Bisphosphonates are widely used to prevent osteoporotic fractures. Long-term use has resulted in unexpected subtrochanteric fractures in some elderly patients. We report a patient on long-term alendronate therapy who sustained fractures of the ulna and tibia sequentially over a 7-month period, without any trauma or fall.

Open dislocations of the midfoot and subtalar joints are extremely rare injuries. Understanding the anatomy of these joints and the various injury patterns is imperative to obtain stable concentric reduction and provide good functional outcome. We present a report of a 26-year old male who was involved in a road traffic accident and sustained open dislocations of the calcaneocuboid, naviculocuneiform and subtalar joints. He initially underwent external fixation in view of the severe soft tissue injury. After improvement of the soft tissue condition, he underwent K-wiring of the calcaneocuboid joint, buttress plating of the talonaviculocuneiform joint, peroneal tendon reconstruction using hamstring allograft and defect coverage with a free anterolateral thigh flap. With appropriate rehabilitation protocols, patient recovered well and was allowed to weight bear as tolerated by 10 weeks. His wounds healed completely by 4 months. We report this case considering the rarity of the combined calcaneocuboid, naviculocuneiform and subtalar dislocations which were successfully managed.

Background and Aims: We developed a through-the-scope twin clip (TTS-TC) for closing GI wounds. The objective of this study was to evaluate the efficacy and safety of the TTS-TC in GI wound closure.Methods: GI nonperforating and perforating wounds (!2.5 cm) were created in live pigs. TTS-TCs were used to convert the large wounds into small wounds. The remaining small wounds were closed using conventional throughthe-scope clips (TTSCs). The follow-up period was 1 month. Location and size of the wound, time of wound closure, intraoperative and postoperative adverse events, and conditions of wound healing were investigated.Results: Thirteen wounds were created in 5 live pigs, including 2 gastric nonperforating and 3 perforating wounds and 5 large intestinal nonperforating and 3 perforating wounds. The mean long and short diameters of the wounds were 4.1 (AE .9) cm and 3.4 (AE .7) cm, respectively. All wounds were successfully closed using the TTS-TCs combined with TTSCs. The total mean time for wound closure was 9.2 (AE 5.3) minutes, and the mean time for using the TTS-TCs was 3.9 (AE 4.7) minutes. During the 1-month follow-up period, no bleeding, perforation, or death occurred; all wounds healed with scar formation; and all TTS-TCs detached spontaneously. Conclusions:The TTS-TC was successfully used to close large-sized GI wounds. The TTS-TC is a promising tool for large-size wound closure under flexible endoscopy.Minimally invasive surgeries, such as endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFR), and natural orifice transluminal endoscopic surgery, are extensively used for treating GI diseases. A recent study also showed that wound closure after ESD might be useful in preventing delayed bleeding and perfo-ration. 1 Thus, wound closure is a common but challenging problem in these minimally invasive surgeries. [2][3][4] Firm and rapid closure of wounds plays an important role in patient prognosis, especially for perforating wounds. Currently, the main instruments 3-7 for wound closure while using a flexible endoscope are conventional through-the-scope Abbreviations: EFR, endoscopic full-thickness resection; ESD, endoscopic submucosal dissection; OTSC, over-the-scope clip; TTSC, through-thescope clip; TTS-TC, through-the-scope twin clip.

RESULTS Overall, the most common tumours excised from the hand were ganglions (n = 66/116, 56.9%) and giant cell tumours of the tendon sheath (GCTTSs; n = 11/116, 9.5%). However, distal to the MCPJs, GCTTSs (n = 11/39, 28.2%) were more common than ganglions (n = 7/39, 17.9%). Most of the ganglions (n = 59/66, 89.4%) arose from between the CMCJs and RCJ.CONCLUSION Most hand tumours were benign. Ganglions were the most common tumours between the CMCJs and RCJ, while GCTTSs were the most common tumours distal to the MCPJs.

Nontuberculous mycobacteria (NTM) infections of the musculoskeletal system are commonly missed due to its rarity and the absence of systemic symptoms. A high clinical index of suspicion is required to recognize such infections as they may occur in immunocompetent hosts. We present two cases of foot and ankle NTM infections involving Mycobacterium fortuitum and Mycobacterium abscessus in two such patients. The first case involves an 83-year old lady who presented with a two-month history of multiple foot abscesses initially treated at a rural hospital. She underwent drainage and debridement of her foot, with eventual cultures growing Pseudomonas aeruginosa and Mycobacterium abscessus. She was initially treated with clarithromycin and doxycycline. At one year follow-up review, her wound healed completely. The second case involves a 55-year old man who presented with infection following midfoot fusion and anterolateral thigh flap for an open complex fracture dislocation of his right foot. Cultures eventually grew Mycobacterium fortuitum and he was treated with cefoxitin, clarithromycin and doxycycline. 10 months after his initial injury, the infection has cleared and his flap was clean. Through these 2 cases, we hope to highlight the unusual presentations of such infections and illustrate that with a high initial index of suspicion and appropriate treatment, these infections can be treated successfully.