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[This retracts the article DOI: 10.7759/cureus.953.]., Competing Interests: No competing interests declared.

Mucoid degeneration and ganglion cyst are two distinct non-traumatic lesions of the anterior cruciate ligament (ACL) that most commonly occur discretely but occasionally coexist. They are relatively uncommon, and their exact aetiopathogenesis is still not clear. ACL ganglion cyst occurs more frequently among relatively younger patients compared to mucoid degeneration. They could be asymptomatic and discovered incidentally while evaluating the knee for other pathologies. Symptomatic cases of the two conditions present with nonspecific chronic pain, painful limitation of terminal flexion and extension, and mechanical block (among other symptoms), similar to that of other internal derangement pathologies of the knee. Magnetic resonance imaging is the investigation of choice, and diagnostic criteria are defined. Arthroscopic management of these conditions efficiently provides an improvement in symptoms without instability. Computed tomography scan guided aspiration is also useful in selected cases of ACL ganglion cyst. ACL ganglion cyst and mucoid degeneration should be considered in the differential diagnosis of chronic knee pain and stiffness of unspecified etiology., Competing Interests: The authors have declared that no competing interests exist.

With the improvement in outcomes and modern prosthesis design, total knee arthroplasty (TKA) has now become a commonly performed surgery. It is postulated that a total of 2-5% of the primary and revision TKA becomes infected every year, requiring a revision procedure which to date is the conventional two-stage revision. The diagnosis and treatment of these periprosthetic infections is a major and challenging task, as it requires precise identification of the pathogen, meticulous debridement, and postoperative rehabilitation. To date, there have been very few studies in existing literature comparing the outcomes of single-stage versus two-stage procedure in infected TKA. The aim of the review was to provide the clinicians an insight into the outcome of the single-stage procedure compared to two-stage procedures and to suggest ways to improve the results further. In the following critical review, a total of 669 cases that underwent either a single or two-stage revision for infected TKA were studied. The postoperative functional scores were comparable in most studies during the early postoperative period. Our data supports the use of a single-stage revision surgery in infected TKA as an alternative to a conventional two-stage procedure. However, larger prospective and multicentric trials are required to validate our findings., Competing Interests: The authors have declared that no competing interests exist.

A cortical lesion of the tibial diaphysis in a young patient poses a diagnostic challenge to the clinician. Brown tumors, although not very common, may mimic malignancies on radiographs. Brown tumors are destructive lytic lesions of the bone due to increased osteoclastic activity and fibroblastic proliferation in patients with uncontrolled hyperparathyroidism (HPT). They occur after primary or secondary HPT due to renal failure but very rarely due to vitamin D deficiency. We report a rare case of a brown tumor of tibial diaphyses in a young female patient mimicking a locally aggressive tumor with secondary HPT due to a severe vitamin D deficiency. The effect of hyperparathyroidism on bone metabolism is clinically worse in the presence of vitamin D deficiency and, hence, it predisposes patients to brown tumors that can affect any bone in the body. They can be managed conservatively but may require prophylactic fixation in particular cases., Competing Interests: The authors have declared that no competing interests exist.

Simultaneous bilateral intertrochanteric fractures are very rare, and only a few cases have been reported in the literature. They usually result from severe trauma. They are serious injuries with high morbidity and mortality rates. Successful management of these patients involves adequate resuscitation, treatment of associated injuries, early single-stage stable fixation, and good rehabilitation. We report the case of a 47-year-old male who presented with a simultaneous bilateral intertrochanteric fracture along with associated injuries following a car crash., Competing Interests: The authors have declared that no competing interests exist.

Bifidobacterium sp. are anaerobic, Gram-positive, short, irregular rods with rudimentary branching. These organisms are reported to be associated with health benefits and their significance as a pathogen is not much reported. We are reporting two cases of mixed pyogenic infections due to Bifidobacterium sp. In the first patient, the infection mimicked tubercular bone infection. The second patient was a case of hydronephrosis with double J (DJ) stent blockage. In both cases,  Bifidobacterium sp. was isolated in combination with Escherichia coli from the evacuated pus samples. The factors which contributed significantly for detecting Bifidobacterium sp. were gram stain examination, use of rapid and automatic anaerobic cultivation system (Anoxomat, MART Microbiology B.V., The Netherlands), and quick identification by MALDI-TOF (Matrix-Assisted Laser Desorption-Time-of-Flight) Mass Spectrometry (Biomerieux, France). Both strains were found to be resistant to metronidazole and both patients showed a good clinical response to treatment with beta-lactam antibiotics. So, we highlight the importance of seeking Bifidobacterium species in all clinical pyogenic samples., Competing Interests: The authors have declared that no competing interests exist.

Bilateral revision total knee arthroplasty (TKA) is a surgical procedure, which is rarely done simultaneously as it is a difficult surgery and the safety of simultaneous bilateral single stage surgery remains unknown. We report a case of a 67-year-old woman who presented to us with bilateral painful and unstable TKA (right > left) of six months duration. The primary bilateral TKA were done 14 years ago. Bilateral simultaneous revision TKA was performed, using cemented, constrained, long-stem prostheses. The intraoperative and postoperative periods remained uneventful. At last follow-up at four years, she had a pain-free range of motion of up to 0-115°, and the patient had returned to the activities of daily living. She had stable knees with good function and no evidence of loosening or wear., Competing Interests: The authors have declared that no competing interests exist.

Patellar instability is a known but catastrophic complication after total knee arthroplasty (TKA). The occurrence of bilateral dislocation of the patella after TKA is exceedingly rare. It may present as anterior knee pain, and diagnosis can easily be made clinically or by plain radiographs. Early diagnosis with surgical realignment and repair of the extensor mechanism can provide good outcomes after this complication., Competing Interests: The authors have declared that no competing interests exist.

Background: Displaced Colles' fractures are treated by manipulation and below elbow cast application. Malunion is a common complication, resulting in pain, mid-carpal instability, and post-traumatic arthritis. Fracture stabilization by percutaneous pinning is a simple, minimally invasive technique that helps prevent displacement of the fracture, thereby minimizing complications. This study aims to assess the amount of collapse after closed manipulation and percutaneous pinning with Kirschner wires (K-wires) and its correlation with the functional outcome of the wrist after union., Methods: A prospective study was conducted from May 2015 to May 2016 in a tertiary orthopedic center. Ninety patients (60 females, 30 males) with an average age of 54.93 years with Type II fractures underwent closed manipulation and percutaneous pinning with crossed K-wires as the primary procedure. Serial radiographs were taken to document the amount of collapse. The functional outcome was assessed using the Cooney Wrist Score., Results: At the final follow-up at six months, the collapse in the mean dorsal angle was 0.94 and mean ulnar variance was 0.51. Functionally, 48 patients (53.33%) had an excellent outcome, 36 patients (40%) had a good outcome, and six patients (6.67%) had a fair outcome., Conclusions: Displaced Colles' fractures should be reduced and stabilized with percutaneous K-wires to achieve an excellent functional outcome., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Fractures of the medial humeral epicondyle represent approximately 10% of all pediatric elbow fractures. Surgically treated pediatric fractures of the medial humeral epicondyle were analyzed retrospectively for their epidemiological, clinical, radiological and surgical parameters. The evaluation includes the Mayo elbow performance score (MEPS)., Methods: Twenty-five surgically treated fractures of the medial humeral epicondyle were analyzed. A valgus stress test was performed under general anesthesia or sedation. All patients underwent open reduction internal fixation using a similar technique. The medial epicondylar fragment was anatomically reduced and fixed in all cases with screws and Kirschner wires. At final evaluation, union was assessed radiologically, and elbow function was assessed by MEPS., Results: An evaluation of all our patients after a mean follow-up of 8.75 months (SD=4.76) after initial surgery was possible. The mean age of patients at the time of injury was 10.8 years (SD=2.3). Fifteen (60%) dominant elbows were injured in our study and twelve (48%) elbows had an associated elbow dislocation. On examination in the operating room post anesthesia, all the elbow injuries revealed some degree of valgus instability. All our patients (n=25) showed good to excellent results in MEPS. Radiographically, union was achieved in all cases. Three patients developed postoperative ulnar nerve neuropraxia; all recovered at time of final follow-up., Conclusion: Our results suggest that open reduction internal fixation of displaced medial epicondyle fractures leads to satisfactory motion and function. A valgus stress test in the operating room can reveal the true nature of joint instability that can warrant operative stabilization of medial epicondylar injuries., Competing Interests: The authors have declared that no competing interests exist.

Background: Tennis elbow is a common disorder of the upper extremity. It can be treated conservatively in the majority of patients, but some resistant cases eventually can be treated by percutaneous release with good functional outcome., Materials and Methods: This non-randomized control trial was conducted at the Department of Orthopaedics Surgery in a tertiary care hospital from July 2015 to June 2016 on 50 patients who underwent percutaneous release of the common extensor origin using an 18 gauge hypodermic needle. These patients did not respond to conservative treatment including rest, nonsteroidal anti-inflammatory drugs (NSAIDS) and local steroid injections. The outcome was graded as Excellent, Good, Fair, and Poor., Results: Fifty patients (50 elbows) were included in the study. Thirty-two patients were female (64%), and 18 were male (36%). The right side was affected in 37 patients (74%) and left side in 13 (26%). The time taken to achieve a completely pain-free elbow ranged from one day to two months (average of 26.2 days). Those who did not achieve a pain-free elbow had a residual pain of 1.5 to six on the visual analogue scale (VAS) (average 2.32). Excellent outcome was noticed in 24 patients (48%); Good result in eight patients (36% ); Fair in four patients (eight percent) and Poor in four patients (eight percent)., Conclusion: Tennis elbow probably results from the degenerative tear of the common extensor origin, and a percutaneous tenotomy using an 18 gauge hypodermic needle is a simple, safe, patient-friendly, efficient, and easily reproducible method of treating tennis elbow in those who are resistant to conservative treatment, and it can be done as an outpatient procedure., Competing Interests: The authors have declared that no competing interests exist.

Although it is common for separate elbow joint dislocation and fracture of forearm bones to occur, it is a rare sighting for both elbow dislocation and ipsilateral fracture of the distal radius. We report a case of an anterior dislocation of the elbow with ipsilateral fracture of the distal radius. The case was treated operatively. We describe two possible mechanisms of injury for these rare injury types. The case underlines the importance of assessing the wrist in the case of an elbow fracture and vice versa., Competing Interests: The authors have declared that no competing interests exist.

Haglund's deformity was first described by Patrick Haglund in 1927. It is also known as retrocalcaneal exostosis, Mulholland deformity, and 'pump bump.' It is a very common clinical condition, but still poorly understood. Haglund's deformity is an abnormality of the bone and soft tissues in the foot. An enlargement of the bony section of the heel (where the Achilles tendon is inserted) triggers this condition. The soft tissue near the back of the heel can become irritated when the large, bony lump rubs against rigid shoes. The aetiology is not well known, but some probable causes like a tight Achilles tendon, a high arch of the foot, and heredity have been suggested as causes. Middle age is the most common age of affection, females are more affected than males, and the occurence is often bilateral. A clinical feature of this condition is pain in the back of the heel, which is more after rest. Clinical evaluation and lateral radiographs of the ankle are mostly enough to make a diagnosis of Haglund's syndrome. Haglund's syndrome is often treated conservatively by altering the heel height in shoe wear, orthosis, physiotherapy, and anti-inflammatory drugs. Surgical excision of the bony exostoses of the calcaneum is only required in resistant cases., Competing Interests: The authors have declared that no competing interests exist.

Total knee replacement (TKR) comprises a significant, growing aspect in the management of patients with advanced arthritis of the knee for which conservative medical therapy has failed. Obesity, a rising epidemic, is considered an important independent risk factor in the development of osteoarthritis (OA). An aging population and increasing incidence of obesity contribute to a higher prevalence of OA and a subsequent greater need for TKR. The numbers of morbidly obese (MO) people undergoing TKR has consistently been rising. However, there have been concerns among patients and surgeons about the outcomes and complications of TKR in MO patients, especially given the morbidities associated with obesity. The goal of this systematic review was to assess relevant, up-to-date data on the safety, outcomes, and complications associated with TKR in MO patients., Competing Interests: The authors have declared that no competing interests exist.

Osgood-Schlatter disease (OSD) is a condition in which the patellar tendon insertion on the tibial tuberosity becomes inflamed. It is a well-known condition in late childhood characterized by pain and a bony prominence over the tibial tuberosity. The pain is usually exacerbated by physical activities like running, jumping, and climbing stairs. In the acute stage, the margins of the patellar tendon become blurred in radiographs due to the soft tissue swelling. After three to four months, bone fragmentation at the tibial tuberosity is viewed. In the sub-acute stage, soft tissue swelling resolves, but the bony ossicle remains. In the chronic stage, the bone fragment may fuse with the tibial tuberosity which can appear normal. The primary goal in the treatment of OSD is the reduction of pain and swelling over the tibial tuberosity. The patient should limit physical activities until the symptoms are resolved. In some cases, the patient should restrict physical activities for several months. The presence of pain with kneeling because of an ossicle that does not respond to conservative measures is the indication for surgery. In these cases, the removal of the ossicle, surrounding bursa, and the bony prominence is the treatment of choice., Competing Interests: The authors have declared that no competing interests exist.

Open segmental fractures of both bones of the forearm with the loss of the middle segment of the radius is a rare injury in children. An eight-year-old boy presented to our clinic four days following a road traffic accident. The child's mother was carrying a 12-cm long extruded and soiled segment of the radius bone. The extruded bone segment seemed necrotic, and we decided not to use it for replantation. The wound over the forearm fracture was infected. It was debrided and regularly dressed until it became healthy. We planned to use a fibular graft for the gap and to fix the graft with a Kirschner wire (K-wire). The operation was delayed due to the poor wound condition. At the four-week follow-up, we noticed unexpected signs of bone regeneration in the bone defect of the radius. After eight weeks, a complete spontaneous reconstruction of the bone was noted. This case highlights the excellent healing potential of the bones in children, where even if a long segment of the bone is lost, we can expect spontaneous complete regeneration of the bone if the periosteum is intact and continuous., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Ganglion cysts are benign soft tissue swellings commonly found in the wrist. The presence of these cysts in the elbow is uncommon, and few case reports have been reported for this condition at this location. These lesions can compress on the neighbouring structures or cause restriction of the joint movement. The awareness of this entity is a must, to arrive at an early diagnosis., Materials and Method: We report a patient with swelling in the anterolateral aspect of the elbow which had been causing intermittent pain for the last 13 months. The MRI revealed a fluid-filled cystic swelling which was communicating with the radio-capitellar joint., Results: The lesion was excised in toto, using anterolateral approach for the elbow, and sent for histopathological examination which confirmed the diagnosis of a ganglion cyst., Conclusion: Thus, due to the infrequent presentation, an awareness of this condition is necessary to prevent a delay in diagnosis and its subsequent management.

Giant Cell Tumour (GCT) of the distal fibula is extremely rare and poses challenges in the surgical management. Wide excision or intralesional curettage, along with adjuvant chemical cauterisation can prevent the recurrence of GCT. The excised bone gap needs reconstruction using tricortical iliac autograft and supportive plate fixation. In addition to wide excision, preservation of ankle mortise is advisable in locally aggressive and large lesions of the distal fibula. We report a GCT of the distal fibula in a young female patient. As part of the treatment, en bloc resection, chemical cauterisation with phenol, and distal fibula reconstruction with a tricortical iliac crest bone graft was done. Eighteen months after the treatment, the patient has no recurrence and her ankle is stable with full range of movement. We suggest this method to be worthwhile for the treatment of this uncommon lesion in quantifying recurrence and functional outcome.

Total hip arthroplasty (THA) in a patient with chronic lymphedema of both lower limbs is rarely reported in the literature. Chronic lymphedema is a challenging condition associated with various complications especially in a patient with THA. However, dislocation of the total hip prosthesis due to acute exacerbation of lower limb swelling in the postoperative period is an extremely rare complication. The cause that led to the dislocation of the prosthesis is intricate and difficult to assess, as this has not been discussed in the literature yet. We believe that the excessive weight of the limb due to chronic lymphedema had a deleterious effect on the biomechanics of total hip prosthesis, thereby increasing the tendency for dislocation. This case illustrates that chronic lymphedema of the lower limb should be dealt with aggressively using various modalities like intermittent pneumatic compression pumps and compression stockings after THA in such patients.

Pyrexia of unknown origin (PUO) in a patient with acquired immunodeficiency syndrome (AIDS) is a challenging clinical problem despite recent advances in the diagnostic modalities. The diagnosis of the cause of fever is especially difficult in the postoperative period as the focus remains on the operative site. We present an unusual cause of PUO in a patient with advanced HIV disease during an immediate postoperative period following total hip arthroplasty (THA) for osteoarthritis (OA) of the left hip. The fever started on the eighth postoperative day, and after an extensive workup to rule out infection it was found that the patient was allergic to sulfa drugs. The fever subsided after discontinuation of trimethoprim/sulfamethoxazole. Fever in an immunocompromised patient should not be attributed only to infection. A high index of suspicion along with careful history making is required to diagnose drug fever. An early diagnosis of drug fever can reduce hospital stay and the costs of investigations and treatment.

Heterotopic ossification (HO) is the abnormal development of bone within soft tissue. It is a frequent complication after traumatic as well as atraumatic central nervous system (CNS) insult. It has rarely been found to be associated with Guillain-Barré syndrome (GBS). Only a few cases of HO associated with GBS have been reported so far in medical literature. We present a 30-year-old female patient with severe bilateral knee stiffness following axonal polyneuropathy type of GBS that developed 10 months ago in her immediate post-partum period. She was put on mechanical ventilation for two weeks. She was diagnosed as HO based on clinical and radiological studies. This is an extremely unusual presentation of HO encircling both the knees following GBS without any other well-known risk factors. We have coined a new nomenclature-Heterotopic Ossification Circumferentia Articularis (HOCA)-for this type of presentation. In our patient, various factors such as prolonged ICU stay, mechanical ventilation, hypoxia, and long-standing hypomobility could be attributed to the development of this severe form of HO.

Extensor mechanism disruption following total knee arthroplasty (TKA) is a rare but devastating complication. These patients may require revision of the implants, but even then, it may not be possible to restore the normal function of the knee after the disruption. The patterns of extensor mechanism disruption can broadly be classified into three types: suprapatellar (quadriceps tendon rupture), transpatellar (patellar fracture), or infrapatellar (patellar tendon rupture). Infrapatellar tendon ruptures are the worst injuries, as they carry maximum morbidity and are challenging to manage. The disruption of the extensor mechanism may occur either intra-operatively or in the immediate postoperative period due to an injury. The treatment of extensor mechanism complications after TKA may include either nonsurgical management or surgical intervention in the form of primary repair or reconstruction with autogenous, allogeneic, or synthetic substitutes. We have provided an algorithm for the management of extensor mechanism disruption after TKA.

Fibrocartilaginous dysplasia (FCD) is a rare variant of fibrous dysplasia (FD) which frequently involves the long bones, and the proximal femur is the most commonly affected site. This benign, lytic, and expansile bone lesion causes progressive deformity in the bones and may lead to pathological fracture. Radiologically, this lesion may mimic cartilaginous benign and malignant bone tumors. Therefore, histopathological differentiation of FCD from other cartilaginous tumors is of the utmost importance. The treatment is often surgical, in the form of curettage and bone grafting or corrective osteotomy, to treat progressive deformity in the long bones. The risk of pathological fracture is high in FCD with bony deformity and often requires surgery.

'Brown tumors' are known as 'osteitis fibrosa cystica' or 'Von Recklinghausen's disease' of the bone. A high index of suspicion is required by the treating doctor for diagnosing a 'brown tumor' in its early stage. Clinical suspicion, along with laboratory and radiological investigations, is required to diagnose this condition. We present a case of a 65-year-old woman who had multiple bony lesions and a thyroid nodule, which was initially considered as a metastatic bone disease, but later turned out to be 'brown tumors.' In all cases with multiple osteolytic lesions, a possibility of 'brown tumor' must be kept in mind.

Anterior cruciate ligament reconstruction (ACLR) is an accepted and established surgical technique for anterior cruciate ligament (ACL) injuries and is now being practiced across the globe in increasing numbers. Although most patients get good to excellent results in the short-term after ACLR, its consequences in the long-term in prevention or acceleration of knee osteoarthritis (OA) are not yet well-defined. Still, there are many debatable issues related to ACLR, such as the appropriate timing of surgery, graft selection, fixation methods of the graft, operative techniques, rehabilitation after surgery, and healing augmentation techniques. Most surgeons prefer not to wait long after an ACL injury to do an ACLR, as delayed reconstruction is associated with secondary damages to the intra- and periarticular structures of the knee. Autografts are the preferred choice of graft in primary ACLR, and hamstring tendons are the most popular amongst surgeons. Single bundle ACLR is being practiced by the majority, but double bundle ACLR is getting popular due to its theoretical advantage of providing more anatomical reconstruction. A preferred construct is the interference fixation (Bio-screw) at the tibial site and the suspensory method of fixation at the femoral site. In a single bundle hamstring graft, a transportal approach for creating a femoral tunnel has recently become more popular than the trans-tibial technique. Various healing augmentation techniques, including the platelet rich plasma (PRP), have been tried after ACLR, but there is still no conclusive proof of their efficacy. Accelerated rehabilitation is seemingly more accepted immediately after ACLR.

Osteoarthritis of the manubriosternal joint is a rare cause of chest pain. The diagnosis is difficult, and other serious causes of chest pain have to be ruled out first. We report one case that was treated with fusion of the manubriosternal joint using an iliac crest bone graft with a cervical locking plate and screws with excellent results. Preoperative CT scan images were used to measure the screw length and the drill stop depth. In this case report, we have shown that arthrodesis can be an effective way of treating osteoarthritis of the manubriosternal joint when other measures fail. Furthermore, the use of a cervical locking plate with appropriate and careful preoperative planning affords a safe surgical technique, rapid pain relief, and ultimately, sound and asymptomatic union of the joint.

Sickle cell disease (SCD) is an inherited disorder of abnormal haemoglobin commonly encountered in the West African sub-region. It has varied osteoarticular and non-osseous complications that mimic some surgical conditions. The most common orthopaedic complications include avascular necrosis, osteomyelitis, septic arthritis, etc. A cautious and painstaking evaluation is required in handling these patients. Acute care and anaesthetic precautions are vital in ensuring an uneventful postoperative period.

The need for an ideal approach for the nonunion of the tibial shaft with anteromedial soft tissue scarring has long baffled surgeons. Many different approaches have been suggested in the past, but all those approaches were haggled by a multitude of problems. We have described a novel 'transfibular approach' for this selective situation. An appropriate patient with a mid-shaft tibial non-union was selected. After preoperative workup, the patient underwent an open reduction internal fixation (ORIF) with lateral tibial plating, bone grafting, and partial fibulectomy. In this new approach, the plane between tibialis anterior and extensor hallucis longus was used combined with a conventional posterolateral approach using the same incision. Subsequently, the patient was followed up for adequacy of the fixation and wound-related problems with a convincing outcome.

We report our experience of handling 80 major musculoskeletal injuries in a brief span of three days immediately after the major earthquake of Nepal in April 2015. Planning, proper utilization of resources, and prioritizing the patients for surgical intervention is highlighted. The value of damage control by orthopaedics in these disasters is discussed. Timely and appropriate surgical treatment by a skilled orthopaedic team not only can save these injured limbs but also the lives of the victims of a major disaster.

Giant cell tumor of the bone (GCTB) presents as a lytic lesion of epiphyseometaphyseal regions of the long bones usually during the second to the fourth decade with female predilection. Histologically, they are formed of neoplastic mononuclear cells with a higher receptor activator of nuclear factor kappa-B ligand (RANKL) expression responsible for the aggressive osteolytic nature of the tumour. RANKL helps in the formation and functioning of osteoclasts. A newer molecule, Denosumab, is a monoclonal antibody directed against RANKL and thus prevents the formation and function of osteoclasts. Management of refractory, multicentric, recurrent, or metastatic GCTB remains challenging as achieving a tumor-free margin surgically is not always possible. Denosumab may play a crucial role, especially in the management of such difficult lesions. We present three cases of locally aggressive GCTB (involving proximal humerus, sacrum, and proximal femur) that were treated and responded very well to Denosumab therapy.