INTERNAL FIXATION OF TYPE I CAPITELLUM FRACTURE WITH HEADLESS SCREWS: A CASE REPORT

Background: Capitellum fractures are relatively rare. Distal humeral fractures that include capitellum and trochlea constitute approximately 6% of all distal humeral fractures and 1% of all elbow fractures. Despite the rarity of these injuries, an increasing number of clinical series have emerged, enhancing our understanding of these fractures.Case Report: A 26-year-old woman came to the emergency department with complaints of swelling and localized pain on the lateral side of her left elbow 2 hours after she fell off her motorcycle. Routine imaging such as plain radiographs and computed tomography scanning confirmed the fracture. She underwent open reduction and internal fixation surgery, stabilization of articular fragments with headless screws, and was fixated by a back slab and arm sling. The patient was also encouraged to do early elbow mobilization to avoid contractures and joint stiffness, routine follow-up every two weeks for a ROM evaluation. Preoperative Mayo Elbow-Performance Index score (MEPI) was 15, and postoperative 100.Discussion: The aim of capitellum fracture treatment is anatomical reconstruction and fixation to reduce the risk of non-union. In this case, we performed open reduction, secured two headless screws, which allow rigid fixation at the fracture site, provide fracture site compression through variable thread pitch design, and remained not removed later. These screws are suitable for use in anteroposterior and posteroanterior directions.Conclusion: The patient at two months follow-up has shown significant improvement. Accurate reduction, stable fracture fixation, and early postoperative mobilization were reported to provide good results with a MEPI score of 100.

SPASTIC PARAPARESIS IN YOUNG MEN WITH SPINAL MENINGIOMA AND SPINAL ARTERIOVENOUS MALFORMATION: A CASE REPORT

Background: Compared to trauma cases, the publication of non-traumatic events is much less, although the incidence is estimated to be as much as a traumatic event. This case report presents spinal cord tumors together with arteriovenous malformation (AVM) in young men, where there are no previous case reports that the authors can find.Case Report: A 22-year-old male patient with complaints of pain in the back (NPRS 8-9), followed by difficulty moving the lower limb accompanied by a burning sensation, problem in defecation, and urination. We found motor weakness in the lower extremities (1/1), positive pathological reflexes, and sensibility disorders on physical examination.Discussion: According to history taking, physical examination, and MR Imaging, the spastic paraparesis symptom in this patient is likely due to a spinal cord tumor, which is meningioma (according to histopathological examination). Where back pain rarely presents in the patient with spinal AVM. Laminectomy and tumor destruction were the gold standards of therapy, and the symptom was relieved.Conclusion: A complete examination is the main key in determining the appropriate therapy for the patient's disease. In this case, the manifestation of spastic paraparesis was likely to be caused by meningioma rather than spinal AVM. Laminectomy and extirpation of the spinal meningioma were done as the gold standard of therapy, and the symptom was relieved. In contrast, spinal AVM was not performed­ and is still under observation.

FIXATION OF A CLOSED DISPLACED MIDSHAFT CLAVICLE FRACTURE BY INTRAMEDULLARY K-WIRE: A CASE REPORT

Background: Fractures of the clavicle record for practically 50% of all injuries in the shoulder girdle. In recent years, the treatment paradigm for clavicle fractures has shifted from nonoperative treatment toward operative treatment, especially in fractures with significant displacement or shortening. Case Report: A 16 years old female presented to the emergency room with an injury on her right shoulder after a motorcycle accident. The radiograph showed a displaced midshaft clavicle fracture, classified as Robinson 2B1. Operative measures were performed using intramedullary K-Wire. Discussion: There is no universally agreed gold standard for clavicle fracture fixation. The majority of midshaft clavicle fractures with a displaced fragment can be successfully repaired without surgery. On the other hand, conservative therapy of Robinson type 2B clavicle fracture has been linked to a higher rate of nonunion and a decrease in strength and endurance of the shoulder. In this patient, on the two-week follow-up after wire removal surgery, the patient regained full shoulder range of motion without any limitation on activities of daily living with a minimal post-operative scar.Conclusion: We recommend that intramedullary fixation using K-wires is a useful technique in displaced midshaft clavicle fracture as it is effective, has a good cosmetic outcome, and is well-suited for the BPJS era as it had the low-cost burden.

FUNCTIONAL OUTCOME BY EVALUATION OF DASH SCORE ON DROP HAND PATIENT TREATED WITH JONES’ TENDON TRANSFER: A RETROSPECTIVE STUDY

Background: Drop hands due to radial nerve injuries cause functional and structural disabilities. Tendon transfer became the last option when nerve repair could not give patients restoration. The most popular method was Jones' Tendon transfer to restore wrist dorsiflexion, extending the thumb and the fingers. The Disabilities of Arm, Shoulder, and Hand (DASH) score measures functional outcomes in patients with upper extremities injuries. This study was to acknowledge the functional outcome and evaluate the DASH score in drop hand patients who undergone surgery by Jones’ Tendon Transfer in Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta from January 2014 to June 2016.Methods: The collected data from the medical record was evaluated based on functional outcome and DASH score. Eleven patients were included, ten male patients (90.9%) and one female patient (9.1%). The mean age of patients was 27.4 years old, with the most frequently injured arm was the right arm, counted to be eight patients (72.7%), and the left arm was three patients (27.3%).Results: The result from the evaluation of the DASH score indicated ten patients (90.9%) were minimal disability, and one patient (9.1%) was moderate disability. The average score was 12.48, which means that most patients could cope with most daily living activities post-operatively.Conclusions: In conclusion, surgery for drop hand due to radial nerve palsy by Jones’ Tendon Transfer gave a satisfactory functional outcome based on the DASH score.

PROXIMAL FIBULAR AUTOGRAFT RECONSTRUCTION AFTER RESECTION GCT DISTAL FIBULA

Background: Giant cell tumor (GCT) is a destructive bone tumor. The predilection of the GCT is mostly on the epiphysial of long bones. GCT of the distal fibula is a very rare case that becomes challenging in surgical management. The chosen surgical management is crucial and still under debate.Case Report: A 38-years-old male complaint of a painful lump in the lateral side of his left ankle for three months. Plain radiographs demonstrate a lytic lesion involving distal fibula, appropriate with 2nd-grade Campanacci. MRI showed a mass centered on the distal fibula with intermediate to high T2 signal, low T1 signal, and homogenous contrast enhancement. The patient underwent a wide excision and reconstruction of the distal fibula with a fibular head graft from the ipsilateral side. After fifteen months of evaluation, the result was excellent. The patient can full-wight-bearing with a full range of ankle joint movement, return to daily activities without pain, and no signs of recurrence. Functional status measured by the MSTS and CAIT showed good results, with total scores was 28 and 27.Discussion: Ten centimeters distal fibula is a crucial component to form stability of the ankle. Reconstruction of the distal fibula after wide excision requires the bone graft and is considered to maintain ankle stability. It can be achieved using autograft from fibula or iliac crest.Conclusion: Reconstruction of distal fibula GCT with proximal fibular autograft showed a great result. This method is a viable option as it provides good pain relief and functional improvement.

OPEN SURGERY FOR PATELLAR TENDON RUPTURE AND TIBIAL TUBEROSITY AVULSION FRACTURE IN PRE-EXISTING OSGOOD SCHLATTER LESION: A CASE REPORT

Background: In Osgood Schlatter Disease, despite being a self-limiting disease during adolescence, various complications of Osgood Schlatter Disease could also present in adulthood. An uncommon injury pattern requires surgical treatment. This study aims to understand the implementation of surgery in managing complications case of Osgood Schlatter Disease.Case Report: We present a rare case of complete patellar tendon rupture and tibial tuberosity avulsion fracture following a low-energy motor vehicle accident landing on his left knee in a 42 years old active male, who later discovered is having a pre-existing Osgood Schlatter Disease. This patient is treated with an open surgery fixating the tibial tuberosity using a single lag screw and eight tension wires, followed by primary repair of the patellar tendon, including its retinaculum.Discussion: Weakened structure from pre-existing Osgood Schlatter lesion may cause uncommon and profound injury pattern that requires surgical treatment. Conservative treatment no longer has a place in this case. The various surgical treatment methods have been reported; however, surgical modification technique is performed accordingly due to the complicated case presentation.Conclusion: Surgical treatment is the most suitable treatment option in managing this uncommon injury pattern complication of Osgood Schlatter Disease.

DIFFERENCES OF BONE REGENERATION USING BOVINE HYDROXYAPATITE AND BOVINE HYDROXYAPATITE WITH FREEZE-DRIED PLATELET RICH PLASMA ALLOGRAFT IN BONE DEFECT OF FEMORAL WHITE RABBIT

Background: Bone defects to date have been a significant problem in the Orthopedics field. Hydroxyapatite is a bone graft that is often chosen if it has osteoconductive properties. Platelet-rich plasma (PRP) has a higher platelet concentration than the concentration in normal blood, capable of providing many bioactive molecules in physiological proportions. Hydroxyapatite given freeze-dried PRP is expected to create a graft that can strengthen the matrix while promoting osteoinduction.Methods: This study compares the effects of regeneration on the bone between bovine hydroxyapatite (BHA) and bovine hydroxyapatite with freeze-dried platelet-rich plasma (FD-PRP) as a bone graft in bone defect of the femoral white rabbit. The 12 equal New Zealand white rabbits aged 6-9 months are divided into two groups. Bone defects were made in the lower femoral meta-diaphysis with a diameter of 2.5 mm. The defects were filled with BHA with FD-PRP allograft in the treatment group and BHA in the control group. Both groups will be sacrificed in the third and sixth weeks, then evaluated histologically for microvascular structure, osteoblasts, woven bone, type-I collagen, osteocalcin, alkaline phosphatase, and immunoglobulin G.Results: During the evaluation in week 3 and 6, microvascular structure, osteoblast, and type-I collagen decreased in both groups with insignificant differences (p>0.05). Woven bone, osteocalcin, and immunoglobulin G increased in the treatment group but was not significant (p>0.05). Alkaline phosphatase increased higher in the treatment group, with a considerable difference in the sixth week (p=0.008).Conclusion: The elevation in the production of woven bone, osteocalcin, and alkaline phosphatase at the third and sixth-week evaluations highlight the possibility that administering BHA given FD-PRP may have contributed to the healing of bone defects.

TUBERCULOUS ARTHRITIS OF THE ANKLE MIMICKING SYNOVITIS IN CHILD - A CASE REPORT

Background: Extrapulmonary Tuberculosis is approximately 10% of all tuberculosis (TB) cases, and the musculoskeletal system’s involvement was only 2-4. The incidence of ankle TB was found to be less than 2% of all musculoskeletal TB. The rare occurrence, uncommon site, non-specific symptoms, lack of awareness frequently causes diagnosis difficulties.Case Report: A 2,5-year-old child came to the hospital with the main complaints of swelling and pain on the left ankle since one year ago. She was diagnosed with the ankle’s synovitis from the previous hospital and was given analgesics and a warm compress on the left ankle. However, the swelling of her left ankle increased during the last seven months, causing limitation of the left ankle movement, then she was admitted to the hospital for further examination. Radiologic examination revealed peripheral osseous erosions, reduced bone mineral content, and soft tissue swelling. A Mantoux test was positive with 15 mm induration and 25 mm erythema. Anti-tuberculous drugs (ATD) therapy was given with isoniazid 50 mg, rifampicin 75 mg, pyrazinamide 150 mg, and ethambutol 230 mg for two months, as an intensive phase therapy following rifampicin 75 mg and isoniazid 50 mg for ten months.Conclusion: Tuberculous arthritis of the ankle poses a diagnostic-difficulties, it should be considered especially in the endemic area. It is often misdiagnosed with other musculoskeletal conditions, which can delay the initiation of appropriate treatment. TB must be confirmed by histological pathology. A combination of ATD and surgery can lead to clinical improvement.

INFLUENCE OF MEDICATION ON FLARE UP AND INFECTION AFTER ELECTIVE ORTHOPEDIC SURGERY IN RHEUMATOID ARTHRITIS PATIENT - A NARRATIVE REVIEW

Background: Orthopedic Surgery in Rheumatoid Arthritis (RA) patients is still controversial between orthopedic surgeons and rheumatologists, mainly due to infection and disease flares. The incidence of postoperative infections may be high due to the immunosuppressive effect of RA medication. Conversely, discontinuance of antirheumatic agents increases the possibility of a disease flare. The objective of our review is to assess the influence of drugs on both incidences.Literature Review: There were 13 studies included in this review. Methotrexate (MTX) is the most common csDMARD option among the included studies. One retrospective study that the incidence of flares tends to be higher among the group of patients who received MTX therapy and stopped more than one week before surgery than the group who did not stop. The use of MTX doses of 5 to 10 mg/week did not show an association with infection or flare incidence. On the use of bDMARD, 37.0% of patients had higher surgical site infection (SSI). Specifically, Tumor Necrosis Factor-alpha (TNF-α) inhibitors significantly (OR: 9.5, 95% CI: 1.0-88.8) increase the incidence of postoperative infections in standard-dose and high-dose, but not significantly in the rate of flares.Summary: csDMARD is recommended for continuous therapy, whereas for bDMARD, although it is recommended for withholding in the perioperative period, the results of the study did not show significant differences. The ideal dosage of medication is by the basic properties of the drug. In comparison, the incidence of flares and infections was significantly higher in biologic than csDMARD.

UNSTABLE LUMBAR FRACTURE-DISLOCATION TREATED BY LONG SEGMENT POSTERIOR PEDICLE SCREW INSTRUMENTATION

Background: Among all the thoracolumbar fractures, 50-60% affects the thoracolumbar transitional zone, and 51% AO Type C Fractures has a neurological deficit. We experienced treating a case of unstable lumbar fracture-dislocation treated with long segment pedicle screw instrumentation.Case: A 26-year-old man came to the ER after his back hit by a canopy while working 2 hours before admission. The motoric function was diminished from the L2-S1 level and hypoesthesia at the T12 level. Plain X-Ray showed Fracture-Dislocation Lumbar Vertebral 1-2 Denis Classification Flexion Rotation (AO Type C) ASIA A. The patient underwent reduction, decompression, and long-segment posterior pedicle screw instrumentation.Discussion: The surgery’s primary purpose is to restore alignment and stability to improve the patient’s quality of life by enabling daily activity in a wheelchair without significant pain. Short segment or long segment pedicle screw instrumentation remains a debate. In this case report, we apply long segment pedicle screw instrumentation for lumbar vertebral fracture-dislocation.Conclusion: Thoracolumbar fracture and dislocation fixation aim to restore alignment and stability, to reduce kyphotic deformity, and to decompress the spinal canal. The long segment pedicle screw instrumentation can resist the deforming force of thoracolumbar fractures and dislocations that will inevitably collapse into further kyphosis, resulting in a better outcome.