatric population. Atypical femoral fractures have been associated in the literature with long-term use of bisphosphonates or denosumab. However, few cases with the characteristics of these fractures have been reported in the past in patients not receiving antiresorptive drugs. To date, no combination of an intertrochanteric fracture with an impending incomplete atypical fracture of the ipsilateral femoral diaphysis has been previously reported in the literature. Case Report: We present a rare case of a 97-year-old female patient with an intertrochanteric femoral fracture, with a preexisting focal cortical thickening along the lateral aspect of the ipsilateral proximal femoral diaphysis which is a warning sing for an incomplete atypical femoral fracture. A long gamma nail was used to fix the intertrochanteric fracture and simultaneously to stabilize and protect the area of the atypical femoral fracture. Conclusion: Any patient with a peritrochanteric hip fracture who was under long-term treatment with antiresorptive agents against osteoporosis, or has other risk factors predisposing to atypical femoral fracture, should undergo a thorough radiological examination of the ipsilateral femur, to exclude the possibility of simultaneous presence of both of the above pathologies. In any such case, the use of a long hip cephalomedullary nail seems to be the best treatment option, because it can treat both fractures at the same time.

Atypical femoral fracture in a metastatic bone disease patient six months after discontinuation of denosumab received sequentially to previous bisphosphonate therapy - A case report.

Although, both bisphosphonates and denosumab are effective in reducing the risk of skeletal-related events in patients with metastatic bone disease, many concerns were being raised about the possible association between their use and atypical femoral fractures. A case of an atypical femoral fracture in a metastatic bone disease patient, six months after discontinuation of long-term zoledronic acid therapy and sequential treatment with denosumab is reported. After extensive laboratory and imaging examination, the fracture was classified as atypical and it was finally treated with discontinuation of denosumab, long cephalomedullary interlocking nailing and vitamin D administration. Sequential treatment with bisphosphonates and denosumab in patients with metastatic bone disease, may lead to an overlapping treatment effect, increasing bone suppression and the risk of atypical femoral fracture. In addition, discontinuation of denosumab may activate bone remodeling units in an area with microdamage accumulation in cortical bone caused by the previous bone suppression from the antiresorptive treatment. The activation of bone remodeling units may accelerate the occurrence of the atypical femoral fractures.

An Educational Module for Pavlik Harness Application for Developmental Dysplasia of the Hip: Study in a Greek Population.

INTRODUCTION: The success of Pavlik harness therapy is based, among other things, upon the correct reapplication by parents. This prospective study assesses the effectiveness of a validated Objective Structured Assessment of Technical Skill (OSATS) educational module for Pavlik harness application among Greek parents. METHODS: Forty consecutive parents of newborns with developmental dysplasia of the hip (DDH), who were treated with Pavlik harness, were divided into two groups. Twenty parents (group 1) were educated with the Greek OSATS version, while the rest (group 2) served as the control. The OSATS score, quality of the final product (Global Rating Scale - GRS) and sonographic imaging of the hips were evaluated during follow-up. RESULTS: Post-intervention evaluation revealed significant higher means of OSATS score (p<0.01), GRS of performance (p<0.05) and GRS of final product (p<0.05) for group 1. At every retention time point, OSATS was signifi cantly higher for group 1, however there were no significant differences between either GRS score between groups. There was no significant difference in radiographic evaluation and successful outcome. CONCLUSIONS: This educative module increased the parents' skill level on application of Pavlik harness. However, this module revealed no significant effect in clinical and radiological evaluation of the hips, in this population.

Atypical Femoral Fracture in a Patient without Bisphosphonate or Denosumab Exposure-A Case Report.

Introduction: Atypical femoral fractures (AFF) are associated with the use of bisphosphonates (BPs) or denosumab. However, few cases that meet the characteristics of these fractures, as established by the American Society of Bone and Mineral Research, have occurred in patients who have never used antiresorptive drugs. Case Report: We report a case of AFF in a 67-year-old woman who had never used antiresorptive medications. The history and comorbidities of the patient, the characteristics of the fracture, and the subsequent treatment are presented. Conclusion: AFFs may occur even in patients who have never been exposed to BPs or denosumab. The absence of antiresorptive osteoporosis therapy and the lack of radiographic focal periosteal reaction in the lateral femoral cortex, as in our case, can make it difficult to detect and prevent the disorder. Prolonged use of proton pump inhibitors and Vitamin D deficiency-related osteomalacia may contribute to the occurrence of these fractures. Further studies are required to accurately understand all inciting factors contributing to the development of AFFs.

Ultrasound-guided Platelet-rich Plasma Application Versus Corticosteroid Injections for the Treatment of Greater Trochanteric Pain Syndrome: A Prospective Controlled Randomized Comparative Clinical Study.

Purpose The purpose of this clinical study was to evaluate and compare the effectiveness of ultrasound (US)-guided platelet-rich plasma (PRP) injections versus US-guided corticosteroid injections (CSI) in the treatment of greater trochanteric pain syndrome (GTPS). Methods Between January 2015 and December 2016, 24 patients with GTPS were enrolled and randomized in two groups (A and B). Group A (study group) patients received US-guided PRP injection treatment, while group B (control group) patients received US-guided CSI treatment. Clinical outcomes in both groups were evaluated and compared using the Visual Analogue Scale (VAS) of pain, the Harris Hip Score (HHS) and the presence or absence of complications at 4, 12, and 24 weeks post-injection. The level of significance was set at p<0.05. Results Both groups showed improved scores (VAS and HHS) compared to the pre-injection period, but patients in group A had a statistically significant (p <0.05) decrease in VAS score and a significantly increased HHS at the last follow-up (24 weeks post-injection). No complications were reported. Conclusions In conclusion, patients with GTPS present better and longer-lasting clinical results when treated with US-guided PRP injections compared to those with CSI. Further studies are needed to optimize the technical preparation of PRP, the sample concentration, the number of injections and the time intervals between them, in order to achieve the maximum desired results.

The Effects of Long-term Use of Nitrogen-containing Bisphosphonates on Fracture Healing.

Nitrogen-containing bisphosphonates (N-BPs) are pharmaceutical agents that have been used for many years to treat osteoporosis, multiple myeloma, Paget's disease, metastatic bone disease, and a variety of other diseases in which bone mineral density is reduced. Given that N-BPs inhibit bone resorption, an important stage in the fracture healing process, they have been extensively studied in preclinical models for their activity. In animal models, treatment with N-BPs is associated with a larger callus formation in fracture area and delay in remodeling from primary woven bone to lamellar bone, but there is no delay in formation of the fracture callus. In humans, all existing evidence suggest that initiating treatment with N-BPs, after upper and lower limb fractures, does not appear to have a significant effect on fracture healing. Rarely, patients with long-term use of N-BPs may develop "atypical fractures" and delay in their healing. Therefore, this clinical condition is not fully understood and many questions remain unanswered. Similarly, there are few studies about the benefits of stopping a long-term treatment with them, if a fracture occurs. Although most studies support that chronic N-BP therapy may lead to fracture healing delay, this is not fully documented. On the other hand, there are studies that are in complete disagreement with them. All of the above suggest that there is a need for more detailed future research into larger patient populations and different types of fractures, with sufficient data on the type, dosage, route and duration of administration of N-BPs, and the control methods of fracture healing, in order to have a safe final conclusion on the effect of their long-term administration in this highly complex process.

The role of negative pressure wound therapy in salvaging a six-year-old child's crushed foot - A case report.

Crushed extremity is an infrequent injury in children and represents a major challenge for the orthopaedic surgeon. Sometimes the decision making process, whether to amputate or save a limb, is very difficult. Several scoring systems have been developed in order to determine the fate of crushed extremities, but they are not always predictive when patients are children. In the past few years, advances in bone and soft tissue reconstruction techniques have improved outcomes, even in the most extreme cases. Negative Pressure Wound Therapy has become an accepted option in the treatment of crushed limbs. We report a 6-year-old child with a crushed left foot from the running chain of his father's motorcycle. Early revascularization and stabilization along with multiple debridement and the application of Negative Pressure Wound Therapy leaded to salvage of the child's limb. At the end of one year follow up, he presented a very good functional and aesthetic result. LEVEL OF CLINICAL EVIDENCE: "4".

MANAGEMENT OF A DISTAL FEMORAL NON-UNION WITH COEXISTING FAILURE OF THE KNEE EXTENSOR MECHANISM USING OSTEOBRIDGE KNEE-ARTHRODESIS SYSTEM--A CASE REPORT.

INTRODUCTION: Reconstruction of bone defects is a long, challenging process both for the patient and for the treating surgeon. Bone defects frequently occur as a result of aggressive surgical debridement and bone resection in case of acute trauma, open fractures, chronic bone infections, tumors and non-unions. Early amputation is often superior to prolonged attempts at salvage because they can create serious problems in the patients' lives. There are numerous alternative methods of limb-salvage nowadays. CASE REPORT: We report a case of a fifty-year-old man with a distal femoral non-union and a co-existing failure of the knee extensor mechanism, who was treated using an intramedullary segmental defect bridging knee arthrodesis system (Osteobridge). At the final check-up twenty four months later, he had excellent clinical, functional and radiological results. CONCLUSION: Osteobridge is an excellent knee arthrodesis system, which is preferable to other methods in case of resection of the distal femur along with the failure of the knee extensor mechanism.

Management of aseptic non-unions of the distal third of the tibial diaphysis using static interlocking intramedullary nailing.

AIM: To evaluate the management of aseptic non-unions of the distal third of the tibial diaphysis, using static interlocking intramedullary nailing. METHODS: Between January 2005 and November 2012, a total number of 42 patients who underwent surgery at our hospital for aseptic non-unions of the distal third of the tibial diaphysis, were included in our study. Preoperatively, all the patients were tested for the presence of infection of non-union. The post-operative follow up was based on clinical and radiological findings. RESULTS: Union was achieved in 41 (98%) patients, at a mean time of 5.8 months (four-eight months). One (2%) patient developed infection of the wound four weeks after the operation. A small decrease of the tibial length, of about one cm was seen in three (7%) patients. Pain of the patellar tendon, at the entry point of the nail, was observed in six (14%) patients, without impacting the range of motion of the knee. In two (5%) patients, a decrease in dorsiflexion of the ankle joint occurred, of about ten degrees angle. CONCLUSION: Static interlocking intramedullary nailing is the preferable technique in the management of aseptic non-unions of the distal third of the tibial diaphysis, because it provides high union rate and few postoperative complications. A good preoperative evaluation for infections, use of proper surgical technique with respect to soft tissues, use of autogenous bone grafts and early mobilization of patients, are the keys to success of this method.

MRSA joint infection in a psoriatic patient with a coexisting respiratory infection.

In September 2011, a 52-year old patient suffering from psoriatic arthritis and being treated for an upper respiratory tract infection, presented to the emergency department of Argos General Hospital with fever and a painful, swollen right knee. He underwent clinical, laboratory and imaging examinations. Initially blood and synovial fluid cultures were negative. After an arthroscopic collection of pus, the culture showed a methicillin resistant Staphylococcus aureus which was sensitive only to daptomycin.