Syndesmosis Changes before and after Syndesmotic Screw Removal: A Retrospective Radiographic Study.

BACKGROUND AND OBJECTIVES: In patients with ankle fractures complicated by syndesmotic injuries, no consensus has been reached on the best method of syndesmosis fixation using syndesmotic screws. One previous study revealed no difference in the tibiofibular overlap between two groups with or without syndesmotic screw removal. Other studies have indicated that distal tibiofibular diastasis exists after the removal of syndesmotic screws. In this study, we aimed to confirm the effect of syndesmotic screw removal on diastasis occurrence. We further analyzed the risk factors that may contribute to the widening of the tibiofibular syndesmosis. MATERIALS AND METHODS: This retrospective study involved a review of the records of 63 patients with ankle fractures accompanied by syndesmosis injuries that required syndesmotic screw fixation. Anteroposterior radiographs were analyzed for each patient at various time points, from syndesmotic screw fixation to outpatient department follow-ups after screw removal. The changes in tibia-fibula overlap (OL), tibia-fibula clear space (CS), and medial clear space (MCS) were analyzed. Further analysis was performed to reveal potential factors that may have contributed to radiographic differences. RESULTS: Compared with the postoperation radiographs following syndesmotic screw fixation, OL decreased (2.0 mm) and CS increased (0.8 mm) in the anteroposterior radiographs from outpatient department follow-ups. No significant changes were noted in OL or CS after syndesmotic screw removal. However, OL decreased (1.8 mm) and CS increased (0.5 mm) before syndesmotic screw removal. No significant change in MCS occurred during the whole observation period. Linear regression analysis did not reveal any significant correlations between potentially related factors and radiographic changes. CONCLUSIONS: Marked diastasis had occurred at final follow-up. Notably, the diastasis occurred before rather than after screw removal. This implies that screw removal does not significantly influence the radiographic outcomes of rotational ankle fractures.

Contracture of extensor hallucis longus after fracture of distal tibia and fibula: A case report.

Post-traumatic isolated big toe extensor contracture after tibiofibular fracture is uncommon and only a few cases have been reported. Major causes of it include anterior compartment syndrome, direct injury, entrapment or adhesion of the muscle or tendon.We present an uncommon case of isolated extensor hallucis longus (EHL) tendon contracture following a distal tibiofibular shaft fracture without compartment syndrome of the affected leg or foot. The clinical outcome is good after Z-lengthening of the EHL tendon and abductor hallux tendon in 1-year follow-up. LEVEL OF CLINICAL EVIDENCE: 5.

Efficacy of Different Energy Levels Used in Focused and Radial Extracorporeal Shockwave Therapy in the Treatment of Plantar Fasciitis: A Meta-Analysis of Randomized Placebo-Controlled Trials.

The objective of this study was to assess the efficacy of different energy levels used in extracorporeal shockwave therapy (ESWT) in the treatment of plantar fasciitis using a systematic review and meta-analysis. We searched PubMed, Embase, and Cochrane library, from inception to March 2019 for randomized controlled trials that compared ESWT with placebo in patients with plantar fasciitis. The risk of bias for selected articles was assessed based on the Cochrane Handbook Systematic Review of Interventions. The pooled data were estimated by the mean difference or odds ratio. The meta-analysis showed that the high-energy ESWT group had a better success rate than the control group only at a three-month follow-up, but no significant difference between groups was observed for the other follow-up visits (1 and 12 months). In addition, no significant differences in visual analog scale (VAS) scores between groups were observed for all the follow-up visits (one-month and three-month). On the contrary, the medium-energy ESWT group had significantly better success rates than the control group for all the follow-up visits (3, 6, and 12 months). In addition, the medium-energy ESWT group had significant improvement in VAS scores compared with the control group for all the follow-up visits (1, 3, 6, and 12 months) after removing the extreme values. The low-energy ESWT group had significant improvement in VAS scores compared with the control group for all the follow-up visits (3 and 12 months). Otherwise, focused ESWT seems to be more effective than radial ESWT when compared with the control group. Use of local anesthesia can reduce the efficacy of low- and high-energy ESWTs. Our meta-analysis suggested that medium-energy ESWT in the treatment of plantar fasciitis was more effective than the control group. A limited number of trials related to low- and high-energy ESWTs were included in our meta-analysis. More research is required to confirm the efficacy of low- and high-energy ESWTs in future studies.

Modified Mitchell osteotomy alone does not have higher rate of residual metatarsalgia than combined first and lesser metatarsal osteotomy.

Transfer metatarsalgia (TM) is a common forefoot disorder secondary to hallux valgus (HV). Some authors suggest that a combined lesser metatarsal osteotomy while undergoing HV surgery improves metatarsalgia, whereas others concluded that isolated HV corrective osteotomy can improve symptomatic metatarsalgia. The main purpose of this retrospective study was to compare clinical outcomes in patients with and without combined lesser metatarsal osteotomy while receiving HV correction surgery. We retrospectively reviewed the patients who underwent osteotomy for HV correction between January 2000 and December 2010. All patients underwent HV correction with modified Mitchell osteotomy. Clinical evaluations including the American Orthopaedic Foot and Ankle Society score and residual metatarsalgia were assessed, and radiographic measurements were carried out. Sixty-five patients (83 feet) meeting the selection criteria were enrolled. Thirty feet receiving a combined lesser metatarsal osteotomy were classified as the combined surgery (CS) group, and the others were classified as the control (CN) group (53 feet). The overall rate of persistent symptomatic metatarsalgia was 19.28% after operative treatment. There were six feet with residual metatarsalgia in the CS group, and 10 feet in the CN group. There was no significant difference in the rate of persistent symptoms between the two groups (p = 0.9). According to this result, modified Mitchell osteotomy alone did not have a higher rate of residual metatarsalgia than CS. We also found that the average recovery rate of TM was about 80.7% and those patients whose preoperative HV angle was > 30° had the higher risk of residual metatarsalgia after surgery.

Why do lesser toes deviate laterally in hallux valgus? A radiographic study.

BACKGROUND: Hallux valgus foot with laterally deviated lesser toes is a complex condition to treat. Ignoring the laterally deviated lesser toes in hallux valgus might result in unsatisfactory foot shape. Without lateral support of the lesser toes, it might increase the risk of recurrence of hallux valgus. We sought to identify associated radiographic findings in patients where lesser toes follow the great toe in hallux valgus and deviate laterally. METHODS: The weight-bearing, anteroposterior foot radiographs of 24 female hallux valgus feet with laterally deviated lesser toes (group L), 34 female hallux valgus feet with normal lesser toes (group H), and 43 normal female feet (group N) were selected for the study. A 2-dimensional coordinated system was used to analyze the shapes and angles of these feet by converting each dot made on the radiographs onto X and Y coordinates. Diagrams of the feet in each group were drawn for comparison. The hallux valgus angle, lateral deviation angle of the second toe, intermetatarsal angles, toe length, metatarsal length, and metatarsus adductus were calculated according to the coordinates of the corresponding points. RESULTS: The mapping showed the bases of the second, third, and fourth toe in group L shifted laterally away from their corresponding metatarsal head (P < .001). The mean 2-3 intermetatarsal angles were: group L, H, N = 7.7 ± 2.6, 4.3 ± 1.9, 4.3 ± 1.3 degrees, respectively (P < .001); mean 3-4 intermetatarsal angles were, for groups L, H, N = 7.3 ± 2.3, 6.1 ± 2.1, 6.3 ± 1.4 degrees, respectively (P < .05). Larger hallux valgus angles (P < .001), more adducted first metatarsal (P < .05), and divergent lateral splaying of the lesser metatarsals (P < .001) were found in group L. CONCLUSION: Larger 2-3 and 3-4 intermetatarsal angles, larger hallux valgus angle, more adducted first metatarsal, and divergent lateral splaying of the lesser metatarsals were associated with lateral deviation of the lesser toes in hallux valgus. LEVEL OF EVIDENCE: Level III, comparative study.

Isolated talonavicular arthrodesis for Müller-Weiss disease.

This study aims to describe the clinical results of isolated talonavicular arthrodesis in rare Müller-Weiss disease, spontaneous osteonecrosis of the navicular in adults. From June 2001 to April 2010, we performed isolated talonavicular arthrodesis on 13 feet of 13 patients (mean age: 55.6 years) with Müller-Weiss disease. The feet were staged by the preoperative radiographs according to the Maceira classification. The average modified American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score improved from 48.5 points preoperatively to 87.2 points at final follow-up (mean 51 months, range 10-114 months). Union was achieved in 10 cases (76.9%). If the subtalar and calcaneocuboid joints are relatively healthy, isolated talonavicular arthrodesis may be an effective and reliable surgical option for treatment of Müller-Weiss disease that is resistant to conservative treatment.

Vitamin D status in non-supplemented postmenopausal Taiwanese women with osteoporosis and fragility fracture.

BACKGROUND: Vitamin D is essential for calcium metabolism, Vitamin D deficiency can precipitate osteoporosis, cause muscle weakness and increase the risk of fracture. The aim of this study was to assess the prevalence of vitamin D inadequacy among non-supplemented postmenopausal women with osteoporosis and fragility fractures of the hip or vertebrae in Taiwan. METHODS: This multi-center, cross-sectional, observational study analyzed the vitamin D inadequacy [defined as 25(OH) D level less than 30 ng/mL] in Taiwanese postmenopausal osteoporotic patients who suffered from a low trauma, non-pathological fragility hip or vertebral fracture that received post-fracture medical care when admitted to hospital or at an outpatient clinic. RESULTS: A total of 199 patients were enrolled at 8 medical centers in Taiwan; 194 patients met the study criteria with 113 (58.2%) and 81 (41.8%) patients diagnosed with hip and vertebral fracture, respectively. The mean serum 25(OH) D level was 21.1 ± 9.3 ng/mL, resulting in a prevalence of vitamin D inadequacy of 86.6% of the patients. CONCLUSIONS: High prevalence of vitamin D inadequacy across all age groups was found among non-supplemented women with osteoporosis and fragility hip or vertebral fracture in Taiwan.

Bicondylar tibial plateau fracture treated by open reduction and fixation with unilateral locked plating.

The management of bicondylar tibial plateau fractures is challenging. A lateral locking plate offers an alternative method to traditional dual plating to avoid further stripping of soft tissue. Nevertheless, the rate of malreduction and fixation loss remains high. From 2007 to 2009, we performed open reduction and fixation with unilateral locked plating to directly reduce the fracture in 15 patients with bicondylar plateau fracture. The average follow-up duration was 16.2 months (range: 12-30 months), and the average age of the patients was 43 years (range: 19-64 years). All fractures were Orthopaedic Trauma Association type 41-C. Postoperative radiographic alignment was evaluated immediately and at 2-4 weeks, 8-12 weeks, 5-7 months, and 11-13 months. Both Oxford knee score and Hospital for Special Surgery knee score were used to evaluate functional outcomes. The average duration within which union was achieved was 4.8 months (range: 2-10 months). One patient incurred wound dehiscence; however, there was no case of deep infection. Malreduction occurred in one patient (6.7%) while fixation loss occurred in three patients (20%) with subsidence of the posteromedial fragment and varus malalignment. Despite the malreduction rate being lower in our study than in previous studies involving unilateral locked plating, a high rate of fixation loss was recorded. Per our limited experience, we believe that unilateral locked plating may have limitations in patients with selective patterns of bicondylar tibial plateau fractures.

Irreducible metatarsophalangeal joint dislocation of the lesser toes: a case report.

Irreducible metatarsophalangeal joint dislocation of the lesser toes is a rare injury. We present a 37-year-old man who was injured in a motorcycle accident and dislocated the first to third metatarsophalangeal joints and fractured the fourth metatarsal head. The left first metatarsophalangeal joint was reduced successfully through the closed method, but multiple attempts at closed reduction under local anesthesia failed to reduce the dislocated second and third metatarsophalangeal joints. We performed a dorsal incision between the second and third metatarsals, and the metatarsal heads were found to be entrapped under the plantar plate. Dislocation reduction was performed without damage to the plantar plate, and one Kirschner wire was used to fix the fourth metatarsal head fracture. The pin was removed 8 weeks after surgery, and the patient regained normal gait and returned to work and his previous physical activity level without recurrent dislocation.

Open reduction and internal fixation of acute intra-articular displaced calcaneal fractures: a retrospective analysis of surgical timing and infection rates.

The choice of surgical timing in open reduction for calcaneal fractures has been proposed to be associated with soft-tissue complications and infection. This study analysed the correlation between surgical timing and postoperative infection rates. We performed a retrospective single-surgeon single-facility study (Kaohsiung Medical University Hospital, KMUH) between January 2006 and January 2010. Fifty patients with 53 close intra-articular calcaneal fractures were included. They received open reduction and internal fixation via the extensile lateral L-shaped approach. We assessed the duration between heel trauma and operation from the medical records and sorted our patients into early (within 3 days), intermediate (from 3 to 10 days) and delayed (over 10 days) surgical groups. The mean follow-up period was 13 months. Only one of the 50 patients, a 74-year-old female with diabetes mellitus, developed deep infection requiring hardware removal and serial debridement. Overall, we did not find a statistical difference in postoperative infection rates in the different timing groups. Our conclusion is that in experienced hands, surgical timing may not affect postoperative infection rates in calcaneal fracture among strictly selected patients who do not have potential risk factors for wound complication. Therefore, early operation may be helpful to these patients.

Longitudinal changes in bone mineral density of healthy elderly women in southern Taiwan.

OBJECTIVE: Longitudinal data on bone decline in ethnic Chinese elderly are sparse, especially in healthy, aged women. This study reviews the longitudinal change in bone mineral density (BMD) at the femoral neck, great trochanter, and Ward's triangle in healthy elderly Taiwanese women. MATERIALS AND METHODS: A prospective cohort study was conducted, with 1500 women aged ≥ 61 years. Fifty-four were eligible for hip evaluation and 52 underwent examination for hip BMD. Two years later, 50 women had a follow-up BMD examination. Linear regression was performed between age and bone density. The paired t test was used for BMD changes between examinations. RESULTS: In the initial study, there was a negative relationship between BMD and age using liner regression at all three sites (p < 0.05). Two years later, there was a significant decrease in BMD at all three sites (p < 0.01). In terms of age cohorts, both age groups showed a significant decrease in BMD at the three sites studied (p < 0.01). There was a peak loss of BMD as high as 2.74% annually at the Ward's triangle in those aged 61-70 years. CONCLUSION: Our findings indicate that BMD is negatively correlated to aging in the healthy female. The loss of BMD at the Ward's triangle in those aged 61-70 years is faster than at other sites. Attention should be given to bone loss in ethnic Chinese females because their bone loss is more severe than that of Caucasians.

Arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using patellar tendon graft compared with hamstring tendon graft.

PURPOSE: The purpose of this study was to compare the outcomes of arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using autologous patellar tendon and hamstring tendon grafts. METHODS: From 1998 to 2007, 59 patients with symptomatic isolated posterior cruciate ligament injury were included in this retrospective study. Twenty-five knees were reconstructed using bone-patellar tendon-bone graft, and 34 knees were reconstructed using hamstring graft. In both groups, surgical techniques were similar, except material of fixation screws. Patients were evaluated pre-operatively and post-operatively at the latest follow-up with several parameters, including symptoms, physical examination, outcome satisfaction, functional scores, radiography and complications. RESULTS: Average follow-up period was 51.6 months in patellar tendon group and 51.1 months in hamstring tendon group. Significantly more kneeling pain (32 vs. 3 %), squatting pain (24 vs. 3 %), anterior knee pain (36 vs. 3 %), posterior drawer laxity and osteoarthritic change were shown in patellar tendon group than in hamstring tendon group post-operatively. No significant differences were found in other parameters between both groups. CONCLUSIONS: Several shortcomings, including anterior knee pain, squatting pain, kneeling pain and osteoarthritic change, have to be concerned when using patellar tendon autograft. In conclusion, hamstring tendon autograft may be a better choice for transtibial tunnel PCL reconstruction.

Aggressive continuous passive motion exercise does not improve knee range of motion after total knee arthroplasty.

AIMS AND OBJECTIVES: The aim of this study was to evaluate the effects of continuous passive motion on the range of motion, postoperative pain and life quality of patients undergoing total knee arthroplasty within six months after the operation. BACKGROUND: Total knee arthroplasty reduces pain and improves range of motion of the osteoarthritic knee joint. Continuous passive motion increases postoperative movement, but there is some controversy regarding whether aggressive continuous passive motion can improve range of motion or life quality, and whether it induces more pain. DESIGN: A prospective controlled study was conducted in a medical centre in Taiwan from January to December 2006. METHODS: One hundred and seven patients were recruited. The patients underwent the basic rehabilitation protocols (the control group) or the basic rehabilitation protocols and additional daily use of continuous passive motion for more than six hours per day (the experimental group). The range of motion, modified Short Form-36 (SF-36) and semi-quantitative visual analogue scale were recorded. Results. Range of motion increased from 109° preoperatively to 125° at six months postoperatively in the treatment group and from 111° preoperatively to 125° at six months postoperatively in the control group. Visual analogue scale decreased from 7·78 preoperatively to 0·37 at six months postoperatively in the treatment group and from 7·92 preoperatively to 0·21 at six months postoperatively in the control group. The SF-36 improved from 3·76 preoperatively to 1·77 at six months postoperatively in the treatment group and from 3·68 preoperatively to 1·83 at six months postoperatively in the control group. There was no significant difference in range of motion, visual analogue scale and SF-36 between groups at each visit. CONCLUSION: With the advances in total knee arthroplasty surgical technique, aggressive continuous passive motion does not provide obvious benefits. RELEVANCE TO CLINICAL PRACTICE: Total knee arthroplasty can alleviate pain and improve range of motion, but aggressive continuous passive motion does not provide additional benefits.

An alternative technique for the management of phalangeal enchondromas with pathologic fractures.

PURPOSE: Enchondroma of the hand with a pathologic fracture is generally treated by tumor curettage and bone grafting after the fracture has healed. However, delayed surgery postpones definitive diagnosis and prolongs the period of disability. We have treated pathologic fractures in a single stage through a modified lateral surgical approach with curettage of the tumor and stabilization using injectable calcium sulfate cement. The aim of this study was to report the outcomes of treatment with this material and the modified approach. METHODS: Between 2006 and 2010, we enrolled 8 patients with solitary hand enchondromas and pathologic fractures. The surgical procedure involved a lateral approach, an extended lateral cortical window, thorough tumor evacuation, and reconstruction of the bone defects using commercially available injectable calcium sulfate cement. We performed evaluations before surgery and in the postoperative follow-up series by radiographs and clinical assessments, including measurement of joint motion by goniometry and a visual analog pain scale. RESULTS: The average time of follow-up was 19 months (range, 12-36 mo). The pathologic fractures of all patients healed clinically and radiographically within 8 weeks after surgery, and the mean active motion arcs of the metacarpophalangeal joints and proximal interphalangeal joints of the involved digit were 90° and 94°, respectively at 3-month follow-up. All patients returned to ordinary daily activities without obvious pain by 3 months postoperatively. We found no major complications, such as unacceptable alignment, nonunion, infection, or tumor recurrence, during follow-up. CONCLUSIONS: This study demonstrated the outcomes of early management of phalangeal enchondromas with pathologic fractures using a lateral approach and injectable calcium sulfate cement for reconstruction. This combined approach avoided the need for supplemental internal fixation, allowed early mobilization, and resulted in minimal joint stiffness. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Modified Mitchell osteotomy with screw fixation for correction of hallux valgus.

BACKGROUND: The authors have performed more than 1500 cases of a Mitchell osteotomy and traditionally used two crossed pins for fixation. The previous series showed some complications related to pin tract infection, pin migration, and transfer metatarsalgia. Since 2009, the authors have used a compression screw for fixation and made some technical modifications and the results are reported in this article. METHODS: A total of 95 patients underwent a Mitchell ostotomy to correct hallux valgus deformity with fixation with multi-use compression (MUC) screws. Hallux valgus angle (HVA), intermetatarsal angle (IMA), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale were measured preoperatively and postoperatively. RESULTS: ~There were statistically differences between the preoperatively and postoperatively HVA, first IMA, and AOFAS hallux metatarsophalangeal-interphalangeal scores. Five patients (8/137 feet, 5.8%) underwent removal of the screw because of screw tip irritation. Eight patients (9/137 feet, 6.5%) had transfer metatarsalgia of the second metatarsal, with two of them caused by dorsal tilt of the metatarsal head. One patient (1/137 feet, 0.7%) had undercorrection. There was no superficial infection, deep infection, nonunion, or osteonecrosis of the first metatarsal head. CONCLUSION: On the basis of the results observed in this study, it appears that the use of a multi-use compression screw provides satisfactory stabilization of the modified Mitchell osteotomy and was not associated with any serious complications. The modified technique also helped reduce transfer metatarsalgia.

Modified basket plate for inferior patellar pole avulsion fractures: a report of three cases.

In patients who have sustained an avulsion fracture of the inferior patellar pole, the extensor mechanism is disrupted and should be repaired. The normal height of the patella can be maintained by preserving the patellar pole, but fractures of the inferior pole of the patella are not easy to reduce and fix firmly. In contrast with partial patellectomy, which requires postoperative immobilization, internal fixation with a basket plate allows for immediate mobilization and early weight-bearing. Owing to the unavailability of the basket plate in Taiwan, we have modified the plate with the titanium mesh as a possible alternative. We present three cases of this modified basket plate, which took place between 2008 and 2010. This technique avoided long-term immobilization of the knee with good clinical results.

Atypical femoral fracture after long-term alendronate treatment: report of a case evidenced with magnetic resonance imaging.

Postmenopausal osteoporosis is commonly treated with alendronate, one of the bisphosphonates used for the prevention and treatment of osteoporotic fractures. However, the correlation between atypical femoral fractures and long-term bisphosphonate therapy has not been clearly identified. We report here the case of a 69-year-old woman with postmenopausal osteoporosis who presented with an atypical femoral subtrochanteric fracture on magnetic resonance imaging (MRI) confirmation after having received alendronate therapy for about 3 years. The fracture united after refixation and after administration of alendronate was stopped. Several published reports were reviewed, and some clinical characteristics of this atraumatic fracture were revealed, including the clinical symptoms of thigh pain, stress reaction or stress fracture, and transverse fracture with unicortical beak in an area of cortical hypertrophy. In addition to a regular radiographic survey, MRI, which may provide early information, and bone biopsy for pathologic analysis may be used as tools for early detection and final diagnosis. Once an insufficiency fracture is suspected or proved to be related to bisphosphonate, the withholding of bisphosphonate should be highly recommended to enhance fracture healing. Prophylactic fixation should be considered if fracture healing is not good or if the patient cannot tolerate protection of weight-bearing.

Successful teriparatide treatment of atypical fracture after long-term use of alendronate without surgical procedure in a postmenopausal woman: a case report.

OBJECTIVE: Bisphosphonates are used as first-line therapy for postmenopausal osteoporosis owing to their potent inhibition of bone resorption. Long-term use of bisphosphonates may lead to low-energy femoral subtrochanteric or shaft fractures in a very few patients. The aim of this study was to describe the clinical course of a patient treated with alendronate for 3 years who developed an atypical femoral fracture and to hypothesize the beneficial effects of teriparatide on the healing of the patient's atypical femoral fracture. METHODS: A 63-year-old Asian woman had a lumbar osteoporotic fracture and received 70 mg of alendronate for 3 years. Pain and soreness in the thigh presented initially and exacerbated thereafter. X-ray revealed a right femoral diaphysis stress fracture. She then received teriparatide for the treatment of osteoporosis and the femoral atypical fracture. RESULTS: Pain and tenderness improved remarkably after teriparatide treatment for 1 month, and these symptoms disappeared after teriparatide treatment for 9 months. The patient also received raloxifen as further therapy, and the fracture line had completely disappeared by 15 months after treatment. CONCLUSIONS: Even though a previous study has reported that teriparatide healed stress fractures in a rat model and even with the time course of fracture healing in our patient, we are still not certain that teriparatide played a primary role in the positive response to therapy. Vitamin D therapy, calcium, and alendronate discontinuation may have played secondary roles. This case report may serve to introduce a direction for future research into the pharmacological treatment of atypical femoral fractures. Surgical treatment of incomplete atypical femoral fractures may be a safer method.

Surgical treatment of melorheostosis: report of two cases.

Melorheostosis is a rare disease that usually burdens the patient with painful disability or soft tissue compromise. The treatment is usually symptomatic and conservative. Patients with severe and complicated forms of the disease may require surgery. Involvement of the distal part of a limb usually carries more morbidity, such as tumefaction pain, cosmetic and psychosocial or functional problems that render conservative treatment unsatisfactory to patients. In our series, surgical debulking or decompression of the mass effect provided prompt symptom relief.

Successful treatment of a delayed presentation of a gunshot injury to the femoral neck in an elderly man: a case report.

Gunshot wounds involving major joints can be lethal as a result of the disruption to major neurovascular tracts. We report on a high-energy ballistic injury resulting in a comminuted femoral neck fracture in an elderly patient with a surgical delay exceeding 20 h. The patient underwent bipolar hemiarthroplasty and led a functional, satisfactory life after surgery. Lead intoxication was also identified, and the blood lead concentration was almost two times the positive diagnostic value (25 µg/dL). The rebound in lead concentration suggested delayed lead toxicity. The patient did not have symptoms of plumbism at the last follow-up 4 years after the injury.