The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan. We reviewed a total of 37 ankles (34 patients) that had undergone bone grafting for periprosthetic bone cysts. A CT scan was performed one year after bone grafting to check the status of graft incorporation. For accurate analysis of cyst volumes and their postoperative changes, 3D-reconstructed CT scan processed with 3D software was used. For functional outcomes, variables such as the Ankle Osteoarthritis Scale score and the visual analogue scale for pain were measured.Aims
Methods
With an aging population and increase in total knee arthroplasty, periprosthetic distal femur fractures (PDFFs) have increased. The differences between these fractures and native distal femur fractures (NDFF) have not been comprehensively investigated. The purpose of this study was to compare the demographic, fracture, and treatment details of PDFFs compared to NDFFs. A retrospective study of patients ≥ 18 years old who underwent surgical treatment for either a NDFF or a PDFF from 2010 to 2020 at a level 1 trauma center was performed. Demographics, AO/OTA fracture classification, quality of reduction, fixation constructs, and unplanned revision reoperation were compared between PDFF patients and NDFF patients using t-test and Fisher's exact test.
209 patients were identified with 70 patients having a PDFF and 139 patients having a NDFF. Of note, 48% of NDFF had a concomitant fracture of the ipsilateral knee (14%) or tibial plateau (15%). The most common AO/OTA classification for PDFFs was 33A3.3 (71%). NDFFs had two main AO/OTA classifications of 33C2.2 (28%) or 33A3.2. (25%). When controlling for patient age, bone quality, fracture classification, and fixation, the PDFF group had increased revision reoperation rate compared to NDFF (P < 0.05). PDFFs tend to occur in elderly patients with low bone quality, have complete metaphyseal comminution, and be isolated; whereas, NDFF tend to occur in younger patients, have less metaphyseal comminution, and be associated with other fractures. When controlling for variables, PDFF are at increased risk of unplanned revision reoperation. Surgeons should be aware of these increased risks in PDFFs and future research should focus on these unique fracture characteristics to improve outcomes.
Determine the prevalence, etiologies, and risk factors of unplanned return to the OR (UROR) in adult orthopaedic trauma patients. Retrospective review of a trauma prospective registry from 2014 – 2019 at a Level 1 academic hospital. An UROR was defined as a patient returning to OR unexpectedly following a planned definitive surgery to either readdress the presenting diagnosis or address a complication arising from the index procedure. Univariate and multivariate logistic regression was performed comparing those patients with an UROR versus those without. A total of 1568 patients were reviewed. The rate of UROR was 9.8% (153 patients). Symptomatic implant was the leading cause of UROR (60%). Other significant UROR causes were infection (15%) and implant failure (9%). The median time between index procedure and UROR was 301 days. For the univariate and multivariate analysis, open fracture (p< 0.05), fracture complexity (p<0.01), and weekend procedure (p< 0.01) were all associated with increased risk of UROR. All other variables were not statistically significant for any associations. Those patients with an UROR for reasons other than symptomatic implants were more likely to have polyorthopaedic injuries (p < 0.05), ISS > 15 (p < 0.05), osteoporosis (p < 0.01), ICU status (p < 0.05), psychiatric history (p < 0.05), compartment syndrome (p < 0.05), neurovascular injury (p < 0.01), open fracture (p < 0.05), and fracture complexity (p < 0.05). The rate of UROR in the orthopaedic trauma patient population is 10%. Most of these cases are due to implant-related issues. UROR for reasons other than symptomatic implants tend to be polytraumatized patients with higher-energy injuries, multiple complex fractures, and associated soft tissue injuries. Future focus on improved implant development and treatments for polytraumatized patients with complex fractures is warranted to decrease a relatively high UROR rate in orthopaedic trauma.
To test the hypothesis that reseeded anterior cruciate ligament (ACL)-derived cells have a better ability to survive and integrate into tendon extracellular matrix (ECM) and accelerate the ligamentization process, compared to adipose-derived mesenchymal stem cells (ADMSCs). Acellularized tibialis allograft tendons were used. Tendons were randomly reseeded with ACL-derived cells or ADMSCs. ACL-derived cells were harvested and isolated from remnants of ruptured ACLs during reconstruction surgery and cultured at passage three. Cell suspensions (200 µl) containing 2 × 106 ACL-derived cells or ADMSCs were prepared for the purpose of reseeding. At days 1, 3, and 7 post-reseeding, graft composites were assessed for repopulation with histological and immunohistochemical analysis. Matrix protein contents and gene expression levels were analyzed.Aims
Methods
The use of routine sampling for histological analysis during revision hip replacement has been standard practice in our unit for many years. It is used to identify the presence of inflammatory processes that may represent peri-prosthetic infection. This study follows up on a smaller study in the same unit in 2019 where an initial 152 cases were scrutinised. In this follow up study we examined 1,361 consecutive patients over a 16-year period whom had undergone revision hip replacement in a tertiary orthopaedic centre for any reason excluding primary bone tumour or malignant metastasis. All patients had tissue sampling for histopathological analysis performed by consultant histopathologists with a specialist interest in musculoskeletal pathology. The presence of bacteria in greater than 50% of samples sent for microbiological analysis in each patient was used as the gold standard diagnostic comparator for infection. This was then compared with the histology report for each patient. After excluding 219 patients with incomplete data and 1 sample rejection, 1,141 cases were examined. Microbiology confirmed infection in 132 cases (prevalence of infection 11.04%) and histopathology analysis suggested infection in 171 cases. Only 64 cases with confirmed infection in more than 50% of microbiology samples had concurrent diagnosis of infection on histological analysis (5.60% of total; PPV 51.20%). Furthermore, microbiology analysis confirmed infection in 62 cases where histological analysis failed to identify infection (5.43% of total; False negative rate 49.21%). Overall, histopathology analysis was seen to have a good specificity of 93.99% but poor sensitivity of 50.79%. We believe that this is the largest series in the literature and is somewhat unique in that all histology analysis was performed by consultant histopathologists with specialist interest in musculoskeletal pathology. Based on the costs incurred by this additional investigation our experience does not support routine sampling for histological analysis in revision hip arthroplasty. This is a substantial paradigm shift from current practice among revision arthroplasty surgeons in the United Kingdom but would equate to a substantial cost saving.
This study aimed to identify the tibial component and femoral component coronal angles (TCCAs and FCCAs), which concomitantly are associated with the best outcomes and survivorship in a cohort of fixed-bearing, cemented, medial unicompartmental knee arthroplasties (UKAs). We also investigated the potential two-way interactions between the TCCA and FCCA. Prospectively collected registry data involving 264 UKAs from a single institution were analyzed. The TCCAs and FCCAs were measured on postoperative radiographs and absolute angles were analyzed. Clinical assessment at six months, two years, and ten years was undertaken using the Knee Society Knee score (KSKS) and Knee Society Function score (KSFS), the Oxford Knee Score (OKS), the 36-Item Short-Form Health Survey questionnaire (SF-36), and range of motion (ROM). Fulfilment of expectations and satisfaction was also recorded. Implant survivorship was reviewed at a mean follow-up of 14 years (12 to 16). Multivariate regression models included covariates, TCCA, FCCA, and two-way interactions between them. Partial residual graphs were generated to identify angles associated with the best outcomes. Kaplan-Meier analysis was used to compare implant survivorship between groups.Aims
Methods
Management and outcomes of fungal periprosthetic joint infection (PJI) remain unclear due to its rarity. Although two-stage exchange arthroplasty is considered a treatment of choice for its chronic features, there is no consensus for local use of antifungal agent at the 1st stage surgery. The purpose of this study was to evaluate the efficacy of antifungal-impregnated cement spacer in two-stage exchange arthroplasty against chronic fungal PJIs after total knee arthroplasty (TKA). Nine patients who were diagnosed and treated for chronic fungal PJIs after TKA in a single center from January 2001 to December 2016 were enrolled. Two-stage exchange arthroplasty was performed. During the 1st stage resection arthroplasty, amphotericin-impregnated cement spacer was inserted for all patients. Systemic antifungal medication was used during the interval between two stage operations. Patients were followed up for more than 2 years after exchange arthroplasty and their medical records were reviewed.Purpose
Methods
The use of open wedge high tibial osteotomy (OWHTO) to reduce knee pain by transferring weight-bearing loads to the relatively unaffected lateral compartment in varus knees and to delay the need for a knee replacement by slowing or stopping destruction of the medial joint compartment. To maintain the stability of OWHTO, the most common type of plate was T-Plate as the locking compression plate (LCP) concept. Anterior portion of T-Plate infringe patient's soft tissue resulted in some complications, whereas anatomical L-plate does not. To evaluate the structural stability of the anatomically contoured L-plate in the present study, the effect of weight bearing after osteotomy should be reviewed in the point of the stress of the plate and screws. We hypothesize that its stress path diverge through collateral portion of tibia and the stress level in screws lowered comparing to the result of T-plate presented in existing literature. Based on the postoperative CT data were made from the reconstruction model for finite-element model. The value of Young's modulus and Poisson's ratio were 17,000MPa and 0.36 for cortical bone and 300MPa and 0.3 for cancellous bone. The anatomically contoured L-Plate system, the material of all plate systems were surgical Ti-Alloy were homogeneous and linear properties (Young's modulus = 113,000MPa, Poisson's ratio = 0.33). The screw system were the same as the material properties of the anatomically contoured L-Plate system. For finite element analysis, both the bone and screws were contacted as general condition. And the screws and plate were contacted as tie contact(Figure 1). The load conditions were applied to the top of the tibia based physiological (=1400N) and surgical loads (=200N). In this study, the compressive-bending load was applied to the two nodal points corresponding to the centers of each tibial condyle and divided into 60% and 40% to the medial and lateral sides, respectively. The physiological loads applied in the quadrant section on the proximal tibia.(Chu-An Luo, 2013)Introduction
Materials and Methods
Open-wedge high tibial osteotomy (OWHTO) is an operation involving proper load re-distribution in the treatment for medial uni-compartmental arthritis of the knee joint. Therefore, stable fixation is mandatory for safe healing of this additive type of osteotomy to minimize the risk of non-union and loss of correction. For stability, screws provide optimal support and anchorage of the fixator in the condylar area without risking penetration of either the articulating surface. The purpose of the study was to evaluate the screw insertion angle and orientation with an anatomical plate that is post-contoured to the surface geometry of the proximal tibia after OWHTO. From March 2012 to June 2014, 31 uni-planar and 38 bi-planar osteotomies were evaluated. Postoperative computed tomography data obtained after open wedge high tibial osteotomy using a locking plate were used for reconstruction of the 3 dimensional model with Mimics v.16.0 of the proximal tibia and locking plate. Measurement data were compared between 2 groups (gap lesser than or equal to 10 mm (Group 1) and gap greater than 10 mm(Group 2)). These data were also compared between the uniplanar (Group 3) and bi-planar (Group 4) osteotomy groups.Background
Methods
The Rotational alignment is an important factor for survival total knee Arthroplasty. Rotational malalignment causes knee pain, global instability, and wear of the polyethylene inlay. Also, the anterior cortex line was reported that more reliable and more easily identifiable landmark for correct tibial component alignment. The aims of the current study is to identify effect of inserting the tibial baseplate of using anterior cortex line landmark of TKA on stress/strain distributions within cortical bone and bone cement. Through the current study, final aim is to suggest an alternative position of tibia baseplate for reduction of TKA failures with surgical convenience. A three-dimensional tibia FE model with TKA was generated based on a traditional TKA surgical guideline. Here, a commercialized TKA (LOSPA, Corentc, Korea) was considered corresponded to a patient specific tibia morphology. Tibia baseplate was positioned at anterior cortex line. Alternative two positions were also considered based on tibia tuberosity 1/3 line and tibia tuberosity end line known as a gold standard Introduction
Materials and Method
Rotational alignment is important for the long-term success and good functional outcome of total knee arthroplasty (TKA). While the surgical transepicondylar axis (sTEA) is the generally accepted landmark on the distal femur, a precise and easily identifiable anatomical landmark on the tibia has yet to be established. Our aim was to compare five axes on the proximal tibia in normal and osteoarthritic (OA) knees to determine the best landmark for determining rotational alignment during TKA. One hundred twenty patients with OA knees and 30 without knee OA were recruited for the study. Computed tomography (CT) images were obtained and converted through multiplanar reconstruction so the angles between the sTEA and the axes of the proximal tibia could be measured. Five AP axes were chosen: the line connecting the center of the posterior cruciate ligament(PCL) and the medial border of the patellar tendon at the cutting level of the tibia (PCL-PT), the line from the PCL to the medial border of the tibial tuberosity (PCL-TT1), the line from the PCL to the border of the medial third of the tibia (PCL-TT2), the line from the PCL to the apex of the tibia (PCL-TT3), and the AP axis of the tibial prosthesis along with the anterior cortex of the proximal tibia (anterior tibial curved cortex, ATCC).Background
Methods
Buechel and Pappas invented a modified version of LCS RP system (Co-Cr) with light material (Titanium), axial rotation limiting bar and improved conformity. The purpose of this prospective randomized study was to compare the minimum 3-year clinical outcomes including lightness, preference, and instability between the Co-Cr implant system and the Titanium implant system in bilateral total knee arthroplasty. We prospectively enrolled 108 patients and 20 patients were lost to follow-up. Therefore, 88 patients (176 knees; mean age, 69.9±6.0years) were included in the study. The range of motion and clinical scores such as Knee Society score (KSS), Hospital for Special Surgery score (HSS) and Western Ontario and McMaster University (WOMAC) scores were measured preoperatively and postoperatively. At each follow-up, patients also complete a Likert scale questionnaire regarding subjective pain, lightness, left-right side preference (naturalness and satisfaction) and subjective instability. There were no significant differences in all preoperative variables between two groups (p>.05). Mean follow-up period was 46.3±8.8 (36 to 72) months. The mean weight of Titanium implants was three times lighter than that of Co-Cr implants (133.9g versus 390.1g, p<.01). At the minimum of 3-year follow-up, there were no significant differences in pain, range of motion (ROM), clinical scores including KSS, HSS, and WOMAC between both groups. Also, the study showed no significant differences with subjective pain, lightness, preference (convenience, naturalness, and satisfaction), and subjective instability between the Co-Cr protheses and the Titanium protheses (p>.05). No differences in clinical outcomes as well as subjective side-to-side differences between the Co-Cr prostheses and the Titanium prostheses were observed in the minimum 3-year follow-up. This implies that patients do not feel differently with two different weighted implants in mid-term follow-up.
Revision total knee arthroplasy (TKA) has been often used with a metal block augmentation for patients with poor bone quality. However, bone resorption beneath metal block augmentation has been still reported and little information about the reasons of the occurrence of bone resorption is available. The aim of the current study is to identify a possibility of the potential occurrence of bone resorption beneath metal block augmentation, through evaluation of strain distribution beneath metal block augmentation in revision TKA with metal block augmentation, during high deep flexion. LOSPA, revision TKA with a metal block augmentation (Baseplate size #5, Spacer size #5, Stem size Φ9, L30, Augment #5 T5) was considered in this study. For the test, the tibia component of LOSPA was implanted to the tibia sawbone (left, #3401, Sawbones EuropeAB, Malmö, Sweden), which was corresponded to a traditional TKR surgical guideline. The femoral component of LOSPA was mounted to a customized jig attached to the Instron 8872 (Instron, Norwood, MA, USA), which was designed specially to represent the angles ranged from 0° to 140° with consideration of a rollback of knee joint (Figure. 1). Here, a compressive load of 1,600N (10N/s) was applied for each angle. Strain distribution was then measured from rossete strain gauge (Half Bridge type, CAS, Seoul, Korea) together (Figure 1).Introduction
Materials and Method
Open wedge high tibial osteotomy (OWHTO) is an operation by the proper load re-distribution in the treatment for medial uni-compartmental arthritis of the knee joint. However, for the proper load re-distribution, stable fixation is mandatory. For the stable fixation, plate should be contoured to the bony surface and screws should be inserted from the central area of the medial side to the hinge area of the lateral side in the proximal fragment because most failures occur at the relatively lesser supported lateral hinge area. Therefore, the purpose of this study was to evaluate the screw insertion angle and orientation that is inserted to the direction of the lateral hinge with an anatomical plate that is post-contoured with a surface geometry of the proximal tibia after the OWHTO. The hypothesis of this study was that the position and orientation would be different according to the correction degree (median value 10 mm) and surgical technique (uni-planar vs bi-planar). Thirty-one uni-planar and thirty-eight bi-planar osteotomies were evaluated. Postoperative CT data obtained after OWHTO were used for the 3D reconstruction of the proximal tibia. Anterior dimension (L1) and posterior dimension (L2) of the proximal tibia were measured in sagittal plane from tibial spine. Screw insertion points using four holes were even distributed using L1 and L2 value. As screw insertion angle was set from four holes to lateral hinge of the ‘Safe Zone’. Those four angles were measured in the axial and coronal plane. These were compared according to the correction degree and surgical technique.Introduction
Materials and Methods
Revision total knee arthroplasty (TKA) has been often used with a metal block augmentation for patients with poor bone quality. However, bone defects are frequently detected in revision TKA used with metal block augmentation. This study focused on identification of a potential possibility of the bone defect occurrence through the evaluation of the strain distribution on the cortical bone of the tibia implanted revision TKA with metal block augmentation, during high deep flexion. Composite tibia finite element (FE) model was developed and revision TKA FE model with a metal block augmentation (Baseplate size #5 44AP/67ML, Spacer size #5 44AP/67ML, Stem size Φ9, L30, Augment #5 44AP/67ML thickness 5mm) was integrated with the composite tibia FE model. 0°, 30° 60°, 90°, 120° and 140° flexion positions were then considered with femoral rollback phenomenon [Introduction
Materials and Methods
We compared the clinical and radiographic results
of total ankle replacement (TAR) performed in non-diabetic and diabetic
patients. We identified 173 patients who underwent unilateral TAR
between 2004 and 2011 with a minimum of two years’ follow-up. There
were 88 male (50.9%) and 85 female (49.1%) patients with a mean
age of 66 years ( The mean AOS and AOFAS scores were significantly better in the
non-diabetic group (p = 0.018 and p = 0.038, respectively). In all,
nine TARs (21%) in the diabetic group had clinical failure at a
mean follow-up of five years (24 to 109), which was significantly
higher than the rate of failure of 15 (11.6%) in the non-diabetic
group (p = 0.004). The uncontrolled diabetic subgroup had a significantly
poorer outcome than the non-diabetic group (p = 0.02), and a higher
rate of delayed wound healing. The incidence of early-onset osteolysis was higher in the diabetic
group than in the non-diabetic group (p = 0.02). These results suggest
that diabetes mellitus, especially with poor glycaemic control,
negatively affects the short- to mid-term outcome after TAR. Cite this article:
To determine the effect of leg dominance on trunk muscle activity during bridging exercises on the floor and a gym ball. Perturbation training including bridging exercises and unstable surfaces have been shown to increase trunk activity. Trunk muscle activity increases on the contralateral side to the stabilising leg during bridging, however, no studies exist on the effect of leg dominance on trunk muscle activity during bridging exercises. This study will investigate whether trunk muscle activity differs when stabilising on the dominant versus non-dominant leg.Purpose
Background
To develop a useful surgical navigation system, accurate determination of bone coordinates and thorough understanding of the knee kinematics are important. In this study, we have verified our algorithm for determination of bone coordinates in a cadaver study using skeletal markers, and at the same time, we also attempted to obtain a better understanding of the knee kinematics. The research was performed at the Medical Simulation Center of Tzu Chi University. Optical measurement system (Polaris® Vicra®, Northern Digital Inc.) was used, and reflective skeletal markers were placed over the iliac crest, femur shaft, and tibia shaft of the same limb. Two methods were used to determine the hip center; one is by circumduction of the femur, assuming it pivoted at the hip center. The other method was to partially expose the head of femur through anterior hip arthrotomy, and to calculate the centre of head from the surface coordinates obtained with a probe. The coordinate system of femur was established by direct probing the bony landmarks of distal femur through arthrotomy of knee joint, including the medial and lateral epicondyle, and the Whiteside line. The tibial axis was determined by the centre of tibia plateau localised via direct probing, and the centre of ankle joint calculated by the midpoint between bilateral malleoli. Repeated passive flexion and extension of knee joint was performed, and the mechanical axis as well as the rotation axis were calculated during knee motion. A very small amount of motion was detected from the iliac crest, and all the data were adjusted at first. There was a discrepancy of about 16.7mm between the two methods in finding the hip centre, and the position found by the first method was located more proximally. When comparing the epicondylar axis to the rotation axis of the tibia around knee joint, there was a difference of 2.46 degrees. The total range of motion for the knee joint measured in this study was 0∼144 degrees. The mechanical axis was found changing in an exponential pattern from 0 degrees to undetermined at 90 degrees of flexion, and then returned to zero again. Taking the value of 5 degrees as an acceptable range of error, the calculated mechanical axis exceeded this value when knee flexion angle was between 60∼120 degrees. The discrepancy between the hip centres calculated from the two methods suggested that the pivoting point of the femur head during hip motion might not be at the center of femur head, and the former location seemed closer to the surface of head at the weight bearing site. Under such circumstances, the mechanical axis obtained through circumduction of the thigh might be 1∼2 degrees different from that obtained through the actual center of femur head. During knee flexion, the mechanical axis also changed gradually, and this could be due to laxity of knee joint, or due to intrinsic valgus/varus alignment. However, the value became unreliable when the knee was at a flexion angle of 60∼120 degrees, and this should be taken into account during navigation surgery.
Clinical assessment of elbow deformity in children at present is mainly based on physical examination and plain X-ray images, which may be inaccurate if the elbow is not in fully supination; furthermore, the rotational deformity is even harder to be determined by such methods. Morrey suggested that the axis of rotation of the elbow joint can be simplified to a single axis. Based on such assumption, we are proposing a method to assess elbow deformity using rotational axis of the joint, and an optimized calculation algorithm is presented. The rotation axis of elbow in respective to the upper arm can be obtained from the motion tract of markers placed at the forearm. Cadaver study was done, in which three skeletal motion trackers were placed over both the anterior aspect of humerus, as well as distal ulna. Osteotomy was created at the supracondylar region of humerus through lateral approach, and the bone fragments were stabilized with a set of external skeletal fixator, leaving the soft tissue intact. The amount of deformity was created manually by adjusting the position of the distal fragment via skeletal fixator. Ultrasound 3D motion tracking system from Zebris® was used in this study, and the program was developed under the Matlab environment. Cycles of passive elbow flexion/extension motion were carried out for each set of deformity. The data were initially transformed to humerus coordinate, and since the upper arm was not absolutely stationary, its influence on the measured position of ulna was adjusted. With this adjusted data, a best fit plane that would include most of the ulna positions ( Fresh frozen cadaver study was conducted in the Medical Simulation Center at Tzu-Chi University. After adjustment of the raw data to eliminate the influence of humerus motion, the ulna motion could be narrowed down from a band of 10mm to 3mm, with a significant smaller standard deviation. The rotation axis was obtained by the normal vector to the best fit plane. Two different approaches were attempted to find the plane. In the first method, the plane was obtained via least square method from the adjusted ulna positions, and the second method found the plane via RANSAC method. Calculations were repeated several times for each method, and the results showed a variation of 5 degrees in the first method and about 2 degrees in the second method. Rotational axis can be used to define the 3-dimensional deformity of elbow joint; however, it is difficult to obtain such axis accurately due to hypermobility and multi-directional motion of the shoulder joint. In this study, we have developed another method to assess the elbow deformity using motion analysis system instead of the conventional image studies, and this may be applicable clinically if the facility becomes more accessible in the future. (This research was supported by the project TCRD-TPE-99-30 granted by the Buddhist Tzu-Chi General Hospital, Taipei Branch).
To determine presenting features, treatment modalities and associated outcome following treatment of spinal dural arteriovenous fistulas in a tertiary centre. Retrospective cohort study of patients with SDAVF assessed at a single tertiary referral centre, between 1999 and 2009. Medical records were used to identify intervention type, pre- and post-intervention Aminoff-Logue disability score (ALDS), recurrence rate, follow-up time and discharge status. Statistical analysis was performed using Wilcoxon signed rank. 26 patients were identified with 23 receiving intervention. Two were unavailable for follow up. Endovascular embolization was performed successfully in 13 patients, recurrence occurred in 6 of these, 3 of which were subsequently treated surgically. Surgery was the initial treatment for 10 patients due to either unsuccessful embolization attempt or proximity of the fistula to spinal artery feeders; only 1 of these recurred. ALDS-gait reduced (improved) by a mean of 0.33 points following intervention but this was not statistically significant ( Both embolisation and surgery achieved the primary aim of reducing disease progression, leading to an improved ALDS. Outcome was superior if initially treated surgically and recurrence occurred more frequently in patients treated endovascularly. The small number of patients in our cohort emphasise the need for further studies into this group of patients.
