[Bifocal avulsion of the patellar tendon in an adult: a case report]. / Avulsion osseuse bifocale du tendon rotulien chez un adulte: à propos d'un cas.

PURPOSE OF THE STUDY: Bifocal proximal and distal avulsion of the patellar tendon is a rare event in adults with, to our knowledge, no previous report in the literature. Exceptional bifocal avulsion of the patellar tendon is generally related to an underlying bone or systemic disease. We report the case of a 90-year-old diabetic patient who developed simultaneous avulsions of the patellar and tibial insertions. CASE REPORT: A 90-year-old woman with noninsulin-dependent diabetes mellitus fell on her left knee and was subsequently unable to extend the knee despite normal quadriceps contraction. Radiographically, the knee joint showed a transverse fracture of the lower third of the patella and a fracture of the anterior tibial tuberosity, evidencing rupture of the quadriceps tendon. Signs of osteoarthritis were minimal. The patient underwent surgery for osteosynthesis of the patella with two vertical pins and a figure-eight wire cerclage in addition to fixation of the anterior tuberosity of the tibia with 3 staples and wire cerclage. The patient recovered well and was walking six months later. DISCUSSION: Bifocal disruption of the extensor system is a rare event in adults. It is usually associated with an underlying bone disease (Paget's disease, osteomalacia, osteitis deformans) or systemic disease (lupus erythematosus, rheumatoid arthritis, hyperparathyroidism, Wilson's disease), but bilateral spontaneous disruption may occur. There have been two reports of patellar full-thickness tendon tears in diabetic patients but no case of a bipolar avulsion involving both insertions. Concurrent forces applied to the ligament were probably the cause of this unique type of patellar tendon avulsion. CONCLUSION: This is the first report of a bifocal disruption of the patellar tendon. Different underlying diseases may be involved. Treatment consists in double fixation.

Quadrilateral space syndrome: case report and review of the literature.

The quadrilateral space syndrome is defined as tenderness over the quadrilateral space and shoulder pain radiating to the arm, secondary to compression of the axillary nerve and posterior circumflex humeral artery in the quadrilateral space. The symptoms are aggravated by forced abduction and extrenal rotation of the arm. The diagnosis is clinical and is documented by arteriography or angio-MR imaging with dynamic maneuvers. A 30-year-old woman presenting with this syndrome is described here, the differential diagnosis discussed, and the literature reviewed.

The epidemiology of fractures of the distal femur.

Between 1980 and 1989, reports on 2,165 fractures of the distal part of the femur (1,051 women and 1,114 men) were collected by AO Documentation and are analyzed in the present paper. The number of fractures showed a bimodal pattern with a marked variation in the number of fractures in relation to gender and age. A larger prevalence of fractures was observed either in young men (about 20 years old, traffic or sport) and in old women (about 70, fall at home, osteoporosis).

The mechanics of internal fixation of fractures of the distal femur: a comparison of the condylar screw (DCS) with the condylar plate (CP).

Distal femoral fractures are rare and usually complex. Mostly, they are fixed with the Dynamic Condylar Screw (DCS) or the 95 degrees condylar plate (CP). The simplicity of applying the DCS compared with the CP led us to investigate whether any possible mechanical deficiencies of the CP would detract from its technical advantages, thus limiting the indications for its use in the treatment of fractures of the distal femur. An in vitro investigation was carried out to measure the stability of a Y-osteotomy (with and without medial metaphyseal bone defect) stabilized either with the CP or the DCS. 8 pairs of human cadaveric femora classified according to their bone density were used. CP and DCS were applied to 1 bone in each pair by means of three lag screws (anterior, posterior and through the plate). Physiological loading was simulated and measurements were taken at the level of the osteotomy in the frontal and sagittal planes in order to assess rotational instability and the amount of gap opening in the vertical branch of the osteotomy. There was no relevant difference in the mechanical properties of the two fixations for fractures without medial defect, even if the stability of the fixation was reduced by removing the distal screw. Furthermore, interfragmental movement was minimal. In the frontal plane, simulated closure resulted in closure of the medial branch of the osteotomy in every case without any opening of the vertical branch of the osteotomy. In the sagittal plane, the closure of all branches of the osteotomy was confirmed for 11 bones and a rotation of the condyle was observed in 5 bones (3 CP, 2 DCS). Removing the distal lag screw did not increase the instability. Even in osteoporotic bones, the DCS provided the same stability as the CP. For simple Y-osteotomies, the CP did not offer any technical or mechanical advantages. The stability in the frontal plane however was significantly reduced in osteotomies with medial defect. The amplitude of interfragmental movement on all bones fixed by the CP, except for 1 pair, was greater than those fixed by the DCS. The absence of the anterior lag screw did not reduce stability. However, the absence of the lag screw within the implant considerably weakend the fixation--more so for the CP than for the DCS. Instability reached a maximum without any lag screw at all, which again was more pronounced for the CP than for the DCS. The Dynamic Condylar Screw (DCS) must be regarded as the implant of choice both technically and mechanically even in osteoporotic bones, but the distal condylar block must be at least 4 cm in length.

[Reactivation of Staphylococcus aureus osteomyelitis after 49 years]. / Reaktivierung einer Staphylococcus-aureus-Osteomyelitis nach 49 Jahren.

The treatment of chronic osteomyelitis is laborious and ill defined. We report the case of a 57-year-old woman admitted to hospital with Staphylococcus aureus septicemia due to relapse of osteomyelitis after an interval of 49 years. By surgical debridement, suction drainage and 8 months of high-dose antibiotic treatment we were able to control the infection in terms of clinical symptoms and laboratory parameters.