Introduction: Posterior cruciate ligament (PCL) reconstruction needs a large and long graft. An allograft is a preferable option for thicker graft but its availability is limited in Indonesia. Alternatively, autograft needs to be folded several times for sufficient thickness but it will be shorter and only applicable for the inside-out method. We present a case of PCL reconstruction using a double adjustable button fixation with the outside-in tibia tunneling method. Case Presentation: A fifty-five-year-old male came to our office with an unstable right knee after he fell 1 month ago. Physical examination showed positive posterior drawer and mild right knee effusion, other findings were normal. MRI revealed a total PCL rupture. Two weeks later, the PCL reconstruction was done using autograft from gracillis and semitendinous. A large adjustable button was placed on the tibia tunnel, using the outside-in technique. Knee was stable postoperatively. Discussion: PCL reconstruction using double adjustable buttons was chosen to accommodate larger but shorter autografts. The outside-in tibial tunnel has less risk of graft laxity less expensive and more simple technically compared to inside-out adjustable button tunnel. Conclusion: Tibial fixation using an adjustable large button should be considered in PCL reconstruction with short autograft.

Introduction: Rotator cuff calcific tendinitis (RCCT) frequently manifests as acute shoulder pain during the acute resorptive phase. Pain typically worse at night and limited range of motion (ROM) with muscle spasm. Several treatment options have been proposed. In this case, a single needle ultrasound-guided percutaneous lavage (UGPL) combined with corticosteroid subdeltoid bursa injection (SDBI) with a good outcome. Case Presentation: A Female, 59 years old, presents with left RCCT acute pain (VAS 7/10) for 2 days and limited painful shoulder ROM. Inflammation and local tenderness found on the left shoulder, ultrasonography shows calcification in the left infraspinatus tendon with sub-deltoid bursa fluid. Patient in sitting position, ultrasound probe placed at long axis of infraspinatus tendon. Using a 23G needle 5 ml syringe, 1% lidocaine infiltrated until the needle penetrates the calcification site. Then a small amount of normal saline (NaCl) with lidocaine injected in a pulsating manner, observed until chalky matter backflows, mixed with NaCl in the syringe. Repeat this procedure until chalky backflow is minimal. Finally, 10 ml of Triamcinolone Acetonide 40 mg mixed with 2 ml lidocaine 2% SDBI using the same needle. Dramatic shoulder pain relieve (VAS 2/10) is immediately achieved after the procedure. One week follow up, the patient is pain-free and regains full ROM of her left shoulder. Discussion: Several methods are proposed for the treatment of acute RCCT, including corticosteroid injection and arthroscopy debridement. UPGL is an attractive option because it is minimally invasive, can be performed in-office setting, and pain relief is obtained immediately by decompressing and removing inflamed calcified sites. Conclusion: The treatment in acute pain RCCT using UGPL combined with corticosteroid SDBI provides a good outcome.

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Background: About 10% of hip fractures are missed on initial presentation and potentially expose patients to increased morbidity and unnecessary complex surgeries. 2,3 CT-scan and MRI in the emergency settings have been proposed to avoid a misdiagnosis.3,6,7 Case Series: three cases (two female and one male patient) patients with hip pain were presented with normal x-ray on initial presentation. Further investigation using CT-scan and MRI revealed femoral neck fractures. Case 1 : A 77 years-old female presented with right hip pain after a ground-level fall. Plain radiograph was normal and the patient was discharged from emergency. One week later, her hip pain worsened and a follow up x-ray showed a displaced femoral neck fracture. The fracture then treated with bipolar hemiarthroplasty. Case 2 : An 87 years-old female presented with left hip pain after a fall in the bathroom. She was able to bear weight. Initial hip x-ray appeared normal. Further investigation with a pelvic CT scan revealed a displaced femoral neck fracture. Case 3 : A 49 years-old male presented with worsening right hip pain since more than a week. The patient was physically active and has no history of trauma or associated hip injury. Initial x-ray showed a normal hip but further imaging study using MRI revealed an undisplaced femoral neck fracture. The patient was treated conservatively as he refused to do surgery. Conclusion: Traumatic hip pain with negative plain radiograph should be followed by MRI or CT -scan to avoid misdiagnosis. Keywords : Occult hip fracture, Missed hip fracture, Femoral Neck Fracture, Elderly patient

Postoperative limb alignment is important for successful total knee arthroplasty (TKA). Femoral shaft bowing angle (FBA) in coronal plane may influence distal femoral valgus cutting angle (DFVCA) and 5±2º may not perpendicular to mechanical axis. Methods: Sixty-six lower extremity long film x-ray of osteoarthritic knees were collected and analyzed with IntstaRISPACS (digital radiography software). The correlation and linear regression between FBA and DFVCAwere measured using SPSS 24. Results: Our study shows a strong correlation between FBA and DFVCA. Lateral FBA tends to present with DFVCA outside 7º as shown in linear regression test, vice versa. Conclusion: Since DFVCA is influenced by FBA, we recommend preoperative femoral x-ray in all knee replacement candidates. References: Rezende FC, Carneiro M. Is it safe the empirical distal femoral resection angle of 5° to 6°of valgus in the Brazilian geriatric population? Rev Bras Orthop. 2013; 48(5): 421-6. Kim CW, Lee CR. Effects of femoral lateral bowing on coronal alignment and component position after total knee arthroplasty: a comparison of conventional and navigation-assisted surgery. Knee Surg Relat Res. 2018 Mar; 30(1): 64–73. Kim JM, Hong SH, Kim JM, Lee BS, Kim DE, Kim KA, Bin et al. Femoral shaft bowing in the carinal plane has more significant effect on the coronal alignment of TKA than proximal or distal variations of femoral shape. Knee Surg Sports Traumatol Arthrosc. 2015;23(7):1936-42