RESUMO
INTRODUCTION: Spontaneous quadriceps tendon rupture (SQTR) is a rare injury to the knee extensor mechanism that is usually associated with systemic diseases such as end stage renal diseases (ESRD) and it is more prevalent in the elderly. Due to the underlying pathology, quadriceps tendon rupture warrants special considerations and management in its repair. CASE REPORT: We present two cases of quadriceps tendon rupture in end-stage renal disease (ESRD) patients. The first case; a 57 years old female who had bilateral SQTR and is undergoing hemodialysis. The second patient, a 26 years old male had unilateral quadriceps tendon rupture caused by minimal trauma. The first patient had a trans-osseous repair by direct suturing the quadriceps tendon stump to the proximal pole patella. The second patient was repaired with a modified Bunnel suture and anchor placement on the proximal pole patella. The first case had a re-rupture of the right quadriceps tendon and the second case has recovered with improved outcomes. DISCUSSION: Spontaneous quadriceps tendon rupture is usually underlined by degenerative changes of the tendons. Special care is needed to address the pathologic tendon underlying SQTR. The current surgical literature still lacks the statistical data that shows which surgical approach is most optimal for SQTR in ESRD patients. CONCLUSION: SQTR rupture is generally an injury of brittle tendons caused by underlying diseases. A multidisciplinary and comprehensive approach including a proper surgical approach and postoperative managements are crucial for good functional outcomes of the extensor mechanism.
RESUMO
INTRODUCTION: Congenital insensitivity to pain with anhidrosis (CIPA; OMIM 256,800) is a rare autosomal recessive disease. Although the clinical symptoms are known, the consensus of CIPA treatment has not been recognized. This is the first report of CIPA in Indonesia, a case of two siblings, male and female, whom we followed-up for 27 years. PRESENTATION OF CASE: After a series of multiple fractures from an early age, both patients who lived wheelchair-bound with their parents had been suffering from a recurrent debilitating infection on their lower extremities. The male patient eventually died from sepsis due to bronchopneumonia, years after the nonunion of both legs. The female patient underwent double above knee amputation. DISCUSSION: Observation showed that fracture in joint and metaphysis treated with open reduction ultimately end in disastrous outcomes like infection and non-union. On the contrary, the diaphyseal fracture has a better expectation to unite with casting immobilization. CONCLUSION: Unrecognizing of the clinical pictures of CIPA and minimal literature references in the past, misleads to late diagnosis and management. Genetic evaluation should be done for infants with unknown causes of high fever, anhidrosis combined with insensitivity to pain. Surgical intervention of metaphyseal fractures should be avoided due to tendencies of implants loosening, metal failures, recurrent infections followed with non-union, and instability.
RESUMO
INTRODUCTION: Uncemented total hip for neglected nonunion femoral neck fracture hopefully could minimize the post operative complications. Nevertheless, due to plasticity of the brittle osteoporotic bone, unexpected fracture may occur. We presented an unusual reconstruction of acetabulum which was accidently perforated during uncemented cup insertion. PRESENTATION OF CASE: A 76 years old wheelchair bound female showed a nonunion fracture of the right femoral neck due to a fall 7 years ago. She had right hip instability with 5 cm leg shortening. Uncemented total hip replacement was originally planned, however, due to unexpected perforation of the acetabulum, it was ended in total hip after creating a composite layers to fix a cemented cup. Patient was full ambulatory with walker at 4 months. Harris Hip Score at 15 months showed 71.3%, compared with 20.2% before surgery. DISCUSSION: The plasticity of the osteoporotic acetabulum floor was the reason why the uncemented cup could not be fixed, instead it caused massive perforation of the floor. The acetabulum reconstruction was done by composite layers made from remaining chondral bone shell, absorbable hemostatic gelatin sponge and cancellous bone of the femoral head, porous collagen matrix and uncemented titanium acetabulum cup fixed with two screws. CONCLUSION: In unexpected acetabulum perforation, the remaining chondral shell of femoral head together with uncemented cup as a cage support and bone cement can be used to reconstruct the acetabulum floor. More stability can be achieved using reconstruction cage with allograft and or metal augments or using a cemented total hip arthroplasty.
