Bilateral Triple Talocalcaneal,Calcaneonavicular, and Talonavicular Tarsal Coalition: A Case Report

We report a rare case of a female, aged 42 years, with symptomatic bilateral triple tarsal coalition, that is, talocalcaneal, calcaneonavicular, and talonavicular tarsal coalition. The patient was treated conservatively by adjusting her activities. At the 12-month follow-up, the patient was asymptomatic. Bilateral triple tarsal coalition is a rare disorder, especially in nonsyndromic patients. The purpose of this case report was to highlight this rare type of multiple bilateral tarsal coalitions and to discuss the relevant existing literature.     

Technique Article: Tarsal Coalition Resection Using Kirschner Wires Across the Subtalar Joint in a Two-Incision Approach

Subtalar coalitions are a significant cause of morbidity, especially in the pediatric population. Arthrodesis was considered the standard of care, with coalitions involving >50% of the joint until the mid-1990s. Today, some are recommending resection of the coalition first and to save hindfoot arthrodesis as a salvage procedure. As a result, resection of talocalcaneal coalitions is becoming more common, and optimizing the surgical technique is a necessity in the field of orthopedics. We present a technique to optimize surgical resection of talocalcaneal coalitions by using Kirschner wires inserted from the lateral side, which allows us to demarcate the coalition. This gives us a greater ability to perform a more complete resection and also helps prevent iatrogenic trauma to the articulating surface.     

An Unexpected Intra-operative Encounter of Anterior Tibial Vessels Entrapment in the Fracture of Tibial Pilon: A Case Report and Literature Review

We present a rare case of a comminuted tibial pilon fracture with entrapment of anterior tibial vessels in fracture site, which was unexpectedly discovered intra-operatively. Following safe extrication of vessels and fracture fixation through minimally invasive approach, the patient recovered uneventfully. Phenomenon of anterior neurovascular entrapment should be kept in mind while dealing with high-energy tibial pilon fractures. Astute clinical examination, judicious use of imaging modality, and strict intra-operative vigilance are key to successful outcome.     

Calcaneus Secundarius Presenting as Calcaneonavicular Coalition: A Case Report

Calcaneus secundarius is an accessory ossicle of the anterior calcaneal facet identified in up to 5% of the population. Calcaneus secundarius rarely leads to symptoms, but its presence may generate pain around the ankle. The purpose of this case report is to describe this atypical accessory ossicle, which can mimic a calcaneonavicular coalition, and to explain the clinical approach to reach a diagnosis and determine treatment. The authors report the case of a 13-year-old girl who sustained several lateral sprains of the right ankle and had local chronic pain. Clinical findings were consistent with calcaneonavicular coalition but radiographic examinations revealed a calcaneus secundarius. The location of this ossicle may limit the range of motion of the subtalar joint, mimicking a calcaneonavicular coalition. Surgical excision of this bulky accessory ossicle was performed, and this treatment fully resolved the pain and improved subtalar motion.     

Open Talar Neck Fracture With Medial Subtalar Joint Dislocation: A Case Report

We present a unique case of an open talar neck fracture with medial subtalar joint dislocation. This rare and traumatic injury was treated with immediate open reduction of the subtalar joint and open reduction internal fixation of the talar neck fracture. After a follow-up of 2.2 years, highlighted by numerous complications including posttraumatic arthritis, soft tissue abscess, and fibrotic adhesions, the patient recovered sufficiently to return full activity.     

Calcaneal Apophyseal Fracture Followed by Subtalar Joint Instability in a Young Female: A Case Report

Calcaneal apophyseal fractures are usually considered sport-related injuries. Previous repetitive microtrauma has been proposed as a predisposing factor for such injuries. However, unlike previously reported cases, in our patient, the fracture resulted from acute trauma after stepping on uneven ground. Although the first treatment option for such cases is closed reduction, most cases will require surgical treatment. Furthermore, lesions accompanying this injury have not been sufficiently considered. We report the case of a 9-year-old female with a calcaneal apophyseal fracture treated by fixation of the avulsed proximal part of the apophysis using Kirschner wires and a cerclage wire. However, subsequently, instability developed in the subtalar joint. Fifteen months after the first osteosynthesis, surgery was performed to fixate the subtalar joint and secure the insertion region of the tendo calcaneus. After the first surgery, subtalar joint instability might have developed because of simultaneous disruption of the subtalar ligaments at the initial injury. Subsequently, the instability could have caused failure of the first fixation. Debridement and fixation of the subtalar joint in the second surgery provided a stable subtalar joint. A calcaneal apophyseal fracture might be associated with additional injuries at the hindfoot. Before treating these cases, other injuries that might be obscured by the more apparent injuries should be considered. Accompanying soft tissue injuries, such as subtalar joint ligament lesions, can be revealed with magnetic resonance imaging evaluation. To the best of our knowledge, this is the first report of an apophyseal fracture of the calcaneus followed by subtalar joint instability.     

Osteochondritis Dissecans of the Talus Involving the Subtalar Joint: A Case Report

Osteochondritis dissecans can affect any joint, although the ankle is the third most common location after the knee and elbow. When the ankle is involved, the lesion usually affects the talar dome. The authors report a case of osteochondritis of the subtalar joint affecting the talus in a 14-year-old girl without any history of trauma. Plain radiographs did not show any bony pathology, and the diagnosis was made with computerized tomography. The patient was treated initially in a non-weight bearing plaster cast with antiinflammatory medication and subsequent physiotherapy. The conservative treatment failed to relieve her symptoms, and she underwent subtalar arthroscopy followed by surgical excision, curettage, and drilling through a mini-arthrotomy. Postoperatively, the patient was managed with protected weight bearing and physiotherapy. A year after surgery, she had returned to her routine activities, including sports, with no further complaints related to the affected foot.     

Ankle and Subtalar Synovitis in a Ball-and-Socket Ankle Joint Causing Posterolateral Painful Coarse Crepitus: A Case Report

A 17-year-old girl with bilateral ball-and-socket ankles reported left medial heel pain. Her left heel had gone into a varus position on tiptoeing, and a painful clunk had occurred when returning to normal standing. The clunk persisted after physiotherapy and treatment with an orthosis. Subtalar arthroscopy and peroneal tendoscopy showed mild diffuse synovitis of the ankle joint, especially over the posterior capsule, and a patch of inflamed and fibrotic synovium at the posterolateral corner of the subtalar joint. The clunk subsided immediately after arthroscopic synovectomy and had not recurred during 5 years of follow-up. We found no other reported cases of ankle and subtalar synovitis occurring in patients with a ball-and-socket ankle joint.     

Cystic Adventitial Disease of the Tibial Vein Arising From the Subtalar Joint: A Case Report

Soft tissue ganglion cysts are a well-known cause of tibial nerve compression in the tarsal tunnel. We describe a patient who presented with tibial nerve symptoms and was found to have an adventitial cyst of the tibial vein arising from the subtalar joint, with the joint connection confirmed both on imaging and at surgery. Surgical decompression of the cyst with transection of the vascular pedicle arising from the subtalar joint improved her symptoms at 6 months, and postoperative magnetic resonance imaging showed resolution of the cyst. Cystic adventitial disease is a rare, poorly understood condition in which a cyst is identified in the adventitia of a vessel, usually an artery. Only 3 cases of adventitial cysts have been reported in the foot and ankle region, 2 in the lesser and 1 in the greater saphenous vein. None of the previous cases have been recognized to be joint connected. This case provides additional evidence for an articular origin for adventitial cysts and helps guide management strategies for these joint-connected cysts.     

Post-Traumatic Periprosthetic Tibial and Fibular Fracture After Total Ankle Arthroplasty: A Case Report

Periprosthetic fractures after total ankle arthroplasty are uncommon, with most cases occurring intraoperatively. We describe a post-traumatic periprosthetic fracture of the distal tibia and fibula after total ankle arthroplasty that was treated with minimally invasive plate osteosynthesis. It is important for orthopedic surgeons not only to recognize the risk factors for postoperative periprosthetic total ankle arthroplasty fractures, but also to be familiar with the treatment options available to maximize function and minimize complications. The design of the tibial prosthesis and surgical techniques required to prepare the ankle joint for implantation are important areas of future research to limit the risk of periprosthetic fractures.     

Irreducible Fracture Dislocation of a Finger Metacarpophalangeal Joint: A Case Report

A case of unusual displacement in a finger, with an avulsion fragment from the dorsal metacarpal head of the finger displaced in the palmar direction under the volar plate is described. An 18-year-old woman presented with complaint of difficulty flexing the metacarpophalangeal (MP) joint of the right little finger after a fall onto the outstretched hand. Three-dimensional computed tomography (CT) was useful for diagnosing this condition. Use of both palmar and dorsal approaches was needed to reduce the displacement and to fix the bones with a single screw. Bone union was achieved, and the patient has been asymptomatic for more than 10 months.     

Posterior Tibial Nerve Lymphoma Presenting as Tarsal Tunnel Syndrome: A Case Report

We report a case of isolated posterior tibial B-cell lymphoma of the posterior tibial nerve presenting as tarsal tunnel syndrome. This diagnosis was considered because of the clinical presentation and electrophysiologic abnormalities. It was further confirmed by the magnetic resonance imaging findings of the ankle and tissue pathologic findings. Whole body positron emission tomography confirmed this to be a localized lymphoma involving the peripheral nerve. The patient underwent chemotherapy with complete tumor resolution. She had had no relapse after 8 months of follow-up. Isolated peripheral nerve lymphomas are very rare, and involvement of the posterior tibial nerve has not been previously reported. Furthermore, the present case report highlights the importance of the clinical examination in the diagnosis of tarsal tunnel syndrome before performing surgical decompression.     

Incidental Finding of Multiple Synchronous Neoplasms in Explanted Liver After Transplantation: A Case Report

Liver transplantation is the only potentially curative treatment for patients with end-stage liver disease. After the procedure, histopathologic analysis of the liver explant may reveal neoplasms that were not previously diagnosed in preoperative imaging examinations. This incidental finding of primary liver neoplasms in the explant is not an uncommon situation in liver transplant, and hepatocarcinomas and cholangiocarcinomas are the types of tumors most frequently encountered in this scenario. These are the most common primary neoplasms of the liver, and liver transplantation is often a curative treatment for these types of tumors when they are in their earlier stages. In contrast, liver plasmacytoma is a rare type of plasma cell neoplasm, consisting of a single mass of monoclonal plasma cells, which is treated primarily by radiotherapy and is seldom encountered in the setting of liver transplant. We report the case of a patient who underwent liver transplantation for the treatment of cryptogenic cirrhosis, with no preoperative diagnosis of liver tumors. Analysis of the liver explant revealed the presence of three synchronous neoplasms with different histologic origins: a 27-mm hepatocellular carcinoma, a 17-mm intrahepatic cholangiocarcinoma, and a 25-mm solitary hepatic plasmacytoma. The patient received no further adjuvant treatment and remained well and with no signs of disease recurrence over an observation period of 44 months. We found no previous report in the literature of the synchronous presence of these three types of liver neoplasms.     

Dorsal Dislocation of the Intermediate Cuneiform with Fracture of the Lisfranc Joint: A Case Report

Tarsal cuneiform dislocation in association with Lisfranc fracture-dislocation is a rare pedal injury. In this report, we describe the case of a patient who sustained a dorsal dislocation of the intermediate cuneiform in association with tarsometatarsal fracture-dislocation following traumatic axial loading and torsion of his foot. A satisfactory outcome was achieved by treating the injury by means of closed reduction and percutaneous Kirschner wire fixation. ACFAS Level of Clinical Evidence: 4.     

Modified Dwyer Osteotomy with Rotation and Reinsertion of Autograft Bone Wedge for Residual Heel Deformity Despite Previous Delayed Subtalar Joint Arthrodesis After Calcaneal Fracture

Calcaneal fracture patterns vary widely, and many factors determine the type and timing of the treatment rendered. Severe calcaneus fractures involving joint damage, loss of heel height, and varus deformity of the tuberosity are ideally treated with open reduction and internal fixation to repair the joint surface and re-establish anatomic structure. This is not always possible owing to delayed presentation, soft tissue compromise, unrelated injuries, unstable medical condition, or lack of expertise by the treating physician. We present the case of a patient who had residual forefoot and rearfoot deformity despite undergoing delayed subtalar joint arthrodesis at an outside hospital 10 years before for a calcaneal fracture that was initially treated nonoperatively. At 4 years of follow-up after modified Dwyer calcaneal osteotomy with rotation and reinsertion of the autograft bone wedge and Cotton midfoot osteotomy, the postoperative gait was relatively normal, other than the expected lack of hindfoot mobility. The lateral column pain was resolved. The patient remained highly satisfied with the outcome at long-term follow-up of 48 months, with improved heel alignment, lack of a wide stance gait, a functional medial column, and a relatively normal gait. This case demonstrates the value of periarticular calcaneal osteotomies without the need to revise the subtalar joint arthrodesis for this challenging clinical situation.     

Massive Osteochondral Lesion of the Talus in a Skeletally Immature Patient Associated With a Tarsal Coalition and Valgus Hindfoot

Rarely, osteochondral lesions of the talus occur without a history of trauma. Accurate interpretation of the mechanical load distributions onto the ankle leading to potential atraumatic cartilage damage must always be studied. The published data on the optimal treatment of talar osteochondral lesions in skeletally immature patients are scarce, especially when the lesions are associated with hindfoot malalignment. We describe the case of a pediatric female with an atraumatic osteochondral lesion of the talus associated with a talocalcaneal coalition and a valgus hindfoot, which we consider the first case to be reported. She presented with prolonged bilateral ankle pain and catching during gait of approximately 2 years’ duration with a restricted range of motion, with the pain more excruciating in the right ankle. Radiographs revealed a large osteochondral lesion located at the lateral talar dome. The patient underwent partial osteochondral allograft transplantation, together with hindfoot realignment and coalition resection with a fat graft interposition. At the 2-year follow-up examination, the patient was free of pain in her right foot and ankle, with no signs of radiologic failure.     

Synovitis of the Tarsal Canal: An Uncommon Cause of Lateral Heel Pain After Triple Arthrodesis

Lateral heel pain after triple arthrodesis can have numerous causes, including nonunion of the fusion site, hindfoot malalignment, degenerative arthritis in adjacent joints, and deep infection. We present a case of lateral heel pain after triple arthrodesis due to synovitis of the tarsal canal that was successfully treated with anterior subtalar arthroscopy.     

Pseudotumor After Metal Fixation of a Fracture Surgery: A Case Report

The present report describes an unusual complication after surgical treatment of a femoral fracture. Metal particles, produced by mechanical damage to an intramedullary rod by the insertion of screws perpendicular to the rod, were found to have initiated a tumor-like change in the soft tissues 4 years after removal of the metal implants. Conventional X-ray, angiography and CT-scan showed adjacent to the healed fracture a large tumor mass, which was interpreted as a soft tissue sarcoma. However, histopathological assessment revealed extensive necrotic changes around scattered metal particles in the biceps femoris muscle, which may be assumed to have been induced either chemically or bacterially.