Peculiar Periprosthetic Fracture Involving Trochanteric Region Along With Shaft of Femur in a 68-Year Male Treated With Locking Plate Fixation and Additional Augmentation with Cable – A Case Report and Review of Literature

Tubercle bacilli has been known to live in symbiosis with mankind since centuries. Tubercle bacilli mainly causes pulmonary disease but extra pulmonary manifestations are fairly common with spine being the most common site

Minimally Invasive Technique for Treatment of Osteoid Osteoma: A Case of Anatomically Critical Lesion in an Adolescent Patient

Background: Osteoid osteoma is a benign osteogenic tumor affecting adolescents and young adults. It is managed using different treatment options. The lesions located around the lesser trochanter is rare and the management of these lesions is troublesome. Here, we report a case of an osteoid osteoma in the lesser trochanteric region, managed with a minimally invasive surgical excision of the lesion. Case Report: In a 14-year-old girl patient with nocturnal left thigh pain from 2 years before, conservative treatment with administration of non-steroidal anti-inflammatory drugs (NSAIDs) was not effective, and symptoms were refractory to medication. The day after surgery the patient was pain-free. Conclusion: The surgical management of osteoid osteoma in the region of the lesser trochanter is troublesome. The minimally invasive surgical excision of the lesion using CT-guided percutaneous drilling and resection of the osteoid osteoma is a safe, simple, cost-benefit, and effective technique.

The case of ‘A Rhino Horn’: case report and proposal for modification to the Hetsroni and Kelly classification

Subspine impingement syndrome by definition involves a prominent antero-inferior iliac spine (AIIS) which can lead to impingement on the femoral neck thereby causing symptoms. We present the case of a 22-year-old semi-professional athlete who presented with a Type III AIIS morphology leading to subspine impingement syndrome and was managed via a mini open anterior approach. Radiological examination revealed a fairly prominent left AIIS resembling the ‘horn of a rhino’ extending to the trochanteric region anteriorly. A mini-anterior surgical approach was utilized for the resection of the ‘rhino horn’ and the rectus femoris was reattached. The patient remained asymptomatic at the one-year follow-up and had resumed weightlifting. Following this case, we propose a new classification of the type III AIIS morphology in view of the clinical presentation. The AIIS type III-Standard represents an extension from the acetabular rim to less than 1 cm (type III-S) and type III-Large, with an extension from the acetabular rim beyond 1 cm (type III-L). The type III-L will further be divided into two groups based on its relation to the ilium, type III-Lr (‘rib shape’) and type III-Lrh (‘rhino horn’).

LIPOSTRUCTURE: EXPERIENCE OF THE DEPARTMENT OF PLASTIC SURGERY OF THE MOHAMMED VI UNIVERSITY TEACHING HOSPITAL OF MARRAKESH

This is a descriptive retrospective study of 42 cases of patients who underwent the lipostructure procedure at the Department of Plastic Surgery of Mohammed VI Teaching Hospital of Marrakesh, over a period of 6 years, from January 2012 to December 2017. It aims to report our experience, and to review the procedure, applications, and outcomes of lipostructure. A total of 61 procedures were performed. The average age of our patients was 28.78 years. A female predominance was noted (86%). The main indications were: burn sequelae (33%), trauma sequelae (17%), infection sequelae (10%) and facial rejuvenation (10%). In terms of local conditions, most of our patients suffered from skin scars (61.9%), atrophy (14.28%), wrinkles (9.52%), facial asymmetries (7.14%), and nasal deformities (7.14%). The samples was mainly harvested from the abdomen (42%), followed by the trochanteric region (saddle bags) in 38% of cases. 67.21% of the samples were harvested from a single donor site. The average volume collected was 74.52 ml. All the samples were centrifuged by the Regenlab system. 52% of the lipostructure procedures were performed on the face, with an average injected volume of 23.25ml. 42.62% of the lipostructures were associated with an injection of PRP, and 6.55% with a facelift.

Identification of hypercoagulability with thrombelastography in patients with hip fracture receiving thromboprophylaxis

Background: Venous thromboembolism (VTE) is the second most common complication after hip fracture surgery. We used thrombelastography (TEG), a whole-blood, point-of-care test that can provide an overview of the clotting process, to determine the duration of hypercoagulability after hip fracture surgery. Methods: In this prospective study, consecutive patients aged 51 years or more with hip fractures (trochanteric region or neck) amenable to surgical treatment who presented to the emergency department were eligible for enrolment. Thrombelastography, including calculation of the coagulation index (CI) (combination of 4 TEG parameters for an overall assessment of coagulation) was performed daily from admission until 5 days postoperatively, and at 2 and 6 weeks postoperatively. All patients received 28 days of thromboprophylaxis. We used single-sample t tests to compare mean maximal amplitude (MA) values (a measure of clot strength) to the hypercoagulable threshold of greater than 65 mm, a predictor of in-hospital VTE. Results: Of the 35 patients enrolled, 11 (31%) were hypercoagulable on admission based on an MA value greater than 65 mm, and 29 (83%) were hypercoagulable based on a CI value greater than 3.0; the corresponding values at 6 weeks were 23 (66%) and 34 (97%). All patients had an MA value greater than 65 mm at 2 weeks. Patients demonstrated normal coagulation on admission (mean MA value 62.2 mm [standard deviation (SD) 6.3 mm], p = 0.01) but became significantly hypercoagulable at 2 weeks (mean 71.6 mm [SD 2.6 mm], p < 0.001). There was a trend toward persistent hypercoagulability at 6 weeks (mean MA value 66.2 mm [SD 3.8 mm], p = 0.06). Conclusion: More than 50% of patients remained hypercoagulable 6 weeks after fracture despite thromboprophylaxis. Thrombelastography MA thresholds or a change in MA over time may help predict VTE risk; however, further study is needed.

Fractures of the trochanteric region in children and young adolescents—a treatment algorithm for a rare injury

For femoral fractures of the trochanteric region in children and adolescents, only two mechanisms have been identified to cause a fracture of the proximal femur: high-energy trauma or predisposing bone pathologies with inadequate trauma (e.g., simple fall, movement). We identified 20 patients between 1993 and 2018 with a trochanteric fracture under the age of 18 (12 males; 8 females; mean age, 12 years; range, 4–17 years) who were treated operatively at our department. The mean follow-up of all patients was 50.06 months. All 20 patients were treated operatively. Complications occurred after a mean time of 6.27 months (range, 0.47 to 12.07 months) in two patients. Harris Hip Score was evaluated in all patients with a mean score of 94.16 (range 11 to 100). Eighty-five percent of the patients reached an excellent clinical outcome after treatment. Trochanteric femoral fractures in children and adolescents are very rare accounting for only 1% of all trochanteric fractures. Excellent long-term results can be achieved with an adequate fracture reduction. Conclusion: Physicians treating pediatric trauma have to be aware of other predisponding diseases when low-energy trauma leads to a trochanteric fracture as in this study, 50% of the trochanteric fractures were associated with bone pathologies. What is Known:• Trochanteric femoral fractures in children and adolescents are very rare• In all patients with trochanteric femoral fractures, malignancies have to be ruled outWhat is New:• Awareness of an underlying bone pathology in a high number of cases• Awareness for necessity of a good fracture reduction leading to highly satisfactory results

Deep gluteal space anatomy and its relationship with deep gluteal pain syndromes

Introduction: Increasing interest has been seen in understanding the anatomy and biomechanics involved in the Deep Gluteal Syndrome, therefore the main objective of our paper was to define the anatomy of the deep gluteal space concerning the important osseous, muscular and neurological structures. Methods: 12 cadaveric models (24 hemipelvises) were used. We proceeded with classical anatomic dissection and evaluated numerous osseous, musculotendinous and neurologic structures and their relationships. We also determined the femoral anteversion and neck-shaft angles. Results: We found that 15.4% of lower limbs examined presented variations in the sciatic nerve (SN) emergence, and this was significantly longer in men. The distance from the SN to the trochanteric region was also significantly lower in males. The average ischiofemoral distance (IFD) was 2.5 ± 1.3 cm, at the same time that the structures comprised in that space showed superior areas, such as the quadratus femoris (QF) with 5.0 ± 1.1 cm and the SN with 1.4 ± 0.3 cm widths. Besides that, we also evaluated the distance from the SN to the lesser trochanter (LT) and the ischial tuberosity (IT), in the ischiofemoral space, reaching average values of 1.1 ± 0.7 cm and 1.5 ± 0.6 cm respectively. Regarding the relationship between the proximal hamstring insertion, we verified that the LT was at an average distance of 1.6 ± 1.1 cm, that the SN was only 0.2 ± 0.3 cm lateral to it, and the PN is just 2.6 ± 1.2 cm proximal to it. Conclusions: Our study confirmed the extreme variation in the SN origin that can contribute to the Piriformis syndrome. The IFD obtained in our study showed that this distance was small for the structures contained in this space. The proximal hamstring insertion showed a significantly more extended footprint in males, which puts the pudendal nerve (PN) at higher risk of iatrogenic injury.