Synovial lipomatosis of the ankle joint: A rare case report.

INTRODUCTION AND IMPORTANCE: Synovial lipomatosis is a rare disease that often results in joint discomfort, swelling, and effusion. Only a few reported cases have been documented so far. CASE PRESENTATION: We reported a 50-year-old woman with synovial lipomatosis of the ankle joint. The patient presented with left ankle pain since the least two years, accompanied by swelling and redness. Physical examination demonstrated swollen ankle with warmth palpation. Magnetic resonance imaging (MRI) demonstrated hyperintensity of the ankle joint on the posterior and anterolateral side, thickening of the synovium, and bone marrow edema around the talar bone, surrounding the sinus tarsi. Histopathological examination demonstrated fatty tissues with nonspecific inflammation, suggesting synovial lipomatosis. We performed synovectomy, and the pain did not recur at 1 year of follow-up. CLINICAL DISCUSSION: Synovial lipomatosis is a highly uncommon benign condition. Histopathologically, synovial lipomatosis is characterized by notable adipocyte infiltration into the subsynovial tissue and a villous or frond-like morphology of the synovium. It also features transversely hyperplastic synovial lining cells. CONCLUSION: Synovial lipomatosis of the ankle joint is a rare entity. Further studies are required to investigate this disease and its management.

Functional, radiological, and quality of life outcome of unstable acetabular fracture with quadrilateral plate involvement at a tertiary care center in Jakarta, Indonesia.

INTRODUCTION: Unstable acetabular fracture remains a complex fracture that requires technically demanding surgery for orthopedic surgeons. Quadrilateral plate (QP) fractures of the acetabulum are a challenging group of acetabular fractures to manage. However, the literature regarding the management of these injuries are limited. The QP is a relatively thin medial wall of the acetabulum and intra-articular; thus, anatomical reduction and stable fixation are required for satisfactory outcome. This study aims to determine the functional, radiological, and quality of life outcome of unstable acetabular fracture with QP involvement. METHODS: This was a retrospective cohort study conducted at Cipto Mangunkusumo General Hospital during the period of 2010-2020. Patients with unstable acetabular fractures with and without QP involvement were included in this study. They were followed up postoperatively at 1, 6, and 12 months. Functional outcome was assessed using the Harris Hip Score (HHS), Merle D'Aubigne, and Oxford Hip Score (OHS); while radiology outcome was assessed using Matta Outcome Grading; and quality of life was assessed using the SF-36. RESULTS: This study involved 53 subjects with a median age was 29 (18-75) years of age. Twenty-eight (52.8%) subjects had unstable acetabular fracture with QP involvement. Twenty-five (47.2%) subjects had unstable acetabular fracture without QP involvement. Twenty-five (47.2%) subjects were fixed using quadrilateral hook plate, 3 (5.7%) with infrapectineal plate, 10 (18.8%) with posterior column plate, and 15 (28.3%) with suprapectineal plate. The median intraoperative bleeding in those with unstable acetabular fracture with QP involvement was 600 (300-4000) ml, which was higher than those without QP involvement (400 [100-1700] ml). Those with QP involvement achieved anatomical reduction in 20 (71.4%) subjects. Whereas, the subjects without QP involvement achieved anatomical reduction 23 patients (92%). Subjects with QP involvement had significantly lower functional, radiological, and quality of life outcomes compared to those without quadrilateral plate involvement based on Harris Hip Score (p = 0.046), Merle D'Aubigne (0.001), Oxford Hip Score (0.001), Matta Outcome Grading (0.004), and SF-36 (0.001). Patients with quadrilateral hook plate showed no significant functional, and radiological outcome difference compared to patients with infrapectineal plate based on Harris Hip Score (p = 0.582), Merle D'Aubigne (0.698), Oxford Hip Score (1.000), and Matta Outcome Grading (1.000). In addition, we also found no significant functional, radiological, and quality of life outcome difference between posterior column plate and suprapectineal plate group based on Harris Hip Score (p = 0.200), Merle D'Aubigne (0.643), Oxford Hip Score (0.316), Matta Outcome Grading (1.000), and SF-36 (0.600). CONCLUSIONS: Patients with unstable acetabular fracture with quadrilateral plate involvement subject had significantly lower functional, radiological, and quality of life outcomes compared to those without quadrilateral plate involvement. Both quadrilateral hook and infrapectineal plates demonstrated non-significant functional and radiological outcomes difference. Posterior column plate also resulted in the same functional, radiological, and quality of life outcome compared with suprapectineal fixation.

Absorbable vs Nonabsorbable Sutures for Achilles Tendon Repair: A Systematic Review and Meta-analysis.

Background: Nonabsorbable sutures are still the main choice for acute Achilles tendon rupture (AATR) repair due to strength provided. However, the rerupture rates, infection risks, foreign body reaction, and postsurgical recovery differences between absorbable and nonabsorbable suture materials in AATR repair have not been carefully reviewed. Methods: A systematic review was done on PubMed, EBSCO, Cochrane Central Register of Controlled Trials, and Embase to find research studies in relation to complications associated with AATR repair using the PRISMA guidelines. The risk of bias from each study included will be assessed using the Cochrane Risk of Bias Tool for randomized study (RoB 2) and Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) for nonrandomized study. Results: Five studies with a total of 255 patients, 105 in the absorbable suture group and 150 in the nonabsorbable suture group, were included for analysis. Risk of rerupture, infection, and foreign body reaction shown no significant difference between groups, and the mean difference of recovery scores were similar. Conclusion: Existing literature shows that absorbable sutures appear to be associated with similar outcomes to nonabsorbable sutures regarding rates of rerupture, infection, foreign body reaction, and outcomes grading following surgical repair of acute Achilles tendon repair.

Intramedullary nailing as a treatment for non-unions of femoral shaft fractures after plating failure: A case series.

INTRODUCTION: The management of implant failure in femoral shaft fractures remains a challenging problem for orthopaedic surgeons. This series aim to evaluate the effectiveness of intramedullary (IM) nailing for treating femoral shaft nonunions after implant failure. CASE PRESENTATION: Three patients presented with pain after walking on crutch and limping with history of fixation using plate for femoral shaft fracture. Implant removal was then performed with subsequent refixation using intramedullary nailing with A2FN. The Lower Extremity Functional Score and Visual Analogue Score evaluation showed excellent result in these patients. CLINICAL DISCUSSION: IM nailing is the mainstay of treatment for patients with femoral shaft fractures. This intervention provides support to fractures and aid in union of fractures. Several advantages have been reported in IM nailing, including shorter length of stay, rapid union, and early functional capacity of the limb. Insertion of IM nailing may preserve anatomical structure in the patients, which leads to better improvement of functional capacity. Nailing also limits soft tissue damage. Thus, in patients presented with previous plate failure similar to our patients, IM nailing with reaming is recommended. CONCLUSION: Nonunion after femoral shaft plating are common. Nailing conversion is one of available treatment options to achieve maximum recover in this type of case.

Management of pelvic ring fractures in limited resources country: a retrospective study.

PURPOSE: Pelvic ring fractures (PRFs) management needs adequate facilities and human resources. However, the prehospital ambulance management role in Indonesia is insufficient. Many hospitals have limited resources that necessitate patients to be referred to higher trauma centers. This study aims to describe the state of PRFs management at a level 1 trauma center in limited-resource country. METHODS: We conducted retrospective studies of PRFs management from 2011 to 2021 at Cipto Mangunkusumo Hospital. We analyzed patient's management flow from injury, referral process, initial to definitive treatment, mortality, and Majeed functional score. RESULTS: From 109 patients, 30.3% were non-referrals that came without ambulance, while 69.7% were referrals using an ambulance. All non-referral patients came without pelvic binder with 54.5% unstable hemodynamic, while 35.5% of the referrals came with unstable hemodynamic and 72.4% had pelvic binder. Median time for non-referrals reaching our hospital is 12.5 h. Unlike local referrals, 75% of regional and 85.7% of national referrals general improvement had to be improved before being referred. Polytrauma cases were 33.9% with 12 days mean interval to definitive treatment. Mortality rate in this study was 13.8%. During post-operative follow-up with a mean of 4 years, 83% of patients could be followed up and reported 93 median Majeed score. CONCLUSION: The management of PRFs at level 1 trauma center in limited-resource country shows a mortality rate of 13.8% through various limitations such as unimplemented ambulance prehospital management, number of patients who were referred without pelvic binder applied, and the long waiting interval for definitive treatment.

Neglected neurogenic clubfoot treated with Achilles tendon lengthening using Z-plasty, total talectomy, and tibiocalcaneal arthrodesis.

INTRODUCTION: The most common foot and ankle deformity from injury to the nervous system is equinocavovarus. This deformity comprises of equinus, cavus, varus, and adduction of the forefoot which leads to pain and poor stability in stance phase of gait. Treatment for this condition is difficult regarding literature limitation of the neurogenic clubfoot management. We reported a 18-year-old female with neglected right neurogenic clubfoot treated with 2 stage deformity correction. CASE REPORT: A 18-year-old female presented with crooked right foot since birth. It caused pain, especially during walking and standing for a long time and resulted in occasional skin infection on the bottom of the foot. However, currently she could walk in limping gait without walking aid. The patient was born aterm 39 weeks through caesarean delivery due to severe preeclampsia. There was delayed development of walking at 2 years and 9 months. Previously, she had history of spina bifida and undergone surgery in 2001. Afterward, she underwent VP shunt surgery. Physical examination demonstrated cavus varus, tenderness of the right foot, and limited ankle motion. The patient was diagnosed with neglected right neurogenic clubfoot and underwent two stage deformity correction consisting of Achilles tendon lengthening using Z-plasty, total talectomy, and tibiocalcaneal arthrodesis followed by posteromedial release, tendon lengthening (Tibialis posterior, FDL, FDB) and plantar fascia release. CONCLUSIONS: Two stage deformity correction can be successful in patients with neglected neurogenic clubfoot. Further studies are required to investigate the safety and efficacy of such procedure in neurogenic clubfoot.

Emergency orthopaedic surgery in the pandemic era: A case series at Cipto Mangunkusumo national tertiary hospital in Jakarta, Indonesia.

INTRODUCTION: Every emergency surgery performed is aimed at saving lives; however, during COVID-19 pandemic, surgeries are often postponed. Many existing recommendations take into account postponing surgery during a pandemic. How these surgeries can lead to increasing infection rates has not been widely published. This study aims to investigate the relationship of emergency orthopaedic surgery and the incidence rate of COVID-19. PRESENTATION OF CASE: This was a case series of 14 patients. The study was performed at the emergency department unit at a national tertiary hospital in Jakarta, Indonesia. A total of 14 patients underwent orthopaedic surgery in the emergency room of our institution. The mean age of the subjects was 40.07 ± 20.5 years. Twelve (85.7%) were male patients and 2 (14.3%) were female patients. The average duration of surgery was 125 minutes. The most used type of anaesthesia was general anaesthesia for 6 operations (50%). Patients were hospitalized for an average length of 4 days. Three patients had infiltrates found on plain x-ray examination, which required further examination to determine whether the cause was COVID-19 infection or not. There was no ground glass appearance (GGO) in the three patients in further follow-up examination. CONCLUSIONS: We found that emergency orthopaedic surgery was not associated with increasing number of COVID-19 cases. Factors including duration of surgery, length of stay, types of anaesthesia and comorbidities were also not associated with COVID-19 cases in this study.

Osteonecrosis of the distal tibia in systemic lupus erythematosus: A rare case report.

INTRODUCTION: Osteonecrosis (ON) is characterized by cellular death of bone components due to interruption of blood supply that leads to bone ischemia and potential joint destruction. There are multiple risk factors and medical condition associated with ON, including systemic lupus erythematosus (SLE). The most common sites of ON are the femoral head, distal femur, proximal humerus, talus and lumbar spine. Very few cases of nontraumatic ON in distal tibia have been reported in the literature. CASE ILLUSTRATION: We present a case of 23-year-old female diagnosed with osteonecrosis of distal tibia and history of SLE. The patient also had history of avascular necrosis of right hip and underwent right total hip arthroplasty. We treated the patients with conservative treatment for intial management. DISCUSSION: The risk of ON in SLE patients is likely due to the results of both the SLE itself and use of corticosteroids. Systemic inflammation in SLE reduces the development of osteoblasts, increases osteoclast maturation and activity and increases protohrombotic agents that can lead to rapid bone loss. Corticosteroids are the most consistent risk factor associated with the development of ON in SLE. Conservative medical management is effective in the early stages of the disease before bone collapse. CONCLUSION: Despite advances in the diagnosis and treatment of SLE, symptomatic ON continues to be a significant comorbidity. Strategies to detect and manage early stage ON is necessary to prevent the progression of this serious complication.

Gamma-treated placental amniotic membrane allograft as the adjuvant treatment of unresponsive diabetic ulcer of the foot.

INTRODUCTION: Diabetic ulcer of the foot is a major cause of morbidity and is a leading cause of hospitalization in patients with diabetes, and causes productivity and financial losses that lower the quality of life of the patient. The wound is categorized as responsive and unresponsive wound, which occurs in debilitated patients as seen in diabetes mellitus. The delay in wound repair can be caused by senescent cells, absence of growth factors, and other cellular abnormalities. METHOD: This is a retrospective, single-centre case series with non-consecutive cases. Patients with diabetic ulcer of the foot managed using gamma-treated placental amniotic membrane, with the minimum follow up of 1 month in academic practice setting were recruited. RESULT: Three patients with 4 weeks period of oozing ulcers and signs of inflammation were included in this case series. Two layers of amniotic membrane dressing was applied weekly after cleaning and debridement for 3 weeks. Wound size and secretion were documented by taking photographs every week. At the end of the third week, the wound healed. DISCUSSION: Placental amniotic membranes are composed of cells, extra-cellular matrix (ECM), and a complex of regulatory cytokines which promote cell proliferation, cell modulation, and cytokine secretion by variety of cell types involved in wound healing. Our study showed that the treatment of diabetic ulcer wound using amniotic membrane was successful in achieving wound healing in unresponsive, chronic wound of diabetic ulcer of the foot. CONCLUSION: Our results clearly indicated the usefulness of the application of amniotic membranes in treatment of diabetic ulcer of the foot. Amniotic membrane favoured healing of unresponsive and non-healing ulcers.

Peroneal groove deepening as the treatment of peroneal tendon subluxation: A case report.

INTRODUCTION: Peroneal tendon subluxation is a relatively rare disorder that is often misdiagnosed as an ankle sprain. It affects mainly young adults, usually during sports activities. It is mostly caused by avulsion of the superior peroneal retinaculum (SPR) from its fibular insertion, which requires surgical intervention, especially for cases of symptomatic chronic peroneal tendon subluxation and/or dislocation. We reported a case of peroneal tendon subluxation of left ankle treated with peroneal groove deepening and retinaculum ligament repair, the objective of which is to illustrate the effectiveness of this procedure. CASE PRESENTATION: We present a case of a thirty-four-year old male with peroneal tendon subluxation of left ankle. The patient was injured while exercising two years prior to admission. He now reported pain and instability on the left ankle. We performed peroneal groove deepening and retinaculum ligament repair to treat this patient. DISCUSSION: Peroneal groove deepening and retinaculum ligament repair shows an excellent clinical outcome; after the procedure, there are no major complications such as infections, wound problems or permanent discomfort. Overall, the result of surgery had been considered satisfactory. Postoperatively, the ankle was placed in a below-knee, non-weight-bearing temporary cast in semi-equinus position for two weeks. CONCLUSION: The incidence rate of peroneal tendon subluxation is relatively low, and surgery is the primary treatment of this type of injury, with various available surgical methods available for the performing surgeon. Peroneal groove deepening and retinaculum ligament repair offers a satisfactory outcome.

A rare combination of closed fracture of right talar body Sneppen 2 with associated medial malleolus: A case report.

INTRODUCTION: Ankle fractures are common, with the incidence of up to 174 cases per 100,000 adults per year. The talus, the second largest tarsal bone, has distinctive imaging characteristics and injury patterns. The combination of talar body fracture in sagittal plane along with medial malleolus fracture is an unusual pattern of injury and rarely reported in the literature. PRESENTATION OF CASE: We presented a case of nineteen-year old male with pain on the right ankle as a result from motorcycle accident twelve hours before admitted to Cipto Mangunkusumo Hospital. After the patient underwent close reduction and immobilization using back slab, patient then underwent open reduction surgery of the right ankle then fixated using plate and screw combined by tension band wiring (TBW) at the right medial malleolus. DISCUSSION: Talar and Medial malleolus fracture was initially evaluated by physical examination and radiographic imaging and classified by Sneppen classification. After the diagnosis was established the patient underwent ORIF plate, screw and tension band wiring. In post-operative x-ray examination, there was a significant improvement in talocrural angle and medial clear space but same result in tibiofibular overlap and tibiofibular. CONCLUSION: Open reduction and internal fixation (ORIF) plate and screw combined by tension band wiring (TBW) is the right surgical treatment for patient with closed fracture of right talar body Sneppen 2 with associated medial malleolus fracture. The outcome of the treatment is excellent because the patient presented was able to fully recover to normal activity.

Osteosarcoma of the talus treated with extraarticular resection " total talectomy" and reconstruction using fibular bone graft: A case report.

INTRODUCTION: In most cases, osteosarcoma occurs in the metaphysis of long bones such as femur, tibia, or humerus. Meanwhile, osteosarcoma of the talus is extremely rare. PRESENTATION OF CASE: We presented a case of a thirty-eight-year-old male patient with osteosarcoma of the talus treatedwith limb salvage surgery. That procedure consists of wide excision as extra-articular resection" totaltalectomy" followed by challenging reconstruction of the defect using fibular graft and followed by internal fixation and arthrodesis. We did an extraarticular resection of the talus, which consists of total talectomy and excision of the distal tibia and fibula. An ipsilateralnon vascularized fibular graft as harvested and placed in a horizontal plane to bridge the distal tibia and fibula to the navicular. The graft was fixated using 7.5mm cannulated headless screw and was followed by arthrodesis across the distal tibia and fibula to the calcaneus. DISCUSSION: Options for surgical treatment for osteosarcoma of the talus islimb salvage surgery. Extraarticular resection "total talectomy" and reconstruction using fibular bone grafttechnique creates a good functional outcome and no signs of local recurrence were found during one-yearfollow-up. CONCLUSION: Extraarticular resection and reconstruction using fibular bone graftis a good technique for management of osteosarcoma of the talus.