Paralabral Cyst of the Hip Causing Deep Vein Thrombosis Treated with Arthroscopic Decompression and Labral Repair.

In the setting of femoroacetabular impingement of the hip joint, paralabral cysts are well-documented sequelae. These cysts are typically associated with labral tears caused by CAM and/or pincer-type bony lesions. Synovial fluid extravasation through a tear in the labrum, similar to a popliteus cyst, leads to formation of a capsular-based cyst that is usually self-limiting. Few documented cases of these cysts causing compression of nearby neurovascular structures exist. There are several studies documenting arthroscopic decompression of these cysts, but none reporting compression of the femoral vein by a paralabral cyst resulting in deep vein thrombosis. We present the case of a large anterior paralabral cyst causing compression of the right femoral vein in a patient presenting with deep vein thrombosis and hip pain. Treatment consisted of arthroscopic decompression, followed by definitive aspiration by interventional radiology after labral repair and bipolar hip osteoplasty. The purpose of this case report was to document this rare presentation and offer learning points from our experience.

Repeat posterior wall acetabular fracture-dislocation: High-energy trauma as a 'second hit phenomenon'.

Acetabular fractures are injuries that require significant force transmission, especially when associated with a femoral head dislocation. The mechanism of injury is typically in the setting of a high-speed motor vehicle collision. In a similar manner, this is an injury that is highly demanding for the orthopaedic trauma surgeon to treat as well. We present a patient who sustained an initial posterior wall acetabular fracture with an associated posterior dislocation. This was treated surgically with open reduction, internal fixation without complication. The patient subsequently sustained a second posterior wall acetabular fracture with dislocation fifteen years later through the plated and healed previous fracture. Both injuries were sustained in high-speed motor vehicle collisions, so it is difficult to presume the patient was predisposed for the repeat injury. At any rate, the repeat injury makes the surgical management significantly more challenging. In complicated acetabular fractures like these, a post or intra-operative CT scan can be of utility to determine quality of reduction as well as assessing for retained bony fragments. Our patient underwent a post-operative CT scan with the finding of intra-articular bony fragments that subsequently required arthroscopic removal. Given the rare nature of this complicated injury occurring twice in a patient, it is difficult to make evidence-based comments on long-term prognosis and functional outcomes. This unique case and the applied treatment will serve as a guide for future similar cases.

Metastatic MSSA infection of the spine and extremities.

Here, we present a rare case of metastatic methicillin sensitive Staphylococcus aureus (MSSA) infection arising from an unknown focus and spreading throughout the lumbar spine with associated pyomyositis of the paraspinal musculature, and septic arthritis of the knee, ankle and sternoclavicular joint. This case highlights the potential for missed aspects and delay in diagnosis in the care of metastatic S. aureus and the need for multispecialty intervention. Treatment of S. aureus infections requires a high index of suspicion and careful examination of multiple organ systems to identify the full extent of the disease. A discussion on metastatic S. aureus infection follows the report.

Extracorporeal shock wave treatment of non- or delayed union of proximal metatarsal fractures.

BACKGROUND: Nonunion or delayed union of fractures in the proximal aspect of metatarsals 1 to 4 and Zone 2 of the fifth metatarsal were treated by high energy extracorporeal shock wave treatment (ESWT) to study the safety and efficacy of this method of treatment in a FDA study of the Ossatron device. MATERIALS AND METHODS: In a prospective single-arm, multi-center study, 34 fractures were treated in 32 patients (two subjects had two independent fractures) with ESWT. All fractures were at least 10 (range, 10 to 833) weeks after injury, with a median of 23 weeks. ESWT application was conducted using a protocol totaling 2,000 shocks for a total energy application of approximately 0.22 to 0.51 mJ/mm2 per treatment. The mean ESWT application time for each of the treatments was 24.6 +/- 16.6 minutes, and anesthesia time averaged 27.1 +/- 10.4 minutes. All subjects were followed for 1 year after treatment at intervals of 12 weeks, 6, 9, and 12 months. RESULTS: The overall success rate at the 12-week visit was 71% with low complications, significant pain improvement as well as improvement on the SF-36. The success/fail criteria was evaluated again at the 6- and 12-month followup, showing treatment success rates of 89% (23/26) and 90% (18/20), respectively. The most common adverse event was swelling in the foot, reported by five subjects (15.6%). CONCLUSION: High-energy ESWT appears to be effective and safe in patients for treatment of nonunion or a delayed healing of a proximal metatarsal, and in fifth metatarsal fractures in Zone 2.