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Kawabata S, Nakasa T, Ikuta Y, Sumii J, Nekomoto A, Sakurai S, Moriwaki D, Adachi N. Safe Insertion Angle of the Suture Button to Avoid Saphenous Structure in Syndesmosis Injury. Foot Ankle Spec 2023:19386400231213761. [PMID: 38018519 DOI: 10.1177/19386400231213761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
In placing the medial suture button for syndesmosis injury, the risk of great saphenous vein and saphenous nerve injury has been reported. This study aimed to determine the safe insertion angle of the guide pin to avoid saphenous structure injury during suture button fixation. The incidence of saphenous structure injury was investigated using 8 legs of cadavers. The greater saphenous vein was depicted on the skin using near-infrared light (VeinViewer® Flex) and the distance between the greater saphenous vein and the posterior edge of the tibia at levels of 10, 20, and 30 mm from the joint line of the tibiotalar joint was measured in the 60 legs of healthy participants. On computed tomography (CT) images, the angles between the greater saphenous vein and transmalleolar axis at levels of 10, 20, and 30 mm from the joint line of the tibiotalar joint were measured. The cadaveric study revealed that the percentages of contact with the saphenous nerve were 8.3% to 16.7%. Using near-infrared light, the vein and tibia distance was 32.9 ± 6.8 mm of 10 mm, 26.6 ± 6.4 mm of 20 mm, and 20.4 ± 6.4 mm of 30 mm. The angle between the vein and transmalleolar axis was 1.0° to 9.4°, and more proximal, the angle was smaller. The veins depicted by near-infrared light can be a landmark to identify great saphenous vein, and injury of the saphenous structure can be prevented using VeinViewer Flex or considering the insertion angle defined in this study when placing the suture button for syndesmosis injuries.Level of Evidence: Level IV.
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Affiliation(s)
- Shingo Kawabata
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tomoyuki Nakasa
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Department of Artificial Joints and Biomaterials, Graduate School of Biomedical and Health Sciences, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasunari Ikuta
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Junichi Sumii
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akinori Nekomoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Satoru Sakurai
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Dan Moriwaki
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Lenz CG, Urbanschitz L, Shepherd DW. Dynamic syndesmotic stabilisation and reinforcement of the antero-inferior tibiofibular ligament with internal brace. Foot (Edinb) 2023; 56:102026. [PMID: 37001344 DOI: 10.1016/j.foot.2023.102026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE Syndesmotic injuries are associated with long recovery times and high morbidity. Systematic reviews show a trend toward better outcomes of suture buttons compared to screw fixation. The anteroinferior tibiofibular ligament (AITFL) confers the most significant component of translational and rotatory stability. Techniques have developed which reinforce the AITFL. This study aimed to assess results of syndesmotic stabilisation with dynamic stabilisation and reinforcement of the AITFL, with an early mobilisation program. MATERIALS AND METHODS Retrospective case series of 30 patients (mean age 31 years). Syndesmotic instability was confirmed with clinical examination, MRI and weightbearing-CT. Dynamic syndesmotic stabilisation with a single suture button was performed followed by the placement of an Internal Brace over the AITFL. A standardised postoperative rehabilitation protocol was established. Foot and Ankle Ability Measure (FAAM) scores were collected postoperatively. RESULTS The average follow-up was 13 months. The total FAAM score for ADL was 95 ± 4.9 % (range, 83 - 100 %) and for sport activities 87 ± 13.6 % (range, 50 - 100 %). The rating of mean postoperative function for ADL was 94 ± 5.5 % (range, 80 - 100 %) and 90 ± 13 % (range, 35 - 100 %) for sportv. The difference between acute and chronic injuries was statistically higher (p < 0.05) for daily activities and sport, but the rating of current level of sport activites as well as for daily activites did not show a significant difference (p = 0.9296 and p = 0.1615, respectively). Twenty-seven patients (90 %) rated their overall current level of function as normal or nearly normal. CONCLUSION This technique aims to directly stabilise the AITFL and the interosseous components of the syndesmosis, and allow early mobilisation and return to sport at 10 weeks. Early results show the procedure is safe, with comparable results to the literature. Acute injuries showed better results of the FAAM score than chronic injuries.
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Affiliation(s)
| | - Lukas Urbanschitz
- Department of Orthopaedic Surgery, Schulthess Klinik, Zurich, CH, Switzerland.
| | - David W Shepherd
- Western Health Victoria, Melbourne Orthopaedic Group, Victoria, Australia.
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Hong CC, Calder J. Local Anesthetic Distension to Reduce Medial Soft Tissue Injury and Entrapment During Suture Button Placement in Syndesmosis Injuries: Technique Tip. Foot Ankle Int 2023; 44:343-347. [PMID: 36912099 DOI: 10.1177/10711007231156423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Affiliation(s)
- Choon Chiet Hong
- Fortius Clinic (FIFA Medical Centre of Excellence), London, United Kingdom
- Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - James Calder
- Fortius Clinic (FIFA Medical Centre of Excellence), London, United Kingdom
- Department of Bioengineering, Imperial College London, London, United Kingdom
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Oliveira Junior ASD, Pigossi BD, Saito GH, Nishikawa DRC, Mendes AAM, Prado MP. Tratamento da lesão da sindesmose tibiofibular distal associada às fraturas do tornozelo com suture button. Rev Bras Ortop 2021; 57:496-501. [PMID: 35785127 PMCID: PMC9246524 DOI: 10.1055/s-0041-1740293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 09/20/2021] [Indexed: 10/25/2022] Open
Abstract
Resumo
Objetivo Avaliar os resultados obtidos do tratamento cirúrgico das fraturas maleolares do tornozelo associadas a lesão da sindesmose tibiofibular distal (STFD) submetidas a procedimento cirúrgico convencional de fixação da fratura e fixação da STFD pelo suture button (SB).
Métodos Avaliou-se retrospectivamente 49 pacientes com uma média de idade de 45 anos e seguimento médio de 34,1 meses. A avaliação clínica e funcional foi baseada na escala visual analógica (EVA) e na escala American Foot and Ankle Society Score (AOFAS, na sigla em inglês) para tornozelo e retropé, retorno às atividades da rotina e retorno ao esporte.
Resultados As médias pós-operatórias das escalas AOFAS e EVA foram, respectivamente, 97,06 (índice de confiança [IC 95%: 95,31 – 98,81] e 0,16 [IC 95% 0,04 – 0,29]. Todos os pacientes retornaram às atividades prévias do cotidiano, sendo que apenas 12 apresentaram algum sintoma residual. Não se verificou instabilidade pós-operatória em nenhum paciente. Ao todo, 46 pacientes retornaram às atividades desportivas e, destes, apenas 1 não retornou ao nível prévio à lesão. Apenas dois pacientes apresentaram alterações relacionadas ao SB. Não houve relato de insatisfação.
Conclusão Em fraturas maleolares do tornozelo com lesão da STFD, a fixação da sindesmose com o SB demonstrou excelentes resultados pós-operatórios.
Nível de Evidência IV, série de casos retrospectiva.
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Affiliation(s)
| | - Beatriz D'Andrea Pigossi
- Faculdade de Ciências Médicas e da Saúde, Pontifícia Universidade Católica de São Paulo, Sorocaba, SP, Brasil
| | - Guilherme Honda Saito
- Departamento de Cirurgia Ortopédica, Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
| | | | | | - Marcelo Pires Prado
- Departamento de Cirurgia Ortopédica, Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
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Hamada T, Matsubara H, Hikichi T, Tsuchiya H. Evaluating the course of the saphenous vein and nerve for risk assessment in the suture button technique. Sci Rep 2021; 11:131. [PMID: 33420271 PMCID: PMC7794578 DOI: 10.1038/s41598-020-80556-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 12/18/2020] [Indexed: 12/04/2022] Open
Abstract
The suture button technique can cause damage to the saphenous vein and nerve. We examined the location and course of the great saphenous vein using magnetic resonance imaging and determined its position at 10, 20, 30, or 40 mm proximal to the tibial plafond. We divided the region from the anterior to the posteromedial tibial edges into segments A, B, C, D, and E, and compared baseline data and vein parameters between 56 healthy (group H) and 296 symptomatic limbs (group D). At 10, 20, 30, and 40 mm proximal to the tibial plafond, segments A (53.4%), B (45.7%), C (50.0%), and D (52.6%), respectively, had the highest probability of the presence of the great saphenous vein. The mean angle of the great saphenous vein from the distal anterior to the proximal posterior side of the tibia in relation to the tibial axis was 32.4° ± 4.8°. There were no significant differences between groups H and D. These findings indicate that the position of the saphenous vein and nerve should be determined prior to performing the suture button technique on the medial side of the tibia. This can be achieved under direct visualization through a small skin incision or via ultrasound.
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Affiliation(s)
- Tomo Hamada
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Hidenori Matsubara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Toshifumi Hikichi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
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Abstract
Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.
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Kaiser PB, Cronin P, Stenquist DS, Miller CP, Velasco BT, Kwon JY. Getting the Starting Point Right: Prevention of Skiving and Fibular Cortical Breach During Suture Button Placement for Syndesmotic Ankle Injuries. Foot Ankle Spec 2020; 13:351-355. [PMID: 32306750 DOI: 10.1177/1938640020914679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The use of suture button (SB) devices in the treatment of syndesmotic ankle injuries is increasing. These constructs have demonstrated better syndesmotic reduction, improved clinical outcomes, and lower rates of hardware removal compared with screw fixation. However, placing a SB device without a fibular plate can be technically challenging. In this technique tip, we use an illustrative case to demonstrate a technique tip that minimizes the risk of anterior or posterior cortical breach of the fibula and helps facilitate more accurate placement of a SB device.Levels of Evidence: Level V: Expert opinion.
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Affiliation(s)
- Philip B Kaiser
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Orthopaedics Residency Program, Boston, Massachusetts (PBK, PC, DSS).,Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Boston, Massachusetts (CPM).,Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania (BTV).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - Patrick Cronin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Orthopaedics Residency Program, Boston, Massachusetts (PBK, PC, DSS).,Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Boston, Massachusetts (CPM).,Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania (BTV).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - Derek S Stenquist
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Orthopaedics Residency Program, Boston, Massachusetts (PBK, PC, DSS).,Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Boston, Massachusetts (CPM).,Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania (BTV).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - Christopher P Miller
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Orthopaedics Residency Program, Boston, Massachusetts (PBK, PC, DSS).,Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Boston, Massachusetts (CPM).,Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania (BTV).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - Brian T Velasco
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Orthopaedics Residency Program, Boston, Massachusetts (PBK, PC, DSS).,Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Boston, Massachusetts (CPM).,Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania (BTV).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
| | - John Y Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Orthopaedics Residency Program, Boston, Massachusetts (PBK, PC, DSS).,Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Boston, Massachusetts (CPM).,Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania (BTV).,Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts (JYK)
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Boyd BS, Doty JF, Kluemper C, Kadakia AR. Anatomic Risk to the Neurovascular Structures With a Medially Based All-Inside Syndesmosis Suture Button Technique. J Foot Ankle Surg 2020; 59:95-99. [PMID: 31882155 DOI: 10.1053/j.jfas.2019.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 02/03/2023]
Abstract
Recent evidence suggests that the use of suture button devices for ankle syndesmosis fixation is increasing. Multiple studies have shown some concern about damaging the greater saphenous neurovasculature with placement of the anchor point on the medial tibial cortex. We hypothesized that an all-inside button deployment technique would allow for a low risk to medial soft tissue structures. A total of 40 syndesmosis suture buttons were placed into 10 separate cadaveric lower limbs, using the newly developed technique. Four suture buttons were sequentially placed from distal to proximal in each limb within the zone of typical syndesmosis fixation, using fluoroscopic guidance. A medial incision was then performed to evaluate the relationship of the suture buttons to the medial soft tissue structures and the medial malleolus. Thirteen of 40 suture buttons (32.5%) were placed anterior, 7 (17.5%) posterior, and 20 (50%) with a portion of the button directly deep to the saphenous vein. Two of 40 buttons (5%) were placed within the tibial periosteum, and 38 (95%) were subfascial and directly superficial to the periosteum. Four of 40 (10%) limbs revealed a perforation in the saphenous vein from the guidepin. In conclusion, risks to the medial neurovascular structures exist with the medial deployment technique, but they appear to be mitigated compared with previous publications. The necessity of a medial incision to evaluate for soft tissue entrapment may not be necessary in all patients, as this technique appears to be safe, accurate, and reproducible.
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Affiliation(s)
- Brandon S Boyd
- PGY-4 Orthopedic Resident, The University of Tennessee, Chattanooga, TN.
| | - Jesse F Doty
- Assistant Professor and Director of Foot and Ankle Surgery, The University of Tennessee, Chattanooga, TN
| | - Chase Kluemper
- PGY-6 Orthopedic Fellow, Philadelphia Hand to Shoulder Center, Philadelphia, PA
| | - Anish R Kadakia
- Associate Professor and Program Director, Foot and Ankle Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL
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9
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Syndesmosis Injury From Diagnosis to Repair: Physical Examination, Diagnosis, and Arthroscopic-assisted Reduction. J Am Acad Orthop Surg 2020; 28:517-527. [PMID: 32109919 DOI: 10.5435/jaaos-d-19-00358] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Injuries to the tibio-fibular syndesmotic ligaments are different than ankle collateral ligament injuries and occur in isolation or combination with malleolar fractures. Syndesmotic ligament injury can lead to prolonged functional limitations and ultimately long-term ankle dysfunction if not identified and treated appropriately. The syndesmosis complex is a relatively simple construct of well-documented ligaments, but the dynamic kinematics and the effects of disruption have been a point of contention in diagnosis and treatment. Syndesmotic ligament injuries are sometimes referred to as "high ankle sprains" because the syndesmotic ligaments are more proximal than the collateral ligaments of the ankle joint. Rotational injuries to the ankle often result in malleolar fractures, which can be combined with ankle joint or syndesmotic ligament injuries. Most of the orthopaedic literature to this point has addressed syndesmosis ligament injuries in combination with fractures and not isolated syndesmotic ligament injuries. Thus, we propose a simplified general video guide to do the diagnostic examinations and arthroscopic-assisted reduction based on current evidence-based medicine.
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Lehtonen EJ, Pinto MC, Patel HA, Dahlgren N, Abyar E, Shah A. Syndesmotic Fixation With Suture Button: Neurovascular Structures at Risk: A Cadaver Study. Foot Ankle Spec 2020; 13:12-17. [PMID: 30712382 DOI: 10.1177/1938640019826699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The objective of this study was to describe the anatomic variations in the saphenous nerve and risk of direct injury to the saphenous nerve and greater saphenous vein during syndesmotic suture button fixation. METHODS Under fluoroscopic guidance, syndesmotic suture buttons were placed from lateral to medial at 1, 2, and 3 cm above the tibial plafond on 10 below-knee cadaver leg specimens. The distance and position of each button from the greater saphenous vein and saphenous nerve were evaluated. RESULTS The mean distance of the saphenous nerve to the suture buttons at 1, 2, and 3 cm were 7.1 ± 5.6, 6.5 ± 4.6, and 6.1 ± 4.2, respectively. Respective rate of nerve compression was as follows, 20% at 1 cm, 20% at 2 cm, and 10% at 3 cm. Mean distance of the greater saphenous vein from the suture buttons at 1, 2, and 3 cm was 8.6 ± 7.1, 9.1 ± 5.3, and 7.9 ± 4.9 mm, respectively. Respective rate of vein compression was 20%, 10%, and 10%. A single nerve branch was identified in 7 specimens, and 2 branches were identified in 3 specimens. CONCLUSION There was at least one case of injury to the saphenous vein and nerve at every level of button insertion at a rate of 10% to 20%. Neurovascular injury may occur despite vigilant use of fluoroscopy and adequate surgical technique. Further investigation into the use of direct medial visualization of these high-risk structures should be done to minimize the risk. Levels of Evidence: Therapeutic, Level II: Prospective, comparative study.
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Affiliation(s)
- Eva J Lehtonen
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Martim C Pinto
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Harshadkumar A Patel
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nicholas Dahlgren
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eildar Abyar
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashish Shah
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Kaiser PB, Riedel MD, Qudsi R, Watkins IT, Ghorbanhoseini M, Nazarian A, Kwon JY. Consideration of medial anatomical structures at risk when placing quadricortical syndesmotic fixation: A cadaveric study. Injury 2020; 51:527-531. [PMID: 31711653 DOI: 10.1016/j.injury.2019.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/18/2019] [Accepted: 10/03/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Surgical fixation of syndesmotic instability using quadricortical fixation, whether screws or suture-button devices, places structures on the medial side of the tibia at iatrogenic risk. This study aims to radiographically map the anatomic course of structures on the medial aspect of the distal tibia to be able to at-risk zones (ARZs) for syndesmotic fixation. METHODS Eighteen fresh-frozen cadaveric ankle specimens were dissected. The saphenous neurovascular bundle (SNVB) and the posterior tibial tendon (PTT) were identified and marked with copper wiring. Standardized and calibrated lateral radiographs of the distal tibia and fibula were analyzed using a grid system consisting of 3 columnar zones from anterior to posterior and five 1-cm rows to chart the anatomic course of the SNVB and the PTT. RESULTS The SNVB was located in the more anterior zones (1, 2, or anterior to Zone 1) in 97.3% of specimens. The SNVB traversed from posterior to anterior as it descended proximal to distal. The PTT was found in Zone 3 (most posterior zone) for all specimens. The PTT was noted to pass behind (radiographically overlap) the tibia in 83.3% (15 of 18) of specimens between 1 and 3 cm above the tibiotalar joint. CONCLUSIONS Placement of quadricortical syndesmotic fixation places structures on the medial ankle at risk. The SNVB is at considerable risk along the anterior course of the distal tibial while the PTT is only at risk in zone 3 at the distal extent of the tibia.
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Affiliation(s)
- Philip B Kaiser
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA.
| | - Matthew D Riedel
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA.
| | - Rameez Qudsi
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
| | - Ian T Watkins
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Ara Nazarian
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - John Y Kwon
- Beth Israel Deaconess Medical Center, Boston, MA, USA.
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12
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Clinical Considerations to Reduce Saphenous Neurovascular Bundle Injury During Suture Button Fixation of Syndesmosis Injuries. J Orthop Trauma 2020; 34:e51-e55. [PMID: 31725085 DOI: 10.1097/bot.0000000000001649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To document angles, from 2 difference starting points, or danger zones that should be avoided to minimize risk of injury or irritation to the saphenous neurovascular bundle (SNVB) during suture button (SB) fixation for distal tibiofibular syndesmosis injuries. DESIGN Retrospective imaging study. SETTING Academic Level 1 trauma center. PATIENTS Forty-eight randomly selected patients with healthy ankles and computed tomography scans for nonankle diagnoses. MAIN OUTCOME MEASURES Computed tomography scans and 3D reconstructed images were used to define the angle between the SNVB and 2 different fibular starting points, using the direct lateral (DL) and the posterolateral (PL) starting points. Descriptive analyses were performed to identify angles that should be avoided during suture button fixation. Distances from the SNVB using preset angles of 0, 10, 20, and 30 degrees were analyzed. In addition, the width of the SNVB, the midsubstance angle of the SNVB, and the distance from the 30-degree point to the tibialis anterior were recorded. RESULTS The mean angle between the SNVB and the standard DL starting point was 13.7 ± 5.0 degrees (P < 0.05), whereas the mean angle using the alternate PL starting point was 17.2 ± 5.3 degrees (P < 0.05). The SNVB width was 5.2 mm [range, 2.6-9.1 mm] (P < 0.05). The distances from the SNVB were greatest for the DL 30-degree group and the PL 0-degree group. CONCLUSIONS The results document angles that should be avoided when using suture button fixation for syndesmosis injuries. Device characteristics and surgery-related variables may require intraoperative modifications, and knowledge of this anatomical relationship may reduce SNVB injury during those situations. Considering our results, we recommend that surgeons place suture buttons from the DL starting point with a 30-degree trajectory to avoid injuries to the SNVB.
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Shimozono Y, Hurley ET, Myerson CL, Murawski CD, Kennedy JG. Suture Button Versus Syndesmotic Screw for Syndesmosis Injuries: A Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2019; 47:2764-2771. [PMID: 30475639 DOI: 10.1177/0363546518804804] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Operative treatment is indicated for unstable syndesmosis injuries, and approximately 20% of all ankle fractures require operative fixation for syndesmosis injuries. PURPOSE To perform a meta-analysis of randomized controlled trials evaluating clinical outcomes between suture button (SB) and syndesmotic screw (SS) fixation techniques for syndesmosis injuries of the ankle. STUDY DESIGN Meta-analysis. METHODS A literature search was performed according to the PRISMA guidelines to identify randomized controlled trials comparing the SB and SS techniques for syndesmosis injuries. Level of evidence was assessed per the criteria of the Oxford Centre for Evidence-Based Medicine. Statistical analysis was performed with RevMan, and a P value ≤.05 was considered statistically significant. RESULTS Five clinical studies were identified, allowing comparison of 143 patients in the SB group with 142 patients in the SS group. Patients treated with the SB technique had a higher postoperative American Orthopaedic Foot & Ankle Society score at a mean 20.8 months (95.3 vs 86.7, P < .001). The SB group resulted in a lower rate of broken implants (0.0% vs 25.4%, P < .001), implant removal (6.0% vs 22.4%, P = .01), and joint malreduction (0.8% vs 11.5%, P = .05) as compared with the SS group. CONCLUSION The SB technique results in improved functional outcomes as well as lower rates of broken implant and joint malreduction. Based on the findings of this meta-analysis, the SB technique warrants a grade A recommendation by comparison with the SS technique for the treatment of syndesmosis injuries.
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Affiliation(s)
- Yoshiharu Shimozono
- Hospital for Special Surgery, New York, New York, USA
- Department of Orthopaedic Surgery, School of Medicine, Teikyo University, Tokyo, Japan
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Eoghan T Hurley
- Hospital for Special Surgery, New York, New York, USA
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - C Lucas Myerson
- Hospital for Special Surgery, New York, New York, USA
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
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14
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Nakasa T, Ikuta Y, Tsuyuguchi Y, Ota Y, Kanemitsu M, Adachi N. Application of a peripheral vein illumination device to reduce saphenous structure injury caused by screw insertion during arthroscopic ankle arthrodesis. J Orthop Sci 2019; 24:697-701. [PMID: 30630767 DOI: 10.1016/j.jos.2018.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/15/2018] [Accepted: 12/10/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Arthroscopic ankle arthrodesis (AAA) is minimally invasive surgery, whereby percutaneous screw fixation is used through the medial aspect of the distal tibia to fusion the ankle, but it carries the risk of the saphenous vein and nerve injuries. The near-infrared (NIR) vascular imaging system, the VeinViewer® Flex, projects an image of the vein onto the skin, and the visualization of the vein may reduce the vein and nerve injuries. The purpose of this study is to investigate the risk of the saphenous vein injury by the percutaneous screw insertion during AAA, and to evaluate the effectiveness of the NIR vascular imaging system in the reduction of the saphenous vein injury. METHODS Ten patients with the ankle osteoarthritis underwent AAA. Three screw insertion sites (proximal as number 1, anterior distal as number 2, and posterior distal as number 3) were marked and then the vein was depicted on the medial malleolus using the VeinViewer® Flex. The distance between the screw insertion sites and the closest vein was measured. Additionally, the pattern of the vein course on the medial aspect of the distal tibia was investigated in 32 ankles using the VeinViewer® Flex. RESULTS The distance of number 1, 2, and 3 from the vein was 2.4 ± 1.4 mm (range from 0 to 5 mm), 6.3 ± 6.6 mm (range from 0 to 20 mm) and 3.5 ± 3.1 mm (range from 0 to 11 mm) respectively. In anterior screw insertion site, 3 of 10 cases showed just on the vein. The veins were observed at the anterior region from the center axis of the tibia more than 75% of ankles which was suspected as the greater saphenous vein with closely running of the saphenous nerve, but also other regions had the crossing vein. CONCLUSIONS Percutaneous screw fixation during AAA runs the risk of causing the saphenous structure injury. The NIR light imaging system is beneficial in reducing the complications of saphenous structure damage in AAA.
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Affiliation(s)
- Tomoyuki Nakasa
- Department of Orthopaedic Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi Minamiku, Hiroshima city, 734-8551, Japan.
| | - Yasunari Ikuta
- Department of Orthopaedic Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi Minamiku, Hiroshima city, 734-8551, Japan
| | - Yusuke Tsuyuguchi
- Department of Orthopaedic Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi Minamiku, Hiroshima city, 734-8551, Japan
| | - Yuki Ota
- Department of Orthopaedic Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi Minamiku, Hiroshima city, 734-8551, Japan
| | - Munekazu Kanemitsu
- Department of Orthopaedic Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi Minamiku, Hiroshima city, 734-8551, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-2-3 Kasumi Minamiku, Hiroshima city, 734-8551, Japan
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15
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Stiene A, Renner CE, Chen T, Liu J, Ebraheim NA. Distal Tibiofibular Syndesmosis Dysfunction: A Systematic Literature Review of Dynamic Versus Static Fixation Over the Last 10 Years. J Foot Ankle Surg 2019; 58:320-327. [PMID: 30612866 DOI: 10.1053/j.jfas.2018.08.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Indexed: 02/03/2023]
Abstract
The goal of the present work was to perform a systematic review of the literature of the past 10 years regarding dynamic and static fixation of the distal tibiofibular syndesmosis to determine any clinical differences between the 2 procedures. A literature search of the PubMed MEDLINE database was conducted to identify relevant studies related to distal tibiofibular syndesmosis. Studies before January 1, 2007, were excluded to limit the project to the recent literature. Clinical outcomes, device removal rates, time to weightbearing after the initial procedure, and the cost effectiveness of each device were explored. In these 26 studies, 350 patients were treated using a dynamic technique and 845 were treated using a static technique. The weighted American Orthopedic Foot and Ankle Score was 91.70 (standard error [SE] 1.87) for dynamic fixation patients and the weighted average was 86.48 (SE 2.17) for static fixation patients (p = .068). A secondary procedure to remove the fixation device was performed in 7.7% of dynamic fixation patients and in 39.4% of static fixation patients when studies with 100% device removal were excluded (p < .0001). The mean time to weightbearing was 5.96 (SE 0.72) weeks for patients who underwent dynamic fixation and 10.45 (SE 0.99) weeks for those who had static fixation (p = .0002). The cost for dynamic fixation was found to be less than that for static fixation when secondary procedures for device removal were considered. Based on similar clinical functional scores, lower secondary procedure rates, faster time to full weightbearing, and lower costs to patients, dynamic fixation of the distal tibiofibular syndesmosis may be a superior option compared with static fixation.
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Affiliation(s)
- Andrew Stiene
- Medical Student, University of Toledo, College of Medicine and Life Sciences, Toledo, OH
| | - Charles E Renner
- Medical Student, University of Toledo, College of Medicine and Life Sciences, Toledo, OH
| | - Tian Chen
- Assistant Professor, University of Toledo, Department of Mathematics and Statistics, Toledo, OH
| | - Jiayong Liu
- Assistant Professor, University of Toledo Medical Center, Department of Orthopedic Surgery, Toledo, OH.
| | - Nabil A Ebraheim
- Professor, Surgeon, and Chair, University of Toledo Medical Center, Department of Orthopedic Surgery, Toledo, OH
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16
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Treatment of Deltoid Injuries Associated With Ankle Fractures. TECHNIQUES IN FOOT AND ANKLE SURGERY 2018. [DOI: 10.1097/btf.0000000000000180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Reb CW, Brandão RA, Watson BC, Van Dyke B, Berlet GC, Prissel MA. Medial Structure Injury During Suture Button Insertion Using the Center-Center Technique for Syndesmotic Stabilization. Foot Ankle Int 2018; 39:984-989. [PMID: 29641268 DOI: 10.1177/1071100718770200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The center-center technique for syndesmosis fixation has been described as an improved and reliable technique for proper reduction of the syndesmosis during ankle fracture repair. Concurrently, the use of flexible fixation with a suture button is becoming an established means of syndesmosis stabilization. The purpose of this cadaveric study was to assess for medial structure injury during the placement of a suture button using the center-center technique for ankle syndesmosis repair at 3 insertion intervals. METHODS Simulated open syndesmosis repair was performed on 10 cadaveric specimens. Three intervals were measured at 10 mm, 20 mm, and 30 mm proximal to the level of the distal tibial articular surface along the fibula. Proper longitudinal alignment of the center-center technique was completed under fluoroscopic guidance and was marked on the medial aspect of the tibia. The 3 intervals were drilled in the appropriate technique trajectory. The suture button was subsequently passed through each drill-hole interval. A single observer used a digital caliper to measure the distance from each suture button aperture with respect to the tibialis anterior tendon, tibialis posterior tendon, and greater saphenous vein and nerve. RESULTS A total of 30 interval measurements (10 cadavers with 3 suture button segments each) were used for data analysis. Direct impingement on the greater saphenous vein was seen in 11 of 30 (36.6%) interval measurements. Six of the 11 (54.5%) observed saphenous structure impingement events occurred at the 10-mm drill hole. CONCLUSION The results of the present study suggest that the use of the center-center technique for syndesmosis repair with suture button fixation risks preventable injury to the greater saphenous neurovasculature. CLINICAL RELEVANCE To understand the medial ankle anatomy, as it pertains to insertion of flexible syndesmotic fixation in a cadaveric model, to aid in prevention of clinical iatrogenic injury.
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Affiliation(s)
- Christopher W Reb
- 1 Foot and Ankle Division, Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | | | | | - Bryan Van Dyke
- 2 Orthopedic Foot and Ankle Center, Westerville, OH, USA
| | | | - Mark A Prissel
- 2 Orthopedic Foot and Ankle Center, Westerville, OH, USA
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18
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Abstract
Orthopedic surgery is not short of situations where there is controversy regarding optimum management. Treating ankle syndesmosis injuries is an example where practice varies widely and there are many questions that remain unsatisfactorily answered. When addressing the type of syndesmosis stabilization that is required it is essential to ascertain the extent of instability. Only then can a logical approach to restoring the ankle mortise be achieved. Fixation of fibula shaft fractures and posterior malleolus fractures can restore sufficient stability to render syndesmosis stabilization unnecessary. The indications and techniques for stabilizing the distal tibiofibular joint are reviewed with clinical examples.
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Affiliation(s)
- Matthew C Solan
- London Foot and Ankle Centre, Hospital of St John and St Elizabeth, 60 Grove End Road, London NW8 9NH, UK; Surrey Foot and Ankle Clinic, Mount Alvernia Hospital, Harvey Road, Guildford, Surrey, GU1 3LX, UK.
| | - Mark S Davies
- London Foot and Ankle Centre, Hospital of St John and St Elizabeth, 60 Grove End Road, London NW8 9NH, UK
| | - Anthony Sakellariou
- Surrey Foot and Ankle Clinic, Mount Alvernia Hospital, Harvey Road, Guildford, Surrey, GU1 3LX, UK
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19
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Imam MA, Matthana A, Kim JW, Nabil M. A 24-Month Follow-Up of a Custom-Made Suture-Button Assembly for Syndesmotic Injuries of the Ankle. J Foot Ankle Surg 2017; 56. [PMID: 28633770 PMCID: PMC7111150 DOI: 10.1053/j.jfas.2017.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In the present retrospective analysis, we introduce a custom suture-button fixation device for acute ankle syndesmotic injuries that allows for early weightbearing without another planned operation for hardware removal. We evaluated 87 consecutive ankles in 87 patients (49 males [56.32%] and 38 females [43.68%]). Of the 87 patients, 15 (17.24%) withdrew or were lost to follow-up, leaving 72 patients (82.76%) in the present study. Their mean age was 35.2 (range 17 to 67) years. Nineteen patients (26.39%) presented with a pure syndesmotic disruption, and 53 (73.61%) had associated malleolar fractures. The American Orthopaedic Foot and Ankle Society scale score improved significantly from 31.2 ± 4.2 preoperatively to 88.5 ± 5.3 at an average of 24 months postoperatively (p < .0043). Revision was undertaken because of implant failure in 4 ankles (5.56%). Two revisions (2.78%) were performed in 2 ankles because of early weightbearing in the first 2 weeks after surgery. The third patient (1.39%) underwent revision at 5 weeks postoperatively. This syndesmotic reduction failure was attributed to failure of the threads, which was noted at the second surgery. The fourth patient (1.39%), a 66-year-old male, underwent revision at 5 months postoperatively because of persistent infection. An 18-month postoperative radiograph was available for all patients. The medial clear space had significantly decreased, from 8.2 ± 3.1 mm preoperatively to 3.5 ± 2.2 mm at 18 months postoperatively (p < .0344). Likewise, the tibiofibular clear space had decreased significantly, from a mean of 8.8 ± 3.7 mm preoperatively to a mean of 3.7 ± 2.2 mm at 18 months postoperatively (p < .0322). In conclusion, suture-button fixation described in the present report delivered satisfactory functional outcomes and anatomic reduction at minimum of 18 months after surgery.
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Affiliation(s)
- Mohamed A. Imam
- Senior Lecturer and Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt,Address correspondence to: Mohamed A. Imam, MD, PhD, FRCS(Tr & Orth), Department of Orthopaedic Surgery, Faculty of Medicine, Suez Canal University, Circular Road, Ismailia, Egypt.
| | - Ahmed Matthana
- Senior Lecturer and Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Ji Wan Kim
- Associate Professor, Department of Orthopaedic Surgery, Haeundae Paik Hospital, Inje University, Busan, South Korea
| | - Mohamed Nabil
- Senior Lecturer and Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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