Extraskeletal Myxoid Chondrosarcoma Identified in a Traumatic Fracture of the Toe: A Case Report

Introduction

Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft-tissue sarcoma that typically presents in the proximal lower extremity and limb-girdle. It can be easily misdiagnosed, especially when located in atypical locations like the foot.

Case Report

We present the case of an 80-year-old Caucasian female with a left 3rd toe pain and swelling that was initially misdiagnosed as a traumatic fracture on radiographs but later determined to be an indolent EMC based on histology. She was successfully treated with amputation of the toe.

Conclusion

EMC should be considered in the differential of osseous and soft-tissue abnormalities on radiographic imaging of the extremities. As reported in the literature, it can present in atypical locations with minimal symptoms and successful treatments include resection. Future cases presenting similarly should be evaluated for EMC and, if present, reported along with their applied treatment protocols to allow for further assessment of current therapeutic guidelines.

A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution

Background

Retrograde intramedullary nailing of the femur is a popular treatment option for femoral shaft fractures. However, this requires accessing the intramedullary canal through the knee, posing a risk of intra-articular infection. The purpose of this study was to examine the rate of intra-articular infection of the knee after retrograde nailing of femoral shaft fractures.

Methods

All patients who underwent retrograde intramedullary nailing for femoral shaft fractures between June 2004 and December 2017 at a level 1 trauma center were reviewed. Six months of follow-up or documented fracture union was required. Records were reviewed for documentation of septic arthritis of the ipsilateral knee during the follow-up period.

Results

A total of 294 fractures, including 217 closed and 77 open injuries, were included. Eighteen had an associated ipsilateral traumatic arthrotomy; 188 cases had an associated ipsilateral lower extremity fracture. No cases of septic arthritis were identified.

Conclusion

There were no cases of septic arthritis in 294 fractures treated with retrograde intramedullary nailing. Retrograde nailing appears safe for risk of postoperative septic arthritis of the knee even in the face of open fractures and traumatic wounds.

Infection of Baker's Cyst without Bacteremia, Sepsis, or Extraneous Source: A Case Report

Introduction

Baker's cysts are benign fluid-filled cysts that commonly form around knee joints which typically resolve spontaneously. Infection of baker's cysts is uncommon, but most often associated with septic arthritis or bacteremia. We describe a unique case of an infected Baker's cyst that presented without bacteremia, septic knee, or external source of infection. This is a rare manifestation that has not been described in the current literature.

Case Report

This is a case of a 46 year-old woman who developed an infected Baker's cyst without bacteremia or septic arthritis. She initially presented with the right knee pain, swelling, and limited range of motion. Blood work and synovial fluid aspiration of her right knee showed no source of infection. The patient subsequently developed erythema and tenderness over her right knee. This prompted MRI imaging that demonstrated a complex Baker's cyst. The patient later developed a fever, tachycardia, and worsening anion-gap metabolic-acidosis. Aspiration of the fluid collection was performed and revealed purulent fluid which grew pansensitive Methicillin-Sensitive Staphylococcus aureus, blood and knee aspiration cultures remained negative. The patient was treated with antibiotics and debridement procedures and her symptoms/infection resolved.

Conclusion

Given that isolated infections of Baker's cysts are rare, the localized aspect of this infection makes this case quite unique. Development of an infected Baker's cyst after negative aspiration cultures, combined with the presence of systemic symptoms including fever, without evidence of systemic spread, has not been seen before in the literature to our knowledge. The unique presentation of this case is important for future analysis of Baker's cysts as it introduces the possibility of localized cyst infections as a possible diagnosis for physicians to consider.

Biomechanical analysis of dual versus lateral locked plating in elderly bicondylar tibial plateau fractures: Does medial comminution matter?

OBJECTIVE

To assess dual plating versus lateral locked plate fixation of bicondylar tibial plateau fractures in an elderly cadaveric model with and without medial bone loss PARTICIPANTS: 10 pairs of elderly (range 78-93 years of age) fresh frozen tibias.

INTERVENTION

Bicondylar tibial plateau fractures were created reproducing AO/OTA 41 C1 (without medial bone loss) and C2 fractures (with medial bone loss). Cadavers were randomized to 4 different groups. Groups 1 and 2 were 41 C1 fractures and fixated with either dual or lateral plating, respectively. Groups 3 and 4 were fixated in a similar fashion with medial metaphyseal bone loss (41 C2 fracture) with dual plating Group 3 and lateral plating group 4. Lateral plating consisted of a 3.5 mm 5-hole lateral plate (ALPS, ZimmerBiomet) with 6 bicortical locking screws proximally and two diaphyseal screws. Dual plating groups underwent lateral plating and additional 3.5 mm 5-hole posteromedial 1/3 tubular plate (ZimmerBiomet) placed at the apex of the fracture with two shaft screws and one unicortical screw proximally. Specimens were tested in a Mechanical Testing System (MTS) machine loading both condyles.

OUTCOME MEASUREMENTS

Specimens were loaded to 300 N and coronal alignment obtained. Specimens were then cycled from 100 N to 700 N for 5000 cycles at 2 Hz. Average axial displacement, maximal displacement, average force and coronal alignment after 5000 cycles were recorded. Lastly, force to failure was recorded at 100 N/sec.

RESULTS

Mean axial displacement was 4.21 mm ranging from 3.12 mm in group 1 to 5.92 mm in group 4 (P = 0.51). Failure force averaged 3340 N ranging from 4342 N in group 1 to 2433 N in group 4 (P = 0.36). Maximal displacement ranged from 3.69 mm in group 1 to 7.37 mm in group 4 (P = 0.21). Change in coronal alignment ranged from 0.98° in group 1 to 1.97° in group 4 (P = 0.45). No statistically significant difference was noted between all four groups for all data points.

CONCLUSION

The results of this study demonstrate that a lateral locked plate may offer an alternative means of fixation in AO/OTA 41 C1 and C2 fractures.

Permanent reduction plate and intramedullary nailing of open tibia fractures: Do we need to take them out?

INTRODUCTION

Provisional reduction plating has been advocated as a reduction aid for tibial shaft fractures. Concerns regarding soft tissue stripping, infection, wound complications and nonunion have been postulated. Recent studies investigating reduction plating present patient cohorts where plates are removed or left to the discretion of the surgeon. This study aims to identify a cohort of open tibial shaft fractures treated with intramedullary nailing aided by permanent reduction plating. Our hypothesis is that permanent reduction plating in conjunction with intramedullary nailing of open tibia fractures does not increase risk of nonunion, infection or time to fracture union compared to intramedullary nailing alone.

METHODS

An IRB approved retrospective study was performed using trauma registry data from January 2014 to June 2018 at a Level 1 trauma center. Open AO/OTA 41A/42 A-C/43A tibial shaft fractures treated with intramedullary nail alone (IM) or intramedullary nail and permanent reduction plates (PP) were included in patients over 18 years of age with at least six month follow up or until fracture union. Patient demographics, fracture characteristics, mechanism of injury, medical comorbidities, and length of follow up were recorded along with time to union, incidence of nonunion and treatment for documented or suspected infections.

RESULTS

During the study period, 389 patients underwent tibial intramedullary nailing with 162 identified as open fractures. 91 patients met inclusion criteria with 39 in the PP group and 52 in IM group. Statistical analysis revealed no difference between the two groups except more AO/OTA 42A fractures were noted in the IM group. Average follow up was 8.0 and 10.2 months for PP and IM respectively. Nonunion occurred in 2 PP group patients and 7 in the IM group (p = 0.29). Time to union was 5.5 months for PP group and 6.1 months for IM group (p = 0.39) with 4 infections in the PP group and 10 infections in IM group (p = 0.38).

CONCLUSION

Despite the small sample size, this study suggests that permanent reduction plating, in the setting of open tibia fractures, does not delay time to fracture union or increase risk of nonunion or infection.