A case of hip joint septic arthritis due to haematogenous infection, which was misdiagnosed sternoclavicular joint septic arthritis as SAPHO syndrome.

Anterior chest pain associated with sternoclavicular arthritis has been considered a symptom specific to SAPHO syndrome. Differentiating aseptic arthritis of the SAPHO syndrome from infectious sternoclavicular joint (SCJ) arthritis is often difficult. We reported a 55-year-old woman with left hip joint and right SCJ pain. Diagnosis and treatment were delayed because she was misdiagnosed with SAPHO syndrome, and haematogenous infection spread to the hip joint septic arthritis. She was diagnosed promptly after presenting to our hospital and underwent early debridement, and her hip joint and SCJ was found to have almost no dysfunction. Differentiation between sternoclavicular arthritis of the SAPHO syndrome and sternoclavicular septic arthritis is clinically important and requires careful attention.

Intramedullary Nail Fixation with Autologous Bone Marrow Transplantation in an Incomplete Atypical Femoral Fracture Patient: Use of Bone Marrow Extracted from the Hollow Reamer.

The present report describes an incomplete atypical femoral fracture (AFF) patient who underwent simultaneous autogenous bone transplantation to the resected fracture region during intramedullary nail fixation. A 73-year-old female with a history of multiple myeloma had been undergoing treatment with intravenous drip injections of Zoledronic Acid. She was introduced to our department due to the left lateral thigh pain, with no trauma incidence. An anteroposterior radiograph showed a transverse thin fracture line with localized periosteal and endosteal thickening, which is compatible with subtrochanteric incomplete AFF. A biochemical investigation revealed the existence of severely suppressed bone turnover. She underwent intramedullary nail fixation for fear of a complete fracture. After the fixation, the cortical bone at the fracture region was excised as a wedge-shaped block, and bone marrow extracted from the hollow reamer was simultaneously transplanted to the resected fracture region. Histological examination showed few bone formation features at the fracture line in the excised lateral cortical bone. At 7 months after surgery, radiographs demonstrated complete bone repair, and no clinical problems were observed two years postoperatively. To the best of our knowledge, this is the first report in which autogenous bone marrow transplantation, noninvasive to the iliac crest, was performed in an incomplete AFF patient. We believe that this low invasive procedure can be a useful technique for AFF treatment.

Evaluation of Bone Atrophy After Treatment of Forearm Fracture Using Nonlinear Finite Element Analysis: A Comparative Study of Locking Plates and Conventional Plates.

PURPOSE: Forearm diaphysis fractures are usually managed by open reduction internal fixation. Recently, locking plates have been used for treatment. In the long-term period after surgery, some patients present with bone atrophy adjacent to the plate. However, a comparison of locking and conventional plates as a cause of atrophy has not been reported. The aim of this study was to investigate long-term bone atrophy associated with use of locking and conventional plates for forearm fracture treatment. METHODS: In this study we included 15 patients with forearm fracture managed by either locking or conventional plates and with more than 5 years of follow-up. Computed tomographic imaging of both forearms was performed to assess bone thickness and local bone mineral density and to predict bone strength without plate reinforcement based on finite element analysis. RESULTS: Mean patient age at surgery was 48.0 years. Eight patients underwent reduction with fixed locking plates and were followed up for a mean of 79.5 months; the remaining 7 patients were treated with conventional plates and were followed up for a mean of 105.0 months. Compared with the conventional plate group, the locking plate group had the same fractured limb-contralateral limb ratio of cortex bone thickness, but had significantly lower ratios of mineral density adjacent to the plate and adjusted bone strength. CONCLUSIONS: This study demonstrated bone atrophy after locking plate fixation for forearm fractures. Treatment plans for forearm fracture should take into consideration the impact of bone atrophy long after plate fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Smith's fracture generally occurs after falling on the palm of the hand.

Orthopedic trauma surgeons often encounter Smith's fracture in patients who report that they have fallen on the palms of their hands. The aim of this study was to clarify the pathogenesis of Smith's fracture in basic clinical aspects. First, a survey was conducted for investigating the mechanism of injury and arm position at the time of injury among patients with Smith's fractures who consulted at our outpatient clinic. Second, we created three-dimensional finite element models (FEMs) to predict the influence of arm position on the type of injury resulting from a fall. These predictions were then used in ten freshly frozen cadavers to provide experimental proof of Smith's fractures resulting from the impact on the palmar side. Twenty-six patients (5 males and 21 females) with Smith's fractures were enrolled in this study. Injury resulting from a fall on the palm of the hand, the dorsum, or ulno-dorsum of the hand, and fisting handle was observed in 16 cases (61%), 3 cases (12%), and 1 case (4%), respectively. Six patients were uncertain of their arm position at the time of injury. FEM analysis showed that Smith's fractures occurred when the angle between the long axis of the forearm and the ground was 30°-45° in the sagittal plane and 75°-90° in the coronal plane. Smith's fractures occurred in 7 of 10 wrists in the experimental study, whereas no Colles' fractures were observed. This study demonstrated that Smith's fracture results from falling on the palm of the hand. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2435-2441, 2017.

Drop finger caused by 8th cervical nerve root impairment: a clinical case series.

PURPOSE: Recently, it has been reported that impairment by an 8th cervical nerve root lesion can cause drop finger, namely C8 drop finger. Here, we report a clinical case series of C8 drop finger to reveal the clinical outcome of surgical treatments to allow for a better choice of treatment. METHODS: The present study included 17 consecutive patients who were diagnosed as having C8 drop finger, in which muscle strength of the extensor digitorum communis (EDC) showed a manual muscle testing (MMT) grade of 3 or less. We retrospectively investigated the clinical characteristics of C8 drop finger and recovery of muscle power was measured by subtraction of preoperative MMT of the EDC from the final follow-up values. RESULTS: Nine cases showed recovery of muscle power of EDC, whereas the remaining eight cases did not show any recovery including two cases of deterioration. None of the conservatively treated patients showed any recovery. Surgically treated cases included two cases of deterioration. In the cases showing recovery, recovery began 9.9 months after surgery on average and recovery took 13.8 months after surgery on average. There was a significant difference in the recovery of MMT grade between the groups treated conservatively and surgically (p = 0.049). Preoperative MMT grade of EDC showed a moderate correlation with postoperative recovery (r 2 = 0.45, p = 0.003). In other words, the severity of preoperative muscular weakness correlated negatively with postoperative recovery. CONCLUSIONS: C8 drop finger is better treated by surgery than conservative therapy.

Closed mallet thumb injury: Our experience of 10 patients treated with surgery and a systematic review.

OBJECTIVE: This retrospective study reports 10 patients with closed mallet thumb injury treated with surgery and compares the clinical outcomes achieved with those of previously described patients who were treated with either conservative therapy or surgery. METHODS: We report the outcomes of a series of 10 patients who received surgical treatment at our institutions. Due to the rarity of closed mallet thumb, a systematic review was conducted, and the results of a literature search were compared with our case series to strengthen our conclusions. The previously described patients were categorized into two groups: the surgically treated group (16 patients) and the conservatively treated group (10 patients). The following patient and injury characteristics were documented: age, gender, injured side, time from injury to treatment, mechanism of injury, extension lag at first visit, postoperative range of motion (ROM) of the interphalangeal joint, immobilization period, and follow-up period. RESULTS: Statistical analyses showed no significant differences in the clinical results, except for shorter immobilization periods between our series and the previously described patients involving conservative treatment (4.9 ± 0.9 vs. 9.5 ± 2.3 weeks, respectively; P = 0.0053). CONCLUSIONS: This study suggests that surgery may result in more rapid recovery.

Accuracy of specimen-specific nonlinear finite element analysis for evaluation of radial diaphysis strength in cadaver material.

The feasibility of a user-specific finite element model for predicting the in situ strength of the radius after implantation of bone plates for open fracture reduction was established. The effect of metal artifact in CT imaging was characterized. The results were verified against biomechanical test data. Fourteen cadaveric radii were divided into two groups: (1) intact radii for evaluating the accuracy of radial diaphysis strength predictions with finite element analysis and (2) radii with a locking plate affixed for evaluating metal artifact. All bones were imaged with CT. In the plated group, radii were first imaged with the plates affixed (for simulating digital plate removal). They were then subsequently imaged with the locking plates and screws removed (actual plate removal). Fracture strength of the radius diaphysis under axial compression was predicted with a three-dimensional, specimen-specific, nonlinear finite element analysis for both the intact and plated bones (bones with and without the plate captured in the scan). Specimens were then loaded to failure using a universal testing machine to verify the actual fracture load. In the intact group, the physical and predicted fracture loads were strongly correlated. For radii with plates affixed, the physical and predicted (simulated plate removal and actual plate removal) fracture loads were strongly correlated. This study demonstrates that our specimen-specific finite element analysis can accurately predict the strength of the radial diaphysis. The metal artifact from CT imaging was shown to produce an overestimate of strength.

Accuracy of specimen-specific nonlinear finite element analysis for evaluation of distal radius strength in cadaver material.

BACKGROUND: Distal radius fracture, which often occurs in the setting of osteoporosis, can lead to permanent deformity and disability. Great effort has been directed toward developing noninvasive methods for evaluating the distal radius strength, with the goal of assessing fracture risk. The aim of this study was to evaluate distal radius strength using a finite element model and to gauge the accuracy of finite element model measurement using cadaver material. METHODS: Ten wrists were obtained from cadavers with a mean age of 89.5 years at death. CT images of each wrist in an extended position were obtained. CT-based finite element models were prepared with Mechanical Finder software. Fracture on the models was simulated by applying a mechanical load to the palm in a direction parallel to the forearm axis, after which the fracture load and the site at which the fracture began were identified. For comparison, the wrists were fractured using a universal testing machine and the fracture load and the site of fracture were identified. RESULTS: The fracture load was 970.9 N in the finite element model group and 990.0 N in the actual measurement group. The site of the initial fracture was extra-articular to the distal radius in both groups. The finite element model was predictive for distal radius fracture when compared to the actual measurement. CONCLUSION: In this study, a finite element model for evaluation of distal radius strength was validated and can be used to predict fracture risk. We conclude that a finite element model is useful for the evaluation of distal radius strength. Knowing distal radius strength might avoid distal radius fracture because appropriate antiosteoporotic treatment can be initiated.

Sciatica caused by pyomyositis of the piriformis muscle in a pediatric patient.

Because the sciatic nerve leaves the pelvis through the greater sciatic notch underneath the piriformis muscle, any pathology of the piriformis muscle could result in entrapment of the sciatic nerve; this is widely known as piriformis muscle syndrome. Pyomyositis of the piriformis muscle may be a cause of piriformis muscle syndrome. Piriformis muscle syndrome caused by pyomyositis of the piriformis muscle in pediatric patients is rare. This article describes a case of sciatica caused by pyomyositis of the piriformis muscle in a pediatric patient. A 6-year-old boy presented with right buttock and thigh pain following a mild fever and sore throat. The pain worsened, and he became unable to walk. On admission, his temperature was 38.4°C. He reported severe right-sided buttock and lateral thigh pain. Positive Freiberg sign was observed. Laboratory examination revealed elevated white blood cell count and C-reactive protein level. T2-weighted magnetic resonance images of the pelvis revealed high-intensity changes of the piriformis muscle and iliosacral joint. Thus, piriformis syndrome caused by pyomyositis of the piriformis muscle was diagnosed. Oral antibiotics (10 mg/kg per day of cefdinir) were administered. Pain gradually decreased, and the patient was able to walk. Final follow-up examination at 6 months after symptom onset revealed no sciatic pain. Follow-up magnetic resonance imaging revealed normalized intensities of the piriformis muscle. The endopelvic fascia provides a route for infection from the pelvis to the piriformis. The pyomyositis of the piriformis muscle in the current case may have occurred secondary to the pyoarthritis of the sacroiliac joint. Endopelvic infections involving the piriformis muscle may mimic hip diseases in pediatric patients.

The Elmslie-Trillat procedure for recurrent patellar subluxation after total knee arthroplasty.

Patellofemoral problems are the most common complications after total knee arthroplasty (TKA). We report a patient who had patellar subluxation twice within 7 months after primary TKA. Postoperative radiographs and computed tomography scans revealed a valgus knee with no evidence of malposition of the prostheses. To eliminate the recurrent patellar subluxation, we finally performed an Elmslie-Trillat procedure in combination with extensive lateral release and succeeded in achieving normal patellar tracking. At 1-year postoperative follow-up, the patient was satisfied with the results. The patella tracked well in the femoral trochlear groove during knee flexion after the revision surgery. This procedure, in combination with lateral release, should be considered as a useful surgical treatment that can eliminate patellar subluxation after TKA in cases without component malposition.

Radial head dislocation with ulnar plastic deformation in children: an osteotomy within the middle third of the ulna.

This retrospective study includes 6 patients (average age, 8.7 years) with a dislocation of the radial head and ulnar plastic deformation. All were Monteggia fractures, Bado type I equivalents. The maximum ulnar bow was near the midulna. Five patients underwent an ulnar osteotomy, with elongation and reduction of the angulation within the middle third of the ulna, and open reduction of the radial head. One patient underwent an ulnar osteotomy with only elongation. The osteotomy sites were stabilized by a plate and screws or Kirschner wires. Mean follow-up was 3.4 years. Postoperatively, the average elbow range of motion was extension to 0 degrees, flexion to 138 degrees, forearm supination to 90 degrees, and forearm pronation to 88 degrees. Results in all patients were rated as excellent. One nonunion occurred. An osteotomy performed within the middle third of the ulna, combined with open reduction of the radial head, resulted in excellent clinical outcomes.

Herbert screw fixation of capitellar fractures.

From 1993 to 2003, 6 patients with displaced fractures of the humeral capitellum were treated by open reduction and internal fixation of the capitellar fragments with Herbert bone screws. By use of the criteria of Grantham et al, there were 2 type II-A fractures, 1 type II-B fracture, 1 type II-C fracture, and 2 type III-A fractures. A lateral approach was used in 4 patients and a posterior approach with olecranon osteotomy in 2. The elbows were immobilized postoperatively for 4 to 28 days (mean, 13.5 days). We evaluated the range of motion, stability, and pain using the criteria of Grantham et al. The follow-up period ranged from 2.5 to 9.3 years (mean, 5.6 years). All patients had a stable, pain-free elbow with good range of motion at follow-up. All fractures healed, and there was no evidence of avascular necrosis or degenerative change.