case_images: PMC5828462_01
case_images: Initial (a) AP radiograph of the knee and (b) Lateral radiograph of the knee were normal.
case_images: CRIOR2018-9301496.001.jpg
case_images: PMC5828462_01_CRIOR2018-9301496.001.jpg
case_images: fig1
case_images: Initial plain radiographs of the knee did not show any obvious abnormality (Figure 1), and he was placed in a knee brace, recommended non-weight bearing, pending further investigation.
case_images: MRI (T2 Fat Sat; (a) axial and (b) coronal views) showing lateral and medial femoral bone oedema (osteochondral collapse of lateral femoral condyle).
case_images: CRIOR2018-9301496.002.jpg
case_images: PMC5828462_01_CRIOR2018-9301496.002.jpg
case_images: fig2
case_images: Magnetic resonance imaging (MRI) (Figure 2) suggested multiple areas of osteonecrosis in the subchondral portion of distal femur.
case_images: (a) and (b) Sagittal CT component of SPECT showing increased focal tracer uptake in the left medial femoral condyle.
case_images: CRIOR2018-9301496.003.jpg
case_images: PMC5828462_01_CRIOR2018-9301496.003.jpg
case_images: fig3
case_images: MRI (T2 Fat Sat; (a) axial and (b) sagittal images of left knee) showing medial femoral condyle marrow oedema.
case_images: CRIOR2018-9301496.004.jpg
case_images: PMC5828462_01_CRIOR2018-9301496.004.jpg
case_images: fig4
case_images: Six months after his initial presentation, he re-presented with bilateral knee symptoms and similar MRI changes (Figures 4 and 5).
case_images: (a) Coronal and (b) sagittal images of right knee showing lateral femoral condyle marrow oedema.
case_images: CRIOR2018-9301496.005.jpg
case_images: PMC5828462_01_CRIOR2018-9301496.005.jpg
case_images: fig5
case_images: Six months after his initial presentation, he re-presented with bilateral knee symptoms and similar MRI changes (Figures 4 and 5).
case_images: PMC5828462_02
case_images: Patient 2 initial presentation. (a) Anterior-posterior radiograph and (b) coronal CT scan.
case_images: CRIOR2018-9301496.006.jpg
case_images: PMC5828462_02_CRIOR2018-9301496.006.jpg
case_images: fig6
case_images: Delayed healing. (a) AP radiograph and (b) coronal CT scan before Exogen treatment.
case_images: CRIOR2018-9301496.007.jpg
case_images: PMC5828462_02_CRIOR2018-9301496.007.jpg
case_images: fig7
case_images: Low-intensity pulsed ultrasound therapy (Exogen, Bioventus LLC) was commenced four months after presentation due to a lack of radiological evidence of bone healing (Figure 7).
case_images: Post-Exogen therapy. (a) Coronal MRI T1 Fat Sat + Gad, (b) sagittal MRI coronal Fat Sat, (c) AP, and (d) lateral radiographs.
case_images: CRIOR2018-9301496.008.jpg
case_images: PMC5828462_02_CRIOR2018-9301496.008.jpg
case_images: fig8
case_images: Low-intensity pulsed ultrasound therapy was stopped after a three-month treatment as the radiographs showed good evidence of bone healing (Figure 8).
case_images: (a) AP and (b) lateral radiographs demonstrating intra-articular femoral and tibial fractures.
case_images: CRIOR2018-9301496.009.jpg
case_images: PMC5828462_02_CRIOR2018-9301496.009.jpg
case_images: fig9
case_images: She was managed in a long leg cast (Figure 9).
case_images: (a) AP and (b) lateral radiographs demonstrating ongoing nonunion and progressive deformity.
case_images: CRIOR2018-9301496.010.jpg
case_images: PMC5828462_02_CRIOR2018-9301496.010.jpg
case_images: fig10
case_images: Despite conservative treatment, there were no radiological or clinical signs of union, and she developed progressive deformity (Figure 10) and a nontender pseudoarthrosis with ongoing instability.