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   Table of Contents - Current issue
September-October 2019
Volume 53 | Issue 5
Page Nos. 583-676

Online since Monday, August 12, 2019

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Orthopedic care a-CROSS Community p. 583
Rajesh Malhotra
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The upsurge in research and publication on articular cartilage repair in the last 10 years Highly accessed article p. 586
Raju Vaishya, Mohit Kumar Patralekh, Abhishek Vaish
This study aims to study the publication trends in articular cartilage repair (ACR) techniques, over the last 10 years. A literature search was performed on the PubMed, Web of Science, and SCOPUS databases. We used suitable keywords and Boolean operators (articular cartilage injury AND “marrow stimulation OR microfracture (MFx),” “osteochondral autograft,” “osteochondral allograft” and “autologous chondrocyte implantation (ACI),” “scaffold”), on January 1, 2019. Trends in publication on these topics were analyzed, focusing on publications over the last 10 years, type of research, authors, institution, and country. There was an increasing trend in publications related to ACR. A search on PubMed revealed 698, 225, 293, 857, and 982 documents on searching for “articular cartilage” AND “marrow stimulation OR microfracture,” “osteochondral autograft,” “osteochondral allograft,” “ACI,” and “scaffold,” respectively. Similar searches revealed 1154, 219, 330, 1727, and 2742 documents on Web of science and 934, 301, 383, 944, and 2026 on SCOPUS, respectively, in the same order of topics. Overall, most papers were published from the United States and European countries, and Cole BJ was the most published author. There was an increasing trend in the number of publications as well as citations, with international collaboration among researchers. It implies that this field is growing rapidly. The authors from globally recognized and leading clinical institutions in the developed world contributed maximally to these publications. Most of these papers were published in high-impact arthroscopy subspecialty journals. Level of evidence: Level IV.
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Does hyaluronan improve pain or function following arthroscopic subacromial decompression (ASD) surgery of shoulder? Results of a level 1 RCT p. 595
Praveen Sarda, David Butt, Sherif Elnikety, Claire Fitzgerald, Steven Corbett
Background: Sodium hyaluronate (hyaluronan) can be used as a synovial fluid substitute following arthroscopic surgery. In this study, we examined its effect on pain and function following arthroscopic subacromial arthroscopic decompression (ASAD). Methodology: A prospective, randomized, and single-blinded design was used (13/LO0427) to compare the effect of a single postprocedure subacromial instillation of 10 ml hyaluronan, against 10 ml saline control. All patients had interscalene block along with general anesthesia and followed standard postoperative rehabilitation protocol. A power calculation for a 6-point difference in Oxford Shoulder Score (OSS) indicated a minimum sample size of 44. Participants were assessed preoperatively, and at 12 weeks using the following outcome measures -Oxford Shoulder Score (OSS), visual analog score (VAS), European quality of life score (EUROQOL), and Disability of the arm, shoulder, and hand (DASH) scores. Results: 46 patients were included for analysis. Both groups showed a mean improvement in OSS of 9 points (P = 0.0001), DASH (10 points, P < 0.05), and EUROQOL (0.13, P < 0.05). No significant difference was observed between groups in any of the recorded outcomes. Apart from one case of frozen shoulder in each group, no other complications were noted. Conclusion: While both groups showed improved pain and function scores after ASAD, no significant difference was seen between groups receiving placebo or hyaluronan. The intervention is safe but, in this study, has not been shown to improve postoperative pain or function over ASAD alone. Level of evidence: I.
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Tamil translation, cross-cultural adaptation, and pilot testing of the disabilities of arm, shoulder, and hand questionnaire p. 602
Cynthia Srikesavan, Praveen Bhardwaj, K Gobinath, A Thangamani Ramalingam, Srikesavan Sabapathy
Background: The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a commonly used patient-reported outcome measure of symptoms and function in people with upper limb conditions. The objectives of this study were to translate and cross-culturally adapt the DASH questionnaire for Tamil population in India and pilot test the questionnaire for feasibility and acceptability. Materials and Methods: The translation and cross-cultural adaptation process recommended by the developers of the DASH questionnaire was followed. The prefinal Tamil DASH was tested in people with a wide range of upper limb conditions. Acceptability and feasibility was evaluated by patient feedback and the time taken to complete the questionnaire. Results: Around 11 items were adapted to improve the relevance of the questionnaire for Tamil population. Thirty patients were recruited for pilot testing. The prefinal Tamil DASH was found to be relevant and comprehensible to patients (n = 29, Males/Females: 21/8; mean (SD) age: 34 (11.3) years) and feasible to administer. One item “Sexual activities” had more non-respondents (n = 16, 55%). Upon consultation with the developers, an item “Wash and blow dry hair” was further modified and the final Tamil DASH was produced. Conclusion: Evaluation of reliability, validity and responsiveness in a large sample would inform the use of Tamil DASH in clinical and research settings.
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Tendon transfer for persistent radial nerve palsy using single-split fcu technique and re-routing of extensor pollicis longus: a prospective study of 25 cases p. 607
Yogesh Kumar Sharma, Narender Saini, Deepak Khurana, Devi Sahai Meena, Vishal Gautam
Purpose: Optimal treatment of persistent radial nerve palsy is controversial. However, most authors agree that tendon transfers lead to satisfactory result in majority of patients. Triple tendon transfer using flexor carpi radialis, pronator teres, and palmaris longus is the most preferred tendon transfer. The aim of this study was to evaluate the results of a split flexor carpi ulnaris (FCU) as a single transfer in such patients and compare our results with other transfers from the available literature. Materials and Methods: A total of 25 patients (20 males and 5 females: mean age: 30.9 years) were selected for FCU split transfer in persistent radial nerve palsy injury from April 2014 to May 2015. All patients were followed up with a mean followup of 1 year. Clinical outcomes were assessed using Bincaz score. Results: Using Bincaz score, 68% of our patients had good-to-excellent result, while 32% patients had fair and none had bad results. Wrist extension was comparatively less in high radial nerve palsy as compared to low radial nerve palsy patients, but all patients were functionally independent. Power grip was assessed using a jammer dynamometer. All patients had adequate grip strength and good active extension of the wrist and fingers. Conclusion: Single transfer using split FCU can be a preferred alternative in patients of low radial nerve palsy, it can be considered for high radial nerve patients in whom multiple donors are absent due to the nature of injury, for example, brachial plexus injury.
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Alternative to vein grafts for arterial repair in avulsion amputations of thumb: Case series p. 613
Chaitanya Dodakundi, Nebojsa Jovanovic, Hamed Badawi, Khalid Alawadi
The first reimplantation of a complete thumb amputation using microvascular anastomosis in a human was successfully conducted by Komatsu in 1968. Avulsion amputations of the thumb at the level of metacarpophalangeal joints pose a tedious task for direct arterial repair, even with adequate bone shortening. Owing to the short length of princeps pollicis from the deep arch, tight working space in the first web under microscope, and the associated intimal injuries, we advise transposing the radial indices artery in such cases which gives adequate length and noninjured artery for a tension-free repair. Using this method, surgeons can avoid the tedious task of vein grafts for arterial repair, reduce the operating time, and improve successful outcomes in thumb reimplantations.
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Fracture of the fifth finger sesamoid: A rare injury p. 616
Okan Aslanturk, Emre Ergen
Fracture of the hand sesamoid bones is rare. Fractures are usually missed initially. Mechanism of injury is usually reported as hyperextension and less frequently as direct compression of metacarpophalangeal joint. Fracture of the hand sesamoid bones has been usually reported in the thumb. We report a case of fifth-digit sesamoid fracture, treated conservatively. In 6 months of followup, the patient had a full range of motion without pain.
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Cup alignment change after screw fixation in total hip arthroplasty p. 618
Yingyong Suksathien, Urawit Piyapromdee, Thanut Tippimanchai
Background: Cup malalignment increase impingement, dislocation, cup migration, and polyethylene wear. Screw fixation for enhanced stability is the preferred option in cases of doubtful primary cup stability. There have been few studies about alignment changes after screw fixation, which may be another cause of cup malalignment. This study aimed to evaluate cup alignment change after screw fixation. Materials and Methods: Patients undergoing imageless navigation total hip arthroplasty using screws fixation for acetabular cup were corrected. After the press-fit cup was fully seated, the cup orientation was recorded. After screws were inserted, the cup orientation was recorded again to calculate the alignment change. Results: There were 99 cases with a mean age 63.7 years (25–93). Alignment change after screw fixation was found in 73 cases (73.7%). There were 56 cases (56.6%) with inclination angle change and the mean change was 2.21° (0°–8°). The inclination angle increased in 47 cases (47.5%) with 9 cases (9.1%) increased by 5° or more and decreased in 9 cases (9.1%). There was statistically significant difference between patients using one screw and patients using two or more screws in inclination angle change, 1.56° (0°–5°) and 3.4° (0°–8°), respectively (P = 0.0039). There was statistically significant correlation between inclination angle change and number of screws (r = 0.5401, P < 0.01). There were 49 cases (49.5%) with anteversion angle change and the mean change was 1.67° (0°–5°). The anteversion angle increased in 31 cases (31.3%), decreased in 18 cases (18.2%) with two cases (2%) decreased by 5° or more. There was significant difference between patients using one screw and patients using two or more screws in anteversion angle change, 1.46° (0°–5°) and 2.21° (0°–5°), respectively (P = 0.009). There was significant correlation between anteversion angle change and number of screws (r = 0.284, P = 0.048). Conclusions: Changes in cup alignment after screw fixation were detected in most cases. It is one possible cause of cup malalignment.
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Differentiating nutrient artery canals of the femur versus fracture lines in patients with total hip arthroplasty on plain radiographs p. 622
Ho Hyun Yun, Gi Won Choi, Wan Tae Kim, Jung Ro Yoon
Background: Nutrient artery canals of the femur are often visible on plain radiographs as radiolucent lines which may mimic fracture lines. The purpose of this study was to distinguish nutrient artery canals from fracture lines on plain radiographs. Materials and Methods: Ninety-three patients (102 hips) with an average age of 65.6 years were included in the study. We retrospectively analyzed nutrient artery canals of the femur on pre and postoperative anteroposterior (AP) and cross-table lateral (CTL) hip radiographs in patients with cementless total hip arthroplasty. The shape, number, location, direction of obliquity, length of nutrient artery canal, and the distance between the tip of the greater trochanter and the proximal end of the nutrient artery canal were measured. Results: Nutrient artery canals were determined in 54 hips (53.0%) on preoperative radiographs. The numbers of nutrient artery canals were entirely found to be one for each hip. The nutrient artery canals of the femur were the most frequently seen in the cortex on CTL radiographs with 32 hips (31.4%), whereas nutrient artery canals were not seen at all in the cortex on AP radiographs. All nutrient artery canals in the cortex on CTL radiographs coursed upward obliquely. Comparing to fracture lines, nutrient artery canals show less radiolucency, smaller diameter, and blunted ends in both the cortex and medullary cavity, show sclerotic walls in the cortex and have the less straight course in the medullary cavity. Conclusions: Based on the results of this study, there are clearly distinguishable differences between nutrient artery canals of the femur and fracture lines on plain radiographs.
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Midterm results of fourth-generation ceramic-on-ceramic total hip arthroplasty p. 630
Kyu-Jin Cho, Kyung-Soon Park, Won-Young Jang, Chun-Gon Park, Taek-Rim Yoon
Purpose: There are limited reports for the results of the fourth-generation ceramic-on-ceramic (CoC) articulation total hip arthroplasty (THA). And, throughout the surgical experience, we encountered some cases of liner pulling-out phenomenon after liner fixation and femoral preparation. The objective of this study was to evaluate the incidence, risk factors of delta ceramic liner or head fractures, and also the clinical and radiological results of using the fourth-generation CoC articulation in THA. Patients and Methods: We retrospectively reviewed 242 patients (263 hips) who underwent primary THA using the fourth-generation CoC articulation with a minimum followup of 2 years. Demographic data, Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Patient's satisfactory level were recorded. The radiological evaluation was used to evaluate the implant fixation and complications. Mean followup duration was 5.2 years. Results: Mean HHS and WOMAC score were significantly (P < 0.05) improved at the last followup. About 98.5% of the patients were satisfied with results of the surgery. All acetabular components were placed in adequate position and there was no osteolysis on acetabular or femoral components and subsidence of femoral stem. Four patients showed complications including one-liner fracture. Conclusion: Our midterm study demonstrated excellent clinical and radiological results with only one ceramic liner fracture. Moreover, the results of this study indicate that one possible cause of pulling-out phenomenon is the resonance effect during implantation in Dorr type A patients with the thick cortex. If the surgeon is aware of the liner malposition throughout the operation, the fourth-generation CoC articulation THA could be an outstanding treatment.
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Total hip arthroplasty using hybrid ceramic bearing: A minimum 10-year followup study p. 637
Jun-Il Yoo, Yong-Chan Ha, Dong-Hyun Kim, Young-Kyun Lee, Kyung-Hoi Koo
Background: Contemporary ceramic articulation in total hip arthroplasty (THA) has shown successful clinical and radiologic outcomes at mid-to-long term. Delta ceramic, which includes 24% zirconia, has been developed to reduce the rate of ceramic fracture. However, the phase transformation of the zirconia that might cause surface roughness, ceramic wear, and subsequent osteolysis remains a concern. The purpose of this study was to evaluate clinicoradiological outcomes, ceramic-related complications, and survivorship of THA with the use of hybrid ceramic bearing; BIOLOX delta liner-on-BIOLOX forte head articulation at a minimum followup of 10 years. Materials and Methods: One hundred cementless THAs (85 patients) were performed with the use of 36-mm hybrid ceramic bearing. The thickness of the delta ceramic liner was 4–6 mm. Four patients (4 hips) were lost and six patients (6 hips) died within 10 years after the operation. Thus, the remaining 75 patients (90 hips) were followed up for 10–12 years. There were 43 men and 32 women. The mean age of these patients at the index operation was 58 years (21–78 years). Results: There were no fractures of ceramic liner or head. There was no measurable ceramic wear, and neither pelvic nor femoral osteolysis was identified. All acetabular and femoral components were bone-ingrown. Three (3/90, 3.3%) patients noted noise of clicking sound. The mean Harris hip score was 87 points (range 72–99 points) at the time of final followup. THA survivorship with revision surgery as an endpoint was 97.8% (95% confidence interval: 91.4%–99.8%). Conclusions: The long term result of cementless THA with the use of a large BIOLOX forte head on the BIOLOX delta liner showed an encouraging result. Wear or osteolysis associated with composite of 24% zirconia in the fourth-generation ceramic was not observed at a minimum followup of 10 years.
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Bicruciate substituting total knee arthroplasty improves stair climbing ability when compared with cruciate-retain or posterior stabilizing total knee arthroplasty p. 641
Takanori Iriuchishima, Keinosuke Ryu
Purpose: The purpose of this study was to compare stair climbing and descent ability following bicruciate substituting (BCS), cruciate retaining (CR), and posterior stabilizing (PS) total knee arthroplasties (TKAs). Materials and Methods: Sixty-three participants undergoing BCS-TKA (journey II: Smith and Nephew), 47 participants undergoing CR-TKA (FINE: Teijin Nakashima Medical), and 38 participants undergoing PS-TKA (FNK: Teijin Nakashima Medical) were included in this study. Before and 12 months after surgery, a questionnaire was administered to assess daily stair climbing and descent ability. In the questionnaire, stair climbing and descent ability were classified as (1) stair climbing and descent one step at a time, (2) stair climbing and descent two steps at a time, and (3) unable to climb or descend stairs. The necessity of a handrail was also evaluated and classified as: (1) necessary, (2) unnecessary, and (3) unable to climb or descend stairs with handrail. Statistical analysis (χ2-test) was performed to compare these data between the types of TKA. Results: Preoperatively, no significant differences in stair climbing and descent ability or between handrail classifications were observed between the three different TKA groups. Postoperatively, the percentage of patients able to climb stairs one step at a time was significantly higher in BCS-TKA group (89%), when compared with CR (72%) or PS (58%) TKA groups. No significant differences in stair descent ability or among the handrail necessity classifications were observed between the types of TKA. Conclusion: BCS-TKA resulted in significantly better stair climbing ability when compared with CR or PS-TKA. This may indicate that the design of BCS-TKA better reproduces native anterior cruciate ligament and posterior cruciate ligament function and improves knee stability during stair climbing activity.
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A clinico-microbiological study of prosthetic joint infections in an indian tertiary care hospital: Role of Universal 16S rRNA gene polymerase chain reaction and sequencing in diagnosis p. 646
Sujeesh Sebastian, Rajesh Malhotra, Vishnubhatla Sreenivas, Arti Kapil, Rama Chaudhry, Benu Dhawan
Background: We determined the magnitude and clinico-microbiological profile of prosthetic joint infection (PJI) at a tertiary hospital. The diagnostic potential of 16S rRNA gene polymerase chain reaction (PCR) and sequencing on periprosthetic tissue samples was evaluated for the diagnosis of PJI. Materials and Methods: This ambispective cohort study consisted of patients who underwent primary or revision hip or knee arthroplasty from June 2013 to June 2017. The patients were classified as either infected or noninfected according to criteria set out by the musculoskeletal infection society (MSIS). Three to five periprosthetic tissue samples were collected from each patient for culture and 16S rRNA gene PCR sequencing. Results: Hundred and six patients were diagnosed to have PJI as per the MSIS Criteria. The cumulative incidence of PJI at our Institute at the end of 36 months was 1.1% (95% confidence interval [CI]: 0.59–2.91). Microorganisms were isolated by periprosthetic tissue culture (PTC) in 84 patients (sensitivity: 79% and specificity: 100%). Gram-negative aerobes were most frequently isolated (61%). Polymicrobial infections were present in 8.3% of cases. The most common infecting microorganism was Staphylococcus aureus (19.5%). Multidrug resistance and methicillin resistance were noted in 54% and 34% of bacterial isolates, respectively. The sensitivity and specificity of 16S rRNA PCR of periprosthetic tissue was 86% (95% CI: 74.9–89.9) and 100% (95% CI: 94.7–100), respectively. Periprosthetic tissue 16S rRNA PCR was more sensitive than PTC (P = 0.008), although both were 100% specific (P = 0.99). Conclusions: The incidence of PJI at our Institute compares well with other published reports. Contrary to previous reports, a predominance of Gram-negative PJI's was found. The preponderance of multidrug-resistant organisms in PJI's is worrisome. The high sensitivity and specificity of the 16S PCR assay used in our study support its use in culture-negative PJI suspected cases.
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Gait pattern of adults with cerebral palsy and spastic diplegia more than 15 years after being treated with an interval surgery approach: Implications for low-resource settings p. 655
Nelleke Gertrude Langerak, Nicholas Tam, Jacques du Toit, A Graham Fieggen, Robert Patrick Lamberts
Background: Single-event multilevel surgery (SEMLS) approach is regarded as the golden standard in developed countries to improve gait and functional mobility in children with cerebral palsy (CP). However, this approach is not always feasible in developing countries. Therefore, orthopedic surgery based on an interval surgery approach (ISA) is still commonly used in developing countries, although little is known about the long term outcomes of an ISA. Therefore, the aim of this study was to describe the gait patterns of adults with CP, who have been treated with ISA, which started more than 15 years ago. Materials and Methods: Thirty adults with CP and spastic diplegia, who received ISA treatment 21.6–33.7 years ago, were recruited for this study and participated in three-dimensional gait analysis. Twenty kinematic and nondimensional temporal-distance parameters were captured, while the overall gait deviation index (GDI) was also calculated. Data of the adults with CP were compared to normative data of typically developing (TD) adults. Results: Although all adults with CP were still ambulant, their gait parameters significantly differed from TD adults, with a lower GDI in the adults with CP. The CP gait patterns were characterized by excessive hip flexion and hip internal rotation as well as a stiff-knee gait. Conclusion: Although different to TD adults, the gait patterns observed in the adult with CP treated with ISA is in line with other studies. Gait patterns suggest that derotation osteotomies potentially could have improved the long term gait patterns. Although SEMLS might be the preferred treatment method, potentially resulting in better outcomes, ISA can also be used to treat children with CP in developing countries as India and South Africa, where a SEMLS approach is not always feasible.
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Langenskiöld classification for blount disease: Is it reliable? p. 662
Serkan Erkus, Ali Turgut, Onder Kalenderer
Backgrounds: Blount disease (BD) is a developmental disease which medial part of the proximal tibial physis resulting genu varum. Plain radiographs are necessary for diagnosis. For this purpose, Langenskiöld classification is used. There are not enough data about Langenskiöld classification's reliability in the English literature. The purpose of this study is to evaluate the intra- and inter-reliability of Langenskiöld classification in BD. Materials and Methods: Thirty seven patients with BD were included in this cross-sectional study. Two separate presentations including clinical findings and standard knee radiographs were evaluated by three different groups (residents, surgeons, and pediatric orthopedic surgeons) and were sent to the observers every other month by hiding patients' personal information. Intraobserver and interobserver reliabilities in these three groups were examined. Intraclass correlation coefficient (ICC) tests were used for this purpose. Results: Intraobserver reliability (ICC) was similar (excellent) in three groups (0.822, 0.804, and 0.763). Interobserver reliability among three groups was meanly excellent. Conclusion: Agreement to Langenskiöld classifications found excellent for three groups. Surgical experience did not change intraobserver and interobserver reliability in Langenskiöld classification.
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The orthopedic manifestations of congenital insensitivity to pain: A population-based study p. 665
Maximillian Mifsud, Michelle Spiteri, Karl Camilleri, Matthew Bonello, Thomas Azzopardi, Massimo Abela
Background: Congenital insensitivity to pain (CIP) is an extremely rare condition in which there is a failure of the development of the afferent sensory nerves in the dorsal root ganglia resulting in indifference to painful stimuli. The associated orthopedic manifestations are various and often present a diagnostic quandary for the treating surgeon. Purpose: This population study provides insight into the orthopedic manifestations and functional scores in patients with CIP, to guide prognosis and management. Patients and Methods: We retrospectively review and describe the orthopedic manifestations of all cases of CIP in Malta. All patients were then scored for upper and lower limb function using the abridged version of the Disability of Arm, Shoulder, and Hand score (QuickDASH) and the Lower Extremity Functional Score (LEFS). Results: Nine patients were recruited in total. Mean age at the time of recruitment into this study was of 33.7 years (range 15–58). All patients were Caucasian of Maltese heritage. None had consanguineous parents. All patients had been diagnosed with the condition in childhood (mean age 8.9 years). In total, these patients had 6 long bone fractures, 1 vertebral fracture, 39 upper limb surgical procedures, 88 lower limb surgical procedures, and 7 major lower limb amputations. These are discussed in detail. The main QuickDASH score was 23.97. The main LEFS was 42.22. Conclusions: This paper is the first population-based study of this condition and one of the largest series with functional scores. A multidisciplinary approach is essential in managing these patients. The surgical treatment of these conditions is often difficult and protracted, and judicious and careful consideration to both the bony and soft tissues aspects of the management need to be taken into account, with functional limb amputation not necessarily being considered as a last resort.
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Femur lengthening in a patient with a pseudoaneurysm of the superficial femoral artery treated with covered stent p. 674
Charles Dejean, Mathieu Desvergnes, Pierre Bouget, Philippe Rigoard, Tanguy Vendeuvre
This case report presents a 29-year-old male patient who presented an articular distal femoral fracture sustained in a road traffic accident in Benin. After the different surgical procedures, the patient presents a knee stiffness and a shortening of the left leg of 7 cm. An ablation of osteosynthesis material and a Judet procedure was done. After this surgical intervention, the patient developed pain, pulsatile swelling of the left knee. A false aneurysm of the superficial femoral artery was evidenced, and a percutaneous endovascular procedure was performed. As a result of the important leg-length discrepancy, a femoral lengthening of 6 cm was performed using intramedullary skeletal kinetic distractor nail. We show that a 6 cm femur lengthening in a patient with a femur stent is possible using intramedullary nails provided that orthopedic and vascular surgeons monitor the patient in strict clinical and paraclinical followup conditions.
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