Anterior Compartment Of Thigh Research Articles

Delayed Compartment syndrome after total knee replacement: A case report with short review

Purpose: We would like to report a case which developed delay anterior thigh compartment syndrome after total knee replacement surgery and review the underlying risk factors. Method: A 67years old lady was suffered from delay thigh anterior compartment syndrome 4 days after total knee replacement surgery. Urgent fasciotomy was performed. Later work up showed a large intramuscular haematoma within the anterior compartment which required drainage. Discussion: Short review was performed to identify the risk factors for developing compartment syndrome after total knee replacement surgery. Management strategy and prognosis was also discussed. Conclusion: Compartment syndrome should be diagnosed and treated promptly. Patient with underlying risk factors must be identified and with close monitoring of this rare complication in post-operative period.

Anterior Thigh Myxofibrosarcoma with Management of Wide Excision and Modified Anterior Thigh Compartment Resection : A Case Report

Introduction: Myxofibrosarcoma (MFS) is a type of malignancy from the group of malignant fibrous histiocytoma. Myfxofibrosarcoma is a type of soft tissue neoplasm that is aggressive. The clinical symptoms are not pathognomonic and the histological picture is very heterogeneous, often receiving delayed treatment and causing misdiagnosis. Complementary histochemical and immunohistochemical staining is mandatory to confirm the diagnosis of MFS. Extensive surgical treatment and followed by radiotherapy is the first choice of myxofibrosarcoma treatment.
 Case Presentation: A 54-years old woman complained of a lump on her left thigh that had been getting bigger for the past 2 years. The lump initially looked the size of a marble, then grew to the size of a tennis ball in the last 7 months. On physical examination, a mass was found in the left thigh area, a hard, fixed mass, the size of a tennis ball. Fine needle aspiration examination showed suspicious results for myxofibrosarcoma. The patient underwent a Magnetic Resonance Imaging examination in the left lower extremity area and underwent wide excision and anterior thigh compartment resection surgery.
 Discussion: Wide resection is the standard treatment for MFS [4]. The choice of procedure for each patient is different and should be based on tumor size, location, stage, surrounding neurovascular and bony elements, as well as functional and cosmetic considerations [4]. The minimum resection margin in MFS is at least 1 cm which aims to minimize the risk of local recurrence [4]. The recommended resection margin is at least 2 cm for MFS resection [4]. We had plan a 2 cm margin of the entire preoperative MRI enhancement area. It should be noted that the local recurrence rate for MFS in margin-negative resections is relatively high compared with other STS subtypes.
 Conclusion: We recommend Wide Excison and Modified Anterior Thigh compartment Resection is recommended procedure for anterior thigh myxofibrosarcoma. This procedure involves preserving uncontaminated thigh neurovascular, and only resecting one of the sarcoma-infiltrated muscle heads and preserving the other quadriceps muscle head of the thigh to maintain knee extension function. This paper is the first report on the successful treatment of anterior thigh myxofibrosarcoma without weakness of knee extension complication.

Cas rare de reconstruction de la loge antérieure de cuisse après résection d’un sarcome de haut grade par technique hybride : lambeau libre de grand dorsal associé à un lambeau gastrocnémien médial pédiculé

The soft tissue sarcomas of the limbs require extensive surgical excision. Reconstructive surgery plays an essential role in its management to preserve the limb, as exposed in a case of thigh sarcoma. A 73-year-old patient has a large sarcoma within the quadriceps. Its excision requires resection of the entire anterior thigh compartment. Preservation of the limb is permitted by reconstruction by latissimus dorsi free flap and medial gastrocnemius pedicled flap. The patient resumed walking using an orthosis at 3months. Surgery to remove a sarcoma of a limb can threaten the integrity of the limb. Plastic surgery, with all the reconstruction techniques, contributes to the preservation of a functional limb.

P.74 Using high-field magnetic resonance spectroscopy to measure muscle glycogen in patients with McArdle disease

Glycogen plays a critical role as an energy source in skeletal muscle. McArdle disease is a recessively inherited disorder in which muscle glycogen breakdown is blocked due to myophosphorylase deficiency. The patients suffer from severe exercise intolerance marked by premature fatigue with muscle contractures and episodic rhabdomyolysis. Additionally, some patients show progressive muscular atrophy when they get older, mainly in lumbar paraspinal muscles but not in thigh or calf muscles. The cause of fat replacement in older McArdle patients is unknown but could relate to a higher glycogen accumulation in their muscles. Utilizing the high sensitivity of 13C magnetic resonance spectroscopy at 7 Tesla field strength, we wanted to quantify muscle glycogen in lumbar, thigh and calf muscles in young McArdle patients as well as healthy controls to test the hypothesis of variable glycogen content in muscles of patients with McArdle disease. Preliminary results from 5 patients and 8 controls, show increased muscle glycogen concentration in the calf (4.4 times normal levels, p = 0.002), hamstrings (2.7 times normal levels, p = 0.02) and anterior thigh compartment (3.2 times normal levels, p = 0.01), while there was no difference in the lumbar muscle glycogen content vs. healthy (p = 0.6). No clear pattern of muscle glycogen distribution was seen in neither the McArdle nor the control groups. Our results are in line with previous studies in that we see a 3-5 times increase in glycogen compared to control. Surprisingly, this is not seen in the lumbar muscle group, which is the muscle group most prone to fat replacement with age. Thus, it does not appear that a difference in glycogen concentration between muscles of McArdle patients can explain the fat replacement seen in specific muscles groups of older patients.

FP.19 Quantification of glycogen distribution in late-onset Pompe patients using 7 Tesla C13 NMR spectroscopy

Pompe disease is an autosomal recessive disorder, caused by acid alpha-glucosidase deficiency, which limits the lysosomal breakdown of glycogen, causing accumulation in muscle tissue. Pompe patients suffer from fat replacement of muscle tissue and muscle atrophy, leading to muscle weakness. MRI studies have shown a characteristic pattern with fat replacement of the axial muscles (latissimus dorsi, paraspinal muscles and psoas) and the hamstrings (especially semimembranosus), while distal muscles, and muscles of the anterior thigh compartment are less affected. The aim of this study is to investigate if higher levels of muscle glycogen precede the fat replacement of muscles in Pompe disease. We used C13 NMR spectroscopy at 7 Tesla, to measure the total glycogen value in four muscle groups; the lumbar muscles, the anterior compartment of the thigh, the hamstrings and the calf. The fat-free muscle volume was found using T1 and Dixon sequences and the glycogen concentrations were determined as the total glycogen levels divided by the fat-free muscle volume of distribution. Young Pompe patients with relatively preserved muscles and healthy controls were included. Preliminary results from the first two patients show a higher glycogen concentration in the lumbar and hamstring muscles than in the anterior compartment of the thigh and the calf. Compared to the calf, the glycogen concentration was about fifty percent higher in the lumbar muscles, and twice as high in the hamstrings. Hamstrings had twice as high glycogen levels compared to the anterior compartment of the thigh. Compared to eight healthy controls, the glycogen concentration was 2-3 times higher in all muscle groups of the patients. No clear pattern of muscle glycogen distribution was seen in the control group. These preliminary results indicate a link between high levels of glycogen accumulation in muscle tissue and the subsequent late pattern of fat replacement in Pompe diseases. This is important for the understanding of pathogenesis of muscle wasting in Pompe disease, but could also be an important biomarker for treatment success.

Prevalence of the additional head of quadriceps femoris in the South Indian population: a cadaveric and radiological study

Quadriceps femoris is an extensor muscle in the anterior compartment of thigh and is traditionally taught to be composed of four heads. Recently, there is an increased interest in the occurrence of an additional muscle head of quadriceps femoris. But scientific knowledge regarding its incidence is lacking in the South Indian population. This study was done to confirm the presence of the additional head by routine anatomic dissection and radiological imaging techniques. Forty-one formalin fixed human cadaveric lower limbs were dissected and the morphology of the additional head was noted. Retrospective analysis of 88 MRI images of patients was done. The additional muscle head was present in 43.9% of the cadaveric lower limbs and was consistently located between the vastus lateralis and vastus intermedius. It originated from variable portions of the greater trochanter, intertrochanteric line, lateral lip of linea aspera and lateral surface of the shaft of femur and inserted either as a muscle belly or as an aponeurosis into the vastus intermedius (55.6%), vastus lateralis (22.2%) or directly into the base of the patella. It received its vascular supply from branches of the lateral circumflex femoral artery and was innervated by branches from the posterior division of the femoral nerve. In addition, the additional muscle head was identified by MRI and its incidence was reported to be 30.68% for the first time in living subjects. The result of this study provides additional information in understanding the morphology of the quadriceps femoris muscle.

Surekha Pai

This is a case report of patient diagnosed as IVDP present with tingling sensation over anterior and lateral compartment of thigh followed by pain over low back region radiates up to right ankle since one year. MRI revealed degenerative changes and disc protrusion at L3-L4, L4-L5 and disc extrusion at L5-S1 levels. Clinically the patient was present with symptoms of vatika Gridhrasi explained in Ayurveda classics. The patient was managed with Katibasti with Sahacharadi taila (7 days) followed by Patrapotali sweda and Erandamuladi Niruha vasti (8 days) along with Sahacharadi kashaya internally (50 ml BD B/F) in first visit. Patient continued the internal medicine and after a gap of one month, she was administered same protocol with Rajayapana vasti on second visit. Two assessment were made after treatment using ODI. After second visit ODI changed from severe to moderate disability.

Anatomical variations in the origins of the lateral circumflex femoral arteries in a South African sample: A cadaver study

BackgroundClinically, the lateral circumflex femoral artery (LCFA) is used in a variety of procedures, these include anterolateral thigh flaps, aortopopliteal bypass, coronary artery bypass grafting and extracranial-intracranial bypass surgeries. Variations in the anatomy of the LCFA, profunda femoris artery (PFA) and their branches have been noted in several studies. There are numerous clinical implications related to the inadequate anatomical knowledge of this region. MethodsThe study sample consisted of 55 cadavers of different ages, ancestry groups and varying body mass index. A total of 90 legs were dissected. The anterior thigh compartment was dissected and the common femoral artery (CFA), superficial femoral artery (SFA), PFA and LCFA further exposed. The course and variations were noted and results documented for further analysis. ResultsThe LCFA was present in all the legs dissected. The origin of the LCFA was found to be the PFA in 75.6% of the left legs and 82.2% of the right legs dissected.In two cases, a male and female limb, the branching of the PFA from the CFA was observed directly from the external iliac artery, deep to the inguinal ligament.A variation was noted in a female cadaver, where the branches of the LCFA on the left limb had different points of origin. Another variation was noted on a male cadaver, the left limb had two different points of branching for the ascending and descending branches of the LCFA, a common trunk was absent. ConclusionThis study indicates that the most common site of origin for the LCFA was the PFA. The branching of the PFA from the CFA was found to be variable in 2.2% of the cases, where the PFA was a direct branch of the external iliac artery. The study also noted variations relating to the origin of the transverse branch of the LCFA, this branch was absent in 4.4% of the limbs dissected.Knowledge of the variations related to the origin of the PFA, LCFA and their branches is important in reducing the chances of intra-operative bleeding, during different surgical procedures.

Noncontrast Magnetic Resonance Imaging of Perforators for Preoperative Evaluation of Anterolateral Thigh Flaps.

Background:The anterolateral thigh (ALT) flap is a commonly utilized perforator-based flap in reconstructive surgery. Although previous studies have used various angiographic techniques to preoperatively image ALT perforators, none have investigated the efficacy of noncontrast magnetic resonance imaging (MRI). Our study investigates the efficacy of our institutional fat suppression noncontrast MRI sequence to characterize the number, location, and course of dominant skin perforators in the ALT for preoperative planning.Methods:We queried our institutional database for 100 noncontrast thigh MRIs from July 2013 to July 2018 that included an axial fat suppression sequence with visualization from the lesser trochanter to the distal musculotendinous junction of the rectus femoris. Perforator course, size, and location relative to bony landmarks were determined.Results:Of the 100 examinations, 70 included bilateral thighs for a total of 170 thighs for perforator analysis. An estimated 277 perforators were identified, of which 101 were septocutaneous (36.5%) and 176 were musculocutaneous (63.5%). An average of 1.63 perforators were visualized in each thigh (min, 1; max, 4). The average perforator diameter at exit from the anterior thigh compartment fascia was 2.5 mm (SD, 0.5). Perforator exit location along the anterior superior iliac spine- or lesser trochanter-patella line could be determined for n = 57 perforators and mapped into 3 predictable clusters.Conclusions:At least 1 perforator was found in each of 170 thighs imaged. Perforator course, size, and location measured with noncontrast MRI are consistent with prior literature. Noncontrast MRI is a low-morbidity imaging modality that may serve as an effective tool in preoperative planning of the ALT flap.

Traumatic Pseudoaneurysm of the Lateral Circumflex Femoral Artery Presenting as Anterior Thigh Compartment Syndrome: A Rare Complication of Intracapsular Hip Fracture Fixation

Vascular complications after orthopedic surgery are rare. These can have disastrous effects and prompt recognition is of utmost importance. Our case report discusses a rare complication of pseudoaneurysm of the lateral circumflex femoral artery, following fixation of an intracapsular hip fracture. We have reviewed literature and suggested learning points. J Med Cases. 2017;8(7):211-214 doi: https://doi.org/10.14740/jmc2807w

Traumatic Pseudoaneurysm of the Lateral Circumflex Femoral Artery Presenting as Anterior Thigh Compartment Syndrome: A Rare Complication of Intracapsular Hip Fracture Fixation

Traumatic Pseudoaneurysm of the Lateral Circumflex Femoral Artery Presenting as Anterior Thigh Compartment Syndrome: A Rare Complication of Intracapsular Hip Fracture Fixation

Skeletal Muscle Magnetic Resonance Imaging of the Lower Limbs in Late-onset Lipid Storage Myopathy with Electron Transfer Flavoprotein Dehydrogenase Gene Mutations.

Background:Lipid storage myopathy (LSM) is a genetically heterogeneous group with variable clinical phenotypes. Late-onset multiple acyl-coenzyme A dehydrogenation deficiency (MADD) is a rather common form of LSM in China. Diagnosis and clinical management of it remain challenging, especially without robust muscle biopsy result and genetic detection. As the noninvasion and convenience, muscle magnetic resonance imaging (MRI) is a helpful assistant, diagnostic tool for neuromuscular disorders. However, the disease-specific MRI patterns of muscle involved and its diagnostic value in late-onset MADD have not been systematic analyzed.Methods:We assessed the MRI pattern and fat infiltration degree of the lower limb muscles in 28 late-onset MADD patients, combined with detailed clinical features and gene spectrum. Fat infiltration degree of the thigh muscle was scored while that of gluteus was described as obvious or not. Associated muscular atrophy was defined as obvious muscle bulk reduction.Results:The mean scores were significantly different among the anterior, medial, and posterior thigh muscle groups. The mean of fat infiltration scores on posterior thigh muscle group was significantly higher than either anterior or medial thigh muscle group (P < 0.001). Moreover, the mean score on medial thigh muscle group was significantly higher than that of anterior thigh muscle group (P < 0.01). About half of the patients displayed fat infiltration and atrophy in gluteus muscles. Of 28 patients, 12 exhibited atrophy in medial and/or posterior thigh muscle groups, especially in posterior thigh muscle group. Muscle edema pattern was not found in all the patients.Conclusions:Late-onset MADD patients show a typical muscular imaging pattern of fat infiltration and atrophy on anterior, posterior, and medial thigh muscle groups, with major involvement of posterior thigh muscle group and gluteus muscles and a sparing involvement of anterior thigh compartment. Our findings also suggest that muscle MRI of lower limbs is a helpful tool in guiding clinical evaluation on late-onset MADD.

Anterior approach in a huge lipomatous tumor of the thigh.

Confronted with a huge lipomatous anterior thigh tumor, the surgical approach had to be assessed. Those described in the literature did not seem appropriate for our case so some modifications were made. We present the case of a 77-year-old woman who presented with a huge anterior thigh compartment tumor with one-year evolution. Magnetic resonance imaging informed the presence of a lipomatous tumor with a possible vascular contact. Based on Thomson's anterior approach, but modifying the skin incision, the medial distal femur was reached until the neurovascular bundle and, proximally, the lesser trochanter. The tumor was totally resected due to a good visualization using this approach.

Topographical anatomy of the profunda femoris artery and the femoral nerve: normal and abnormal relationships.

Femoral nerve (FN) is the largest branch of lumbar plexus. It lies lateral to femoral artery (FA) and it is located outside the femoral sheath. Profunda femoris artery (PFA) is a branch of the FA. The present study aimed to observe the topographical anatomy and relationship of the PFA and the FN. A total of 12 embalmed cadaveric lower limbs (7 lefts and 5 rights) were taken and the thighs were dissected in detail. The relationship of PFA and FN were observed. Appropriate measurements were taken and the specimens were photographed. The PFA originated from the FA in all the 12 specimens (100%). In 10 specimens (83.3%), the PFA was found to originate lateral to the FA while in 2 specimens, the origin of PFA was posterior to the FA (16.7%). The PFA originated from the FA at a distance of 6.5 + 1.5 cm with regard to the midinguinal point. All FN were found to lie outside the femoral sheaths. Out of the 12 specimens, only 2 specimens (16.7%) exhibited the FN to lie posterior to the PFA, while in 10 specimens (83.3%), the FN was found to lie anterior to the PFA. Prior anatomical knowledge of structures in the anterior compartment of thigh may be helpful for surgeons performing nerve block, cannulation and catheterization. Knowledge of abnormal anatomy of the FN and PFA is important in order to prevent any inadvertent injury to the PFA or FN.

G.P.58 Muscle MRI in a filaminopathy family: Involvement of paraspinals is earlier and more severe than of thigh muscles

Mild to severe weakness of proximal and distal limb muscles is common in all types of myofibrillar myopathies (MFM). In clinical practice, it is important to know the specific distribution patterns of muscle involvement in order to differentiate the various subtypes. Muscle MRI is a useful tool to show the distribution and severity of muscle involvement in different muscle diseases. Here we report two patients with p.W2710X in FLNC gene mutation from a Macedonian family with 18 affected members. The patients were a male at 55 and a female at 51 years of age with 14 and 8years of disease duration, respectively. The onset symptom in both patients was difficulty in holding the waist up upon rising from a chair or climbing stairs. Muscle strength evaluation revealed that the most severely affected muscles were the lower extremity proximal and the trunk muscles in each patient without a significant difference in weakness distribution pattern. Muscle MRI scans for thigh, pelvic and lower paraspinal muscles were performed. Regardless of the duration of the disease the most severely affected muscles were the paraspinals, practically almost totally replaced by fat in both patients. Although to a slightly lesser degree, another relatively severely affected group was the posterior thigh muscles. Involvement in this latter group and in even the less affected gluteus maximus showed correlation with the disease duration. Anterior thigh compartment muscles seemed to remain relatively spared. Filaminopathy has not been listed among the myopathies that predominantly involve the trunk muscles. Although more reports are needed, our experience in two patients suggests that the inclusion of the lower paraspinal region in muscle MRIs in the work-up of MFMs may be a useful tool to differentiate filaminopathies from the other MFM subgroups.

Anterior thigh compartment syndrome after prone positioning for lumbosacral fixation

We report a case of a patient who developed anterior thigh compartment syndrome after being positioned prone for instrumented lumbar spine surgery. Although rare, clinicians should be aware that compartment syndrome is a possible complication of spinal surgery.

Compartment syndrome of the thigh after blunt trauma: a complication not to be ignored

We report a case of anterior thigh compartment syndrome, which occurred after man's thigh was bruised after flipping repeatedly over his bike and being hit by the frame of the bike nearly at around 6 pm. The next day at 1:30 am, he was admitted to the hospital. The initial presentation was a hematoma, and the patient was kept in bed with local cooling. The compartment syndrome of the thigh (CST) diagnosis was made around 6:00 pm when the level of pain was interpreted as disproportionate to the treated lesion; anterior compartment pressure measure was 84 mmHg. A compartment fasciotomy was performed. It is difficult to diagnose a CST in case of muscular contusion as the latter causes symptoms that are similar to CST. A conservative treatment without fasciotomy was carried out by several authors, especially in sportsmen showing a CST following contusion. This conservative treatment implies close monitoring of intramuscular pressures and adjuvant measures (bed rest, holding the thigh at the heart level and oxygenotherapy).

Pseudoaneurysm of the Distal Thigh After Manipulation of a Total Knee Arthroplasty

The authors describe a unique complication after manipulation of a stiff total knee arthroplasty in a 47-year-old man. Four days after undergoing manipulation under anesthesia (MUA), the patient presented with increasing pain and swelling of the affected knee and decreased hemoglobin/hematocrit. Computed tomographic angiogram revealed a ruptured pseudoaneurysm of a segmental branch of the deep femoral artery that was treated with embolization and anterior thigh compartment fasciotomy. Although many complications of MUA have been described, we present a novel finding of a ruptured pseudoaneurysm. Ruptured pseudoaneurysm should be included in the differential diagnosis whenever a patient presents with pain and swelling of the thigh after MUA given its potential morbidity.

Necrotising fasciitis of the lower limb due to perforated inguinal hernia

Acute inguinal hernia complications (incarceration, strangulation) are relatively frequent conditions, especially in the elderly. Urgent surgery is the appropriate treatment if manual reduction is not achieved or strangulation or perforation is suspected. We present a 77-year-old patient with necrotising fasciitis of the lower limb as a consequence of extraperitoneal perforation of a sliding inguinal hernia. This devastating condition was diagnosed 20h after the manual reduction of the hernia. Suspicion arose at the physical examination (crepitation, signs of cellulitis) and clinical deterioration of the patient, and was confirmed by computed tomography (CT) scanning. Urgent surgery was performed, including sigmoidectomy, debridement of the necrotic tissues of the medial and anterior thigh compartment, and fasciectomy, combined with optimal intensive care support. No signs of peritoneal or pelvic involvement were found. However, the comorbidities, advanced age and the progression of the disease led to fatal outcome. Early recognition of the complications of strangulated hernias is of vital importance for successful treatment in these cases, even if no signs of acute abdomen are present.

Thigh compartment syndrome after intramedullary femoral nailing: Possible femoral nerve block influence on diagnosis timing

We report a case of anterior thigh compartment syndrome (TCS), which occurred after a closed femoral fracture internal fixation using an intramedullary rod. A 20 ml ropivacaine hydrochloride single-injection femoral block had preceded general anaesthesia to conduct the surgical procedure. The compartment syndrome diagnosis was made the morning after surgery when the level of pain was interpreted as disproportionate to the treated lesion; in addition, compartment pressure measure had increased to 54 mmHg. A compartment fasciotomy was performed. Diagnostic delays have previously been observed and attributed to nerve blocks in cases of tibial fracture. This patient's report raises the question of whether a femoral block may be responsible for delays in diagnosing compartment syndrome, although no series have been published of such occurrences in large numbers. When nerve blocks are used, they should be more analgesic than anaesthetic. Careful patient monitoring remains important.