Brachymetatarsia with accessory navicular in right foot: A rare coincidental finding

A 33 years old female patient presented with posttraumatic pain in the right foot for which radiographs of the right foot was advised. No fracture was detected on radiographs and patient was managed conservatively on medications and posterior splint immobilization. We found coincidentally a short fourth metatarsal and an accessory navicular bone in the right foot radiographs. After 3 weeks of immobilization, she underwent mobilization of the right foot, weight bearing and intensive physiotherapy for 6 weeks. After two months of injury she was still complaining of pain on the plantar aspect of right foot which was diagnosed as metatarsalgia and operated on by excision of the neuroma present in the 3rd web space of the right foot. After surgery she was completely relieved of pain and could do activities well related to the right foot.     

A case of fulminant hepatitis after reexposure to halothane six years later

We reported a case of halothane-induced fulminant hepatitis with acute renal failure which developed 6 days after reexposure to halothane. The patient was a 58-year-old female. She had a history of liver dysfunction after exposure to halothane 6 years previously. She had surgical treatment of clubfoot under halothane anesthesia in other hospital. Preoperative physical examination and laboratory data were normal. On the 6th post-operative day she abruptly developed high fever and general fatigue. Next day, she was transferred to our hospital. At admission, fulminant hepatitis complicated with acute renal failure was diagnosed with severe liver and renal damage. She was immediately treated with plasma exchange, glucose-insulin therapy, and hemodialysis. Serum transaminase level returned to normal value within a week. However, despite repeated hemodialysis, renal function did not improve, and she died of P. aeruginosa sepsis on 28th day after the operation. It may be suggested that in this patient hypersensitivity to halothane has persisted during the six years.     

Simultaneous transarticular intramedullary nailing of the tibia and total knee replacement in tibial nonunion and osteoarthrosis

The combined manifestation of a nonunion of the proximal tibia and an osteoarthrosis of both knee joints is not very common. Yet, this was a kind of "unhappy triad" for a 86 year old lady suffering from a nonunion after one year of conservative treatment of a proximal tibial shaft fracture. Her quality of life has already been reduced by a loss of visual power and she was completely invalidized. She was unable to walk and she was hospitalized for the whole period of time. The operative treatment consisted in an intramedullary tibial nailing through the resected tibial joint surface using an IMSC-nail and, simultaneously through the same surgical approach, in a partially cemented total knee joint replacement. After 5 months a replacement of the second knee joint also was performed and 6 weeks later the almost blind patient could be discharged for home again. After another 7 months a proximal femoral fracture of the first side was repaired using a proximal femural nail. Four years later she still is able to live on her own and runs her flat with only little external help. She can walk as far as 3 km and enjoys a good knee function.     

Lupus nephritis in juvenile myelomonocytic leukemia.

A 13-year-old girl developed lupus nephritis and Hashimoto thyroiditis in the chronic phase of juvenile myelomonocytic leukemia (JMML). At age 7 months, she was diagnosed as having JMML based on the hepatosplenomegaly, leukocytosis, thrombocytopenia, increased levels of fetal hemoglobin, and spontaneous in vitro growth of granulocyte-macrophage progenitors. At the onset of JMML, she had hypergammaglobulinemia, antinuclear antibodies, rheumatoid factors and anti-smooth muscle antibody. She had been placed on oral 6-mercaptopurine for about 12 years, with clinical improvement. At age 13 years, she was found to have hematuria and proteinuria. She also developed arthritis and Raynaud's phenomenon as well. She had antinuclear antibodies, rheumatoid factors, LE phenomenon, beta-1C (C3) nephritic factor (C3NeF), antithyroid antibodies, and hypocomplementemia. The renal biopsy specimens revealed a diffuse increase in the mesangial cells and matrix by light microscopy, and intense staining of IgG, Clq and C3 by immunofluorescence microscopy. The hormonal study ultimately showed decreased thyroid functions. So she was diagnosed as lupus nephritis and Hashimoto thyroiditis. The patient is the first example to show close relationship between stem cell abnormalities in JMML and development of overt autoimmune disorders.     

Simultaneous transarticular intramedullary nailing of the tibia and total knee replacement in tibial nonunion and osteoarthrosis

The combined manifestation of a nonunion of the proximal tibia and an osteoarthrosis of both knee joints is not very common. Yet, this was a kind of “unhappy triad” for a 86 year old lady suffering from a nonunion after one year of conservative treatment of a proximal tibial shaft fracture. Her quality of life has already been reduced by a loss of visual power and she was completely invalidized. She was unable to walk and she was hospialized for the whole period of time. The operative treatment consisted in an intramedullary tibial nailing through the resected tibial joint surface using an IMSC-nail and, simultaneously through the same surgical approach, in a partially cemented total knee joint replacement. After 5 months a replacement of the second knee joint also was performed and 6 weeks later the almost blind patient could be discharged for home again. After another 7 months a proximal femoral fracture of the first side was repaired using a proximal femural nail. Four years later she still is able to live on her own and runs her flat with only little extern help. She can walk as far as 3 km and enjoys a good knee function.     

Pustular psoriasis after renal transplantation

Cutaneous manifestations in renal transplant recipients are frequently represented by infections and cancerous lesions. However, dermatologic lesions secondary to autoimmune diseases are rare. We report a case of pustular psoriasis occurring after renal transplantation in a 31-year-old woman with a history of vitiligo. The patient was on hemodialysis for 2 years for undetermined chronic nephropathy. She received an HLA identical live related transplant from her brother. She was maintained on an immunosuppressive regimen of corticosteroids, azathioprine, and cyclosporine, which was replaced with mycophenolate mofetil because of neurotoxicity and azathioprine was stopped. Thirty-one months after renal transplantation, she developed pustular psoriasis which was treated with retinoids; she experienced a relapse and resistance to treatment despite the reintroduction of cyclosporine.     

Subchondral insufficiency fracture of the second metatatarsal head in an eldery woman treated with autologous osteochondral transplantation

Freiberg's infraction is a rare disorder that arises mostly in adolescent athletes. We describe a 77-year-old woman with the collapse of second metatarsal head with similar clinical appearance to Freiberg's infraction. Radiological findings at initial visit of our hospital were normal. Her condition was obscure and magnetic resonance imaging showed the subchondral insufficiency fracture with bone marrow edema to the second metatarsal head. Despite the conservative treatment, the second metatarsal head collapsed. She was surgically treated with an osteochondral autograft without complications relating surgery. Furthermore, the histological findings showed that the site of collapse was considered to be secondary lesions resulting from the subchondral insufficiency fracture.     

Adamantinoma of the proximal femur: a case report

Adamantinoma is a rare low-grade malignant bone tumor with an indolent course. The tibia is involved in 85%–90% of long-bone cases. We encountered a patient with primary adamantinoma of the proximal femur. A 60-year-old woman fell and fractured her proximal left femur in the area of a cystic lesion. She underwent an osteosynthesis procedure, and bone union was obtained. After 3 years she developed pain in the left thigh, and a radiographic abnormality was found at the fracture site. A metastatic bone tumor was suspected, and curettage and cementing were carried out. Histologically, we found an epithelial component but failed to detect any primary cancer. Local recurrence became evident after another 6 years. A marginal excision was performed and a bipolar femoral prosthesis was implanted. We finally diagnosed the patient with adamantinoma. In this report we describe the characteristics of this tumor and discuss the reasoning concerning the differential diagnosis and therapeutic plan.     

Late development of malignant fibrous histiocytoma at the site of a giant cell tumour 38 years after initial surgery

The authors report on a patient who developed a malignant fibrous histiocytoma at the site of a benign giant cell tumour, which had been treated by curettage 38 years previously. This latency period is, to their knowledge, the longest yet reported. This female patient was initially treated for a benign giant cell tumour of the proximal tibia when she was 33 years old; she underwent curettage and Kiel bone grafting. She had not received radiation therapy. Twenty eight years later, she underwent a second operation due to recurrence of a tumour. No specific histological diagnosis was possible: histology suggested a benign tumour, however compatible with a low-grade malignant potential but not associated with giant cell tumour. The patient underwent a third operation, with extensive curettage and total knee arthroplasty 38 years after the initial surgery, because of progressive knee pain. Postoperative histopathology study showed high-grade malignant fibrous histiocytoma. Finally, she underwent above-knee amputation because of uncontrollable progression of the tumour. The use of xenogenic bone graft, bone cement and associated bone necrosis potentially contributed to the development of a malignant tumour adjacent to the primary giant cell tumour.     

Lower extremity bypass graft occlusion after intramedullary fixation of intertrochanteric hip fracture on a fracture table

This article presents a case of a 90-year-old woman who previously underwent a common femoral to anterior tibial artery bypass grafting with a Gore-Tex graft (Gore Medical, Flagstaff, Arizona). She subsequently sustained an ipsilateral intertrochanteric hip fracture after a mechanical fall and underwent internal fixation with an intramedullary nail using a fracture table. In the immediate postoperative period, she developed limb-threatening ischemia in her leg due to graft thrombosis. The patient underwent a successful thrombectomy and embolectomy. However, she subsequently developed nonhealing ulcers to this extremity over the course of weeks, requiring surgical debridement. Gangrene ensued and she underwent a below-the-knee amputation.Complications from the use of fracture tables have been described for perineal soft tissue injury, leg malrotation or malalignment, neurologic injury, and iatrogenic compartment syndrome of the healthy leg. Arterial complications after intramedullary fixation of femur fractures are rare and may be caused by direct arterial trauma during placement of the locking screws through the intramedullary nail. This article is the first, to our knowledge, to describe an occlusion of a lower extremity bypass graft after intramedullary fixation on a fracture table. Surgeons should be aware of potential limb threatening ischemia in patients with peripheral vascular disease, especially in those with prior lower extremity bypass grafts. Proper preoperative counseling should be given to these patients when using fracture tables during hip fracture surgery.     

Surgical Management of Fifth Metatarsal Diaphyseal Fractures: A Retrospective Outcomes Study

Fifth metatarsal diaphyseal fractures are a common injury treated by foot and ankle surgeons. The limited data on this specific fracture type has promoted nonoperative treatment with immobilization. The primary objective of the present study was to record the radiographic healing time of fifth metatarsal diaphyseal fractures after surgical intervention and present the specific fracture characteristics. The medical records of a series of 64 patients with surgically managed fifth metatarsal diaphyseal fractures were retrospectively reviewed. The data collected consisted of radiographic healing times, fracture characteristics, and patient demographics. The mean average age at injury was 49.23 ± 15.35 years with greatest incidence in females at 73.44%. The mean healing time was 7.73 ± 4.74 weeks, with an overall complication rate of 6.25%. The fractures were classified into 2 specific categories according to the anatomic location. Type I fractures occurred in a significantly older population, were significantly longer in length, and healed faster. The mean displacement and angulation at injury was 3.20 ± 1.22 mm, and 5.89° ± 4.60°, respectively, for all fractures. Of the 64 patients, 1 (1.56%) experienced nonunion, 2 (3.13%) delayed unions, and no malunions. One patient (1.56%) underwent repeat operation for hardware removal. One case (1.56%) of superficial postoperative infection developed and was treated with oral antibiotics. We observed good surgical outcomes with minimal postoperative complications. We also identified 2 specific entities of fifth metatarsal diaphyseal fractures. On the basis of our results, we advocate surgical intervention even for minimally displaced diaphyseal fractures to maintain even weightbearing across the metatarsal parabola.     

Bourneville-Pringle disease for kidney transplantation: a single-center experience

The Bourneville-Pringle disease is an autosomal-dominant disease affecting the kidneys in about 60%, causing end-stage renal disease in about 10% of the cases. Among more than 2800 renal transplant recipients during the last 33 years, we had two patients with this original disease. A third patient who underwent bilateral nephrectomy is currently awaiting a graft. The first patient was diagnosed at the age of 20 years after a few episodes of retroperitoneal bleeding. At the age of 26 years her left kidney was removed after a rupture; it measured 7500 g, and the histology described angiomyolipomatosis. A year later she underwent a cadaveric kidney transplantation. Subsequently her right kidney was removed due to bleeding. She is currently 5 years posttransplant with stable kidney function and good health. Our second patient was nephrectomized at the age of 35 years and 38 years because of angiomyolipomatosis. She underwent a cadaveric kidney transplantation 7 years later. After 5 years of excellent kidney function and a year after her arteriovenous fistula was ligated her upperarm had to be amputated because of uncontrollable bleeding. After another 6 months, she displayed rapid progression of a jejunal tumor and during operation received 54 U of blood transfusion but died at the age of 49 years with a well-functioning graft. Our third patient consecutively underwent two nephrectomies because of angiomyolipomatosis of her kidneys at the ages of 25 and 28 years. She has two children with the same disease. In addition she carries Leyden mutation, which has caused deep venous thromboses and pulmonary emboli. She is currently on our waiting list for kidney transplantation. The Bourneville-Pringle disease is a rare indication for kidney transplantation; the prognosis of the patient is dependent on the original disease.     

Magendie's foramen debridement and catheterisation for the treatment of syringomyelia due to diffuse craniocervical junction arachnoiditis. A case report and technical note

A 36 year old woman was referred to our department for symptomatic lumbar spinal arachnoiditis following an epidural anaesthesia for childbirth. She did not had other known causative factor and she was free of any neurological symptoms before. She rapidly developed lower limbs impairment by compressing intradural lumbar collections and arachnoiditis requiring surgical decompression and subsequently internal cerebrospinal fluid shunting for acute hydrocephalus. Three years and the half later, she developed a severe tetraparesis due to a massive syrinx consecutive to the fourth ventricle outlets obstruction cause by the ongoing diffuse craniocervical junction arachnoiditis. Our aim was to treat all the problems in one step. An open fourth ventriculostomy of the Magendie's foramen with catheter insertion from the fourth ventricle down to the upper cervical subarachnoid space improve both the patient status and imagery.     

Bilateral atypical femoral fractures in a patient prescribed denosumab — A case report

Atypical fractures of the diaphyseal femoral shaft have been reported in the literature at an increasing rate over the past few years. They have been observed mostly in patients who have been on prolonged courses of bisphosphonates, with no reported cases of atypical femoral fractures in those treated with other anti-resorptive medications.A 59 year old woman sustained an atypical fracture of her right femur in March 2013. She had a past medical history of rheumatoid arthritis and osteoporosis. She had been on alendronate but it was discontinued after five years in 1999. She received denosumab by subcutaneous injection in December 2012. At follow up, she complained of pain in her left femur and a radiograph revealed atypical appearances. She was admitted in June 2013 for prophylactic nailing of the left femur.To our knowledge, this is the first reported case of bilateral atypical femoral changes in a patient prescribed denosumab. Given that denosumab has been on the market for a short time period, we expect that the number of these cases will increase with time. We emphasise previous guidance that patients who present with new onset hip or thigh pain should be screened for atypical femoral fractures.     

The Epidemiology of Metatarsal Fractures Among Older Females With Bisphosphonate Exposure

Bisphosphonates (BP) are used to treat osteoporosis, although rare atypical femur fractures have occurred with long-term exposure, especially among Asians. Metatarsal fractures have also been reported with atypical femur fracture. We examined the epidemiology of metatarsal fractures among 48,390 females aged ≥50 years who initiated oral BP and were followed for a median 7.7 years, including 68 females who experienced an atypical femur fracture. Incident metatarsal fractures after BP initiation were identified by clinical diagnoses and validated by record review. The association of BP, clinical risk factors, race/ethnicity, and metatarsal fracture was examined by using Cox proportional hazard analyses. Among 1123 females with incident metatarsal fracture, 61.0% had an isolated fifth metatarsal fracture. The incidence of metatarsal fracture was 312 per 100,000 person-years of follow-up and was substantially lower for Asians. The adjusted relative rate for metatarsal fractures was 0.5 (95% confidence interval 0.4 to 0.6) for Asians compared with whites. Younger age, prior fracture, other risk factors, and current BP were associated with an increased relative rate of metatarsal fracture, but BP duration was not. Females with atypical femur fracture were not more likely to experience metatarsal fracture (2.9% versus 2.3%, p = .7), but only 68 females had an atypical fracture and stress fracture of the metatarsals was not examined. Except for age, the demographic profile for metatarsal fracture after initiating BP was similar to that for osteoporotic fracture, with Asians at a much lower risk. Although metatarsal fractures were not associated with BP duration or atypical femur fracture, the subset of metatarsal stress fractures was not specifically examined.     

Duplication of hemi mandible and oral cavity, presentation of an adult patient--a case report.

We are present a case of duplication of hemi mandible and oral cavity in an adult patient. This is a very rare condition and each and every case warrants publication. This patient is unique in that she would not have presented for surgery if she was married. She presented at 30 years of age. The patient underwent radiological investigations using CAT scan, orthopantogram and routine X-ray films. She was operated on with an elliptical incision around the swelling, excising the whole of the duplicated mandible along with other associated structures such as a salivary gland and the branchial cyst present along with it. Postoperatively the patient had mild marginal mandibular weakness which recovered with time.     

Prophylactic intramedullary fixation for bisphosphonate-related subtrochanteric stress fracture

Bisphosphonates are the most widely used medication to treat osteoporosis. Recent reports have documented an association between chronic bisphosphonate use and femoral insufficiency fractures. This article describes an 84-year-old woman with a diagnosis of osteoporosis treated with bisphosphonate medications for 9 years. She presented with left groin pain, and magnetic resonance imaging revealed a subtrochanteric femoral stress fracture. Operative and nonoperative management was discussed with the patient, and she chose to undergo prophylactic intramedullary nailing of the left femur. Six months postoperatively, she was asymptomatic and ambulating without assistive devices.This article describes successful management of a bisphosphonate-related femoral insufficiency fracture. The presence of groin or thigh pain in a patient taking bisphosphonates should alert the physician to the possibility of insufficiency fracture of the proximal femur, and plain radiographs should be obtained. If these radiographs show lateral cortical thickening, consideration should be given to prophylactic intramedullary femoral nailing. The risks and benefits of prophylactic fixation vs conservative management should be discussed with the patient. A recent series showed a high failure rate with conservative treatment of these fractures. A dialogue with the primary care physician should be initiated to determine the necessity of bisphosphonate therapy, and, if deemed necessary, an alternative class of medications should be considered.     

Two cases of primary urethral carcinoma in females

Two cases of primary female urethral carcinoma are presented and discussed. The patients were 70 years old and 65 years old, and the pathological diagnoses were squamous cell carcinoma and adenocarcinoma, respectively. The patient with squamous cell carcinoma had metastasized inguinal lymph nodes at the first consultation, despite the administration of bleomycin, and the tumor had widely metastasized to skin of the lower extremities. She died of cachexia and disseminated intravascular coagulopathy (DIC). The other patient with adenocarcinoma was treated by postoperative cobalt radiation therapy in a total dose of 6,000 rads. After 18 months, she had recurrence of tumor in urethra, and developed Virchow's node metastasis, she died of acute renal failure. Both patients died within two years.     

Cerebral arterial air embolism associated with pneumothorax in a patient with pressure support ventilation

A 20-year-old woman was admitted to the ICU following a road traffic accident. She had a periorbital haematoma with a normal cerebral state on CT-scan, intrahepatic and intrasplenic haematomas and several fractures of the limb that were fixed on day 3. Twenty-four hours later, she developed a cough with symptoms of decerebration The head CT-scan showed diffuse pneumocephalus suitable with cerebral air embolism and the chest X ray a right tension pneumothorax. A chest tube was inserted. Despite the lack of hyperbaric oxygen therapy the patient recovered fully. The pneumocephalus disappeared totally after 48 hours. Seven days later, CT-scan of the head with coronal slides showed an orbital floor fracture associated with an intra-orbital aerocele.     

Bilateral pathological sub-trochanteric fracture in a long-term biphosphonate user

The number of papers reporting the occurrence of specific pathological fractures in long-term biphosphonate users has recently increased. They refer to the forms of stress fracture probably resulting from an extreme decrease in bone turnover, which may involve sub-trochanteric or isolated transverse fractures, or short transverse fractures with a unicortical beak in an area of cortical hypertrophy. At the time of prodromal signs and symptoms, cortical bone at the site of impeding fracture appears rougher on radiographs. Gradually, an incomplete fracture develops, with a subsequent complete fracture often sustained without any mechanism of injury noted. The occurrence of such fractures is reported in the range of 2 to 8 years from the start of biphosphonate use. The fractures are often bilateral and, at the time the first occurs, it is often possible to diagnose contralateral pathological changes similar to those before the first fracture. The paper presents the case of a female patient who sustained a bilateral pathological sub-trochanteric fracture; the first fracture occurred after 5 and the other after 9 years of Rizendronat use. She was followed up for unilateral incomplete sub-trochanteric fracture from the fourth year of its use. In that period, magnetic resonance imaging showed a pathological finding in the contralateral extremity. She had already had prodromal signs manifested as lasting hip pain before the first fracture. Both fractures were surgically treated. Thirty-three months later she had to undergo repeat surgery for pseudoarthrosis at the site of the first fracture. The pseudoarthrosis healed without complications. However, in the second fracture non-union was still present at 7 months after surgery. The patient took Rizendronat during the whole treatment period and thereafter. In the discussion, certain aspects of long-term biphosphonate use are addressed, as well as some preventive, diagnostic and therapeutic procedures related to this rare complication.