Vasculitis reumatoidea: una manifestación poco habitual. Presentación de tres casos clínicos y revisión de la literatura

La vasculitis reumatoidea es una complicación sistémica y poco frecuente de la Artritis Reumatoidea. Si bien su incidencia ha descendido en los últimos años con el advenimiento de las nuevas terapias inmunosupresoras y biológicas, continua teniendo una alta morbimortalidad. Predomina en el sexo masculino, en pacientes seropositivos y con un largo período de la enfermedad establecida. Requiere de alta presunción diagnostica, siendo el compromiso cutáneo y nervioso periférico el más frecuente. La biopsia de nervio o piel es requerida habitualmente para su diagnóstico. El tratamiento se basa en corticoides e inmunosupresores. Presentamos tres casos clínicos y realizamos una revisión de la literatura.

Rheumatoid vasculitis is a rare systemic complication of rheumatoid arthritis. Although its incidence has decreased in recent years with the advent of new immunosuppressive and biological therapies, it continues to have a high morbidity and mortality. It predominates in males, in seropositive patients and with a long period of established disease. It requires high diagnostic presumption, with skin and peripheral nervous involvement being the most affected. Nerve or skin biopsy is usually required for diagnosis. Treatment is based on corticosteroids and immunosuppressants. We present three clinical cases and carry out a review of the literature.

A vasculite reumatóide é uma complicação sistêmica rara da artrite reumatóide. Embora sua incidência tenha diminuído nos últimos anos com o advento de novas terapias imunossupressoras e biológicas, continua apresentando elevada morbidade e mortalidade. Predomina no sexo masculino, em pacientes soropositivos e com longo período de doença estabelecida. Exige alta presunção diagnóstica, sendo o envolvimento cutâneo e nervoso periférico os mais afetados. A biópsia de nervo ou pele geralmente é necessária para o diagnóstico. O tratamento é baseado em corticosteroides e imunossupressores. Apresentamos três casos clínicos e realizamos uma revisão da literatura.

The Statistical Fragility of Lateral Extra-articular Tenodesis Research: A Systematic Review.

Background: A P value of <.05 is often used to denote statistical significance; however, in many scenarios, this threshold is vulnerable to a small number of outcome reversals. This study joins a body of studies within the orthopaedic literature that evaluate the statistical fragility of existing research via metrics such as fragility index (FI) and fragility quotient (FQ). Purpose/Hypothesis: The purpose of this study was to investigate the statistical fragility of randomized controlled trials (RCTs) and comparative studies on the topic, given the resurgent interest in lateral extra-articular tenodesis (LET) to augment primary or revision anterior cruciate ligament reconstruction (ACLR). It was hypothesized that the outcomes reported in these studies would be statistically fragile. Study Design: Systematic review; Level of evidence, 4. Methods: Comparative studies and RCTs regarding LET as an adjunct procedure to ACLR published between 2000 and 2022 were analyzed. Descriptive characteristics, dichotomous outcomes, and continuous outcomes were extracted. The FI and continuous FI (CFI) were calculated by the number of event reversals to change significance; the FQ and continuous FQ (CFQ) were calculated to normalize the fragility metrics per sample size. Results: Of 455 studies screened, 29 studies were included (9 RCTs, 20 comparative); 79.3% of included studies were published after 2020. A total of 48 dichotomous and 265 continuous outcomes were analyzed. The median FI was 9.0 (IQR, 7.0-13.3), with FQ of 0.1 (IQR, 0.04-0.17); the median CFI was 7.8 (IQR, 4.2-19.6), with CFQ of 0.12 (IQR, 0.08-0.19). The FQ and CFQ for studies on LET with revision ACLR were larger (0.117 and 0.113, respectively) than those focused on primary ACLR (0.042 and 0.095, respectively). Conclusion: Studies focused on LET with primary ACLR were more fragile than those on LET with revision, which suggests that further research on the indications for LET with primary ACLR is necessary. Future orthopaedic comparative research should include fragility metrics alongside traditional P values.

Progress in Computer-Assisted Navigation for Total Knee Arthroplasty in Treating Knee Osteoarthritis with Extra-Articular Deformity.

Total knee arthroplasty (TKA) is a well-established treatment for end-stage knee osteoarthritis. However, in patients with concomitant extra-articular deformities, conventional TKA techniques may lead to unsatisfactory outcomes and higher complication rates. This review summarizes the application of navigated TKA for treating knee osteoarthritis with extra-articular deformities. The principles and potential benefits of computer navigation systems, including improved component alignment, soft tissue balancing, and restoration of mechanical axis, are discussed. Research studies demonstrate that navigated TKA can effectively correct deformities, relieve pain, and improve postoperative joint function and quality of life compared with conventional methods. The advantages of navigated TKA in terms of surgical precision, lower complication rates, and superior functional recovery are highlighted. Despite challenges like the learning curve and costs, navigated TKA is an increasingly indispensable tool for achieving satisfactory outcomes in TKA for knee osteoarthritis patients with extra-articular deformities.

Retrograde tibial intramedullary nail versus minimally invasive locking plate for extra-articular distal tibial fractures: a comparative and retrospective study.

BACKGROUND: Distal tibial fractures represent common lower limb injuries, frequently accompanied by significant soft tissue damage. The optimal surgical approach for managing these fractures remains a topic of considerable debate. The aim of this study was to perform a comparative analysis of the outcomes associated with retrograde intramedullary tibial nails (RTN) and minimally invasive plate osteosynthesis (MIPO) in the context of treating extra-articular distal tibial fractures. METHODS: A retrospective review was conducted on a cohort of 48 patients who sustained extra-articular distal tibial fractures between December 2019 and December 2021. Patients underwent either RTN or MIPO procedures. Various parameters, including operative duration, intraoperative fluoroscopy exposure, time to union, duration until full weight-bearing, American Orthopedic Foot and Ankle Society (AOFAS) scores, and complications, were recorded and compared between the two treatment groups. RESULTS: No statistically significant differences were observed in operative duration, time to union, angulation of the distal tibial coronal plane, or AOFAS scores between the RTN and MIPO groups. However, the RTN group had a higher average number of intraoperative fluoroscopy images (8.2 ± 2.3) compared to the MIPO group (4.1 ± 2.0). The RTN group demonstrated shorter average hospital stays (7.1 ± 1.4 days) and a quicker return to full weight-bearing (9.9 ± 1.3 weeks), which were significantly superior to the MIPO group (9.0 ± 2.0 days and 11.5 ± 1.5 weeks, respectively). In terms of complications, the RTN group had one case of superficial infection, whereas the MIPO group exhibited two cases of delayed union and nonunion, two occurrences of deep infection, and an additional three cases of superficial infection. CONCLUSIONS: Both RTN and MIPO are effective treatment options for extra-articular distal tibial fractures. However, RTN may offer superior outcomes in terms of decreased inpatient needs, faster return to full weight-bearing capacity, and a lower rate of complications.

Lateral extra-articular tenodesis in association to All-inside Anterior Cruciate Ligament reconstruction does not modify return to play in basketball players: a comparative cohort study. / La aumentación con tenodesis extraarticular de la reconstrucción del ligamento cruzado anterior asociado a la técnica "all-inside" no modifica la vuelta al deporte en jugadores de baloncesto federados: estudio de cohortes comparativo.

INTRODUCTION: Return to play rates after anterior cruciate ligament (ACL) reconstruction range between 50-98% depending on sport professionality, without being modified by the addition of an extra-articular augmentation (EA). The objective of the study is to describe the rate of return to play in our cohort. The hypothesis is that the addition of EA increases that rate. MATERIAL AND METHODS: A retrospective, descriptive and analytical study of a 130 basketball players cohort between 18 and 45 years old, whom underwent ACL reconstruction between the years 2018 and 2022, with a minimum follow-up of 18 months. Data was collected by reviewing medical records. IKDC score was registered after one year from surgery. All patients operated from 2020 received an extra-articular tenodesis. RESULTS: Of all patients, 72.31% returned to training, 70.77% returned to competition and 46.15% returned to the same level of performance prior to injury. The EA group (46.15%) did not increase the rate of return to competition (p=0.552) nor to the same level of performance (p=0.664). The mean IKDC. score was 86.83 (SD 14.85), and was not higher in the EA group (p=0.418). However, its value was higher in the players who returned to training, competition and level of performance (p<0.05). EA did not delay the return to play in any group (p=0.282). CONCLUSION: To sum up, the EA does not modify the return to sport rate. Higher IKDC values predict a greater return to sport rate. in all groups. Prospective studies with larger sample size and longer follow-up time are required.

Exploring pulmonary involvement in newly diagnosed rheumatoid arthritis, and psoriatic arthritis: a single center study.

OBJECTIVES: This cross-sectional study aimed to determine the prevalence, manifestation, and risk factors of pulmonary involvement in newly diagnosed, untreated rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients, and to evaluate the efficacy of various diagnostic tools in screening for pulmonary involvement. METHODS: Untreated, newly diagnosed patients with RA and PsA underwent an extensive multimodal diagnostic approach including clinical and laboratory assessment, pulmonary function tests, and chest radiography. RESULTS: We recruited 50 arthritis patients (26 RA, 24 PsA) and 26 control subjects. Respiratory symptoms were found in 36.0 % of arthritis patients and 11.5 % of controls (p = 0.031). Pathologically reduced breathing width (< 3.0 cm) was significantly more common in arthritis patients (64.0 %) than in controls (23.1 %) (p < 0.001). Pulmonary function test results did not differ significantly between groups. Chest radiography revealed pulmonary involvement in 37.0 % of arthritis patients, higher in RA (50.0 %) than in PsA (22.7 %). Notably, only 35.3 % of arthritis patients with radiographic pulmonary involvement were symptomatic, with 64.7 % being asymptomatic. Radiographic pulmonary involvement was associated with advanced age (p = 0.002) and increased rheumatoid factor levels (p = 0.024). CONCLUSION: Our research underscores the significant prevalence of largely asymptomatic pulmonary involvement in newly diagnosed RA and PsA patients. These findings highlight the importance of an early, multidisciplinary screening approach, particularly for high-risk individuals. Further large-scale studies are needed to develop comprehensive screening protocols to improve early detection and treatment of pulmonary involvement in arthritis.

No difference in stability among various knee flexion angles during fixation of anterolateral ligament reconstruction or lateral extra-articular tenodesis: A systematic review and meta-analysis of biomechanical studies.

Purpose: The purpose of this study was to investigate the effect of anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) fixation at low versus high flexion angles during anterior cruciate ligament reconstruction (ACLR) on rotation or translational knee stability. Methods: The inclusion criteria for this study were (1) cadaveric study, (2) cadaveric specimens underwent ACLR, (3) cadaveric specimen underwent ALLR or LET and (4) specimen preparation technique described the knee flexion angle at the time of ALLR or LET tensioning and fixation. A priori, 'low flexion' was defined as 0-30° and 'high flexion' was defined as 60-90° at graft fixation. Main outcomes of interest included internal rotation and anterior translation. Results: Data from 92 cadaveric knees (from 9 studies) were extracted and included in the meta-analysis. The mean pooled value for internal rotation was 10.1° (95% confidence interval [CI], 5.7-14.5°) for the low flexion group and 11.5° (95% CI, 7.4-15.7°) for the high flexion group (n.s.). The mean pooled value for anterior translation was 4.3 mm (95% CI, 0.5-8.1 mm) for the low flexion group and 3.0 mm (95% CI, 1.1-5.0 mm) for the high flexion group (n.s.). Conclusion: This meta-analysis of existing biomechanical research found that the rotational and translational stability of the knee were not significantly different between scenarios in which ALLR or LET fixation was performed at low knee flexion angles (0-30°) versus high knee flexion angles (60-90°). Level of Evidence: Level IV.

Ligament augmentation and reconstruction system (LARS) synthetic grafts are safe and effective for medial collateral ligament and posterolateral corner reconstructions in elite athletes.

PURPOSE: This study documents the efficacy and safety of using a Ligament Augmentation and Reconstruction System (LARS) ligament graft to augment extra-articular knee ligament reconstructions in elite athletes by reporting return-to-play (RTP) rates and levels, career longevity and complications. METHODS: A consecutive series of all extra-articular knee ligament reconstructions augmented by LARS ligaments in elite athletes undertaken by three specialist sports knee surgeons between 2013 and 2020 were reviewed. Seventy-six elite athletes, aged over 16 years old, and more than 2 years postsurgery were included. RTP was defined as competing at professional level or national/international level in amateur sport. RESULTS: There were 64 medial collateral ligament (MCL) and 12 posterolateral corner (PLC) reconstructions. Fifty-two (68.4%) underwent concomitant autograft cruciate ligament(s) reconstruction. The mean age was 25.1 years (SD ± 4.5). Most were football (35, 46.1%) or rugby players (35, 46.1%). Sixty-seven athletes (88.2%) RTP with 65 (97.0%) of these playing at the same or higher Tegner level. Fifty-six (83.6%) of the athletes that RTP were still playing at 2 years postsurgery. Twenty (57.1%) of those who had RTP and were more than 5 years postsurgery were still playing at 5 years. Six (7.9%) players required further surgery relating to the LARS/metalwork. One case had soft tissue inflammation adjacent to the proximal end of the synthetic graft, but it is unknown if this was mechanical irritation or a biological reaction. One MCL reruptured 4 years after RTP. CONCLUSION: Utilising LARS to augment extra-articular knee ligament reconstructions allows 88.2% of athletes with a variety of knee ligament injuries to return to elite sport. The low morbidity rates coupled with 57% of athletes still playing 5 years postsurgery demonstrates that the LARS is safe and effective in these cases. Although there are reports of LARS ligaments being used in MCL and PLC reconstructions, there is very little evidence investigating if they are safe and effective. This study demonstrates that LARS synthetic grafts can be safely used for MCL and PLC reconstructions in elite athletes and they permit a high RTP with a low risk of complications. LEVEL OF EVIDENCE: Level IV.

Ancient Schwannoma Along the Patellar Tendon: Unveiling a Rare Clinical Phenomenon With Literature Review.

Ancient schwannoma, a rare subtype of schwannoma, a benign tumor originating from nerve sheaths, can arise from various nerves, except for the optic, olfactory, spinal, and autonomic nervous systems. Schwannomas are typically characterized by the presence of neoplastic Schwann cells and tend to develop eccentrically. Malignant transformations of schwannomas are exceptionally uncommon. In this case report, a 42-year-old male presented with a painful lump on the front of his left knee. The lump was described as an extra-articular swelling below the kneecap, situated over the patellar tendon. Initially, ultrasonography (USG) indicated the presence of a slow-flow vascular malformation in the infrapatellar region of the left knee. However, subsequent magnetic resonance imaging (MRI) revealed a well-defined mass in the subcutaneous plane below the knee, with minimal septations, leading to an initial suspicion of a large sebaceous cyst. Further investigation through histopathological analysis confirmed the diagnosis of an extra-articular schwannoma. This finding highlights the importance of thorough examination and diagnostic techniques in differentiating between various types of soft tissue masses. Schwannomas, although uncommon in certain locations, should be considered in the differential diagnosis of painful lumps, even in atypical anatomical sites such as the knee.

The Lateral Para-Patellar Approach for Intramedullary Tibia Nailing in Distal Tibia Extra-articular Fractures: A Prospective Cohort Study.

BACKGROUND AND OBJECTIVES:  The treatment of extra-articular distal tibia fractures is still a subject of debate and frequently necessitates surgical treatment, and intramedullary nailing (IMN) offers a minimally invasive approach with excellent results. Important factors in these procedures are positioning, operative duration, and radiation exposure. This study details the semi-extended lateral para-patellar approach for IMN of distal tibia extra-articular fractures and documents our findings regarding operative time, intra-operative radiation exposure, residual anterior knee pain, knee functional and radiological outcomes at six months follow-up. METHODS: We reviewed the cases of 60 patients who underwent IMN for distal tibia extra-articular fractures from May 2022 to March 2024, employing an extra-articular lateral para-patellar approach in the semi-extended position. Patients were evaluated clinically and radio-graphically for a minimum follow-up period of six months. Data collected included duration of surgery, intraoperative radiation exposure, and knee functional score for all patients. Assessment of fracture healing, residual deformities, residual anterior knee pain, and range of motion of the treated knee compared to the contralateral knee was done at a six-month follow-up. RESULTS: The average surgery duration was 54 ± 5 minutes, with intraoperative imaging averaging 48 exposures. The average time to union was 16 ± 3 weeks. Six months post-surgery, the mean Knee Society Score was 86.4 ± 3.5 (out of 100). At the six months follow-up, all patients exhibited clinical and radiographic healing, with only two cases showing mal-alignment (angular deformity <10 degrees). All patients regained a comparable range of motion in their knees. CONCLUSIONS: The semi-extended lateral para-patellar approach for nailing of distal tibia extra-articular fractures enhances reduction, simplifies nail insertion, reduces both fluoroscopy and operative time, minimizes anterior knee pain and improves knee functional outcomes at six months follow-up.

Ankle impingement after extra-articular open fracture of the leg: Full arthroscopic treatment in the supine position.

OBJECTIVE: Extra-articular open fractures of the leg often result from high energy trauma. After healing, a painful ankle impingement may occur. In the event of anterior and posterior impingements, arthroscopic treatment may require two surgical positions. We propose an operative strategy to treat anterior and posterior ankle impingement after extra-articular open fracture of the leg. Our hypothesis is that this strategy is simple, effective and with a low risk of complication. MATERIAL AND METHOD: Anterior ankle impingements were treated by anterior arthroscopy in supine position; anterior and posterior impingements were treated by anterior and posterior arthroscopy in supine position; anterior and posterior impingements associated with retraction of gastrocnemius muscles were treated with anterior arthroscopy in supine position followed by posterior arthroscopy in prone position, and an open tendon lengthening of the calcaneal tendon in the same position. The anterior and posterior arthroscopic release was tested in the cadaver laboratory. Then, the surgical strategy was applied to our patients in our clinical practice. After, we analysed retrospectively the results of the strategy in the first patients treated for a painful ankle impingement after extra-articular open fracture of the leg. The data retrieved were the importance of pain (VAS), the presence of clinical instability, ankle mobility, gastrocnemius retraction and the AOFAS functional score and the post-operative complications. Then, these data were compared before the surgery and at last follow-up. RESULTS: From the cadaver laboratory, anterior and posterior arthroscopic release was possible in all cases without changing position. From our clinical practice, we included 5 patients (3 women and 2 men, mean age 43 years) suffering from an ankle impingement after extra-articular open fracture of the leg (2 patients with isolated anterior impingement, 1 patient with anterior and posterior impingement, and 2 patients with anterior and posterior impingement plus a gastrocnemius retraction). All post-operative parameters (pain, range of motion and AOFAS score) at mean follow-up of 53 months were improved. No post-operative complication was reported. CONCLUSION: We propose a surgical strategy adapted to the different clinical presentations of ankle impingement after extra-articular open fracture of the leg.

Personalized total knee arthroplasty in patients with extra-articular deformities.

Over the years, with a better understanding of knee anatomy and biomechanics, superior implant designs, advanced surgical techniques, and the availability of precision tools such as robotics and navigation, a more personalized approach to total knee arthroplasty (TKA) has emerged. In the presence of extra-articular deformities, performing personalized TKA can be more challenging and specific considerations are required, since one has to deal with an acquired pathological anatomy. Performing personalized TKA surgery in patients with extra-articular deformities, the surgeon can: (1) resurface the joint, omitting the extra-articular deformity; (2) partially compensate the extra-articular deformity with intra-articular correction (hybrid technique), or (3) correct the extra-articular deformity combined with a joint resurfacing TKA (single stage or two-stage procedure). Omitting the acquired lower limb malalignment by resurfacing the knee has the advantages of respecting the joint surface anatomy and preserving soft tissue laxities. On the other hand, it maintains pathological joint load and lower limb kinematics with potentially detrimental outcomes. The hybrid technique can be performed in most cases. It circumvents complications associated with osteotomies and brings lower limb axes closer to native alignment. On the other hand, it creates some intra-articular imbalances, which may require soft tissue releases and/or constrained implants. Correcting the extra-articular deformity (through an osteotomy) in conjunction with joint resurfacing TKA represents the only true kinematic alignment technique, as it aims to reproduce native knee laxity and overall lower limb axis.

Combined ACLR and lateral extra-articular tenodesis with a continuous iliotibial band autograft is a viable option in a population of athletes who participate in pivoting sports.

PURPOSE: The aim of this study was to evaluate the clinical results, return to sport and complications after anterior cruciate ligament reconstruction (ACLR) associated with lateral extra-articular tenodesis using continuous plasty with an iliotibial band. METHODS: This was a prospective multicentre study involving 186 patients who had surgery for anterior cruciate ligament (ACL) rupture. Patients with multiligament ruptures and revision surgery were excluded from the study. All patients included were involved in pivoting sports and wished to resume their activity after surgery. Patients were assessed at a minimum 2-year follow-up using functional and psychological questionnaires (subjective International Knee Documentation Committee [IKDC], Tegner, Lysholm and ACL-RSI scores), ligament assessment including instrumented laxity measurement (Rolimeter), Lachman test and pivot shift and isokinetic testing. Return to sport was assessed using a questionnaire, and complications and repeat surgeries were recorded. RESULTS: At a mean follow-up of 43.1 months, the subjective IKDC, Lysholm, ACL-RSI and objective IKDC scores were significantly improved (59.8 vs. 94.5 p < 0.0001, 75 vs. 99 p < 0.0001, 60 vs. 93 p < 0.0001, IKDC A 0% vs. 72%, B 12% vs. 27%, C 60% vs. 1% D 28% vs. 0% p < 0.0001). The Tegner activity level was 9 (3-10) before the accident and 9 (3-10) at the last review. Seventy-six percent of the patients had returned to sports at the same level. The differential laxity was 6.6 mm (±1.7) preoperatively and 1.1 mm (±1.4) postoperatively. Additionally, 97% were equal in pivot shift at the last follow-up. At the 6-month isokinetic assessment, the muscle strength recovery for the quadriceps and hamstring was over 85% compared with the healthy side for 79% and 70% of the patients, respectively. Ten patients had graft rupture (5.6%). Four (2.4%) patients had a contralateral ACL rupture, and seven (4%) underwent a reoperation with meniscectomy. CONCLUSION: Anterior ligament reconstruction with lateral extra-articular tenodesis using a continuous strip of iliotibial band enables 76% of patients in a population with a high demand for sports to resume their activities at the same level. The clinical results and complication rates, particularly reruptures (5.6%), were similar to those of other techniques involving lateral extra-articular tenodesis. LEVEL OF EVIDENCE: Level II.

Lateral extra-articular tenodesis does not enhance ACL graft healing, however, does reduce graft tunnel widening.

PURPOSE: The study hypothesized that the addition of lateral extra-articular tenodesis (LEAT) in anterior cruciate ligament reconstruction (ACLR) had a significant effect on ACL graft healing. METHODS: A total of 80 patients were divided into two cohorts matched for gender, age, body mass index, time from surgery to post-operative MRI and graft diameter. Forty patients underwent ACL reconstruction alone, while 40 underwent ACLR in addition to LEAT. Patients underwent a magnetic resonance imaging scan at 12 months post-surgery; tunnel apertures were measured using multiplanar reformation, graft healing was assessed using signal-to-noise quotient (SNQ) in three regions of interest and finally graft maturity and integration were classified using the Howell and Ge scale, respectively. In addition, clinical evaluation and patient-reported outcome measures were collected. RESULTS: The mean femoral tunnel widening at 12 months post-surgery was 39.8 ± 14.0% in the ACLR + LEAT group and 55.2 ± 12.7% in the ACLR alone group (p < 0.05). The mean tibial tunnel widening was 29.3 ± 12.7% in the ACLR + LEAT group and 44.4 ± 12.1% in the ACLR group (p < 0.05). The mean adjusted graft SNQ was 9.0 ± 14.9 in the ACLR + LEAT group and 9.5 ± 11.4 in the ACLR group (n.s.). CONCLUSION: At 1 year post-operatively, we noted significantly less femoral and tibial tunnel widening in the ACLR + LEAT group. LEAT did not result in a statistically significant effect on graft healing. LEVEL OF EVIDENCE: Level III.

Can we encourage the endoscopic treatment for external snapping hip (ESH)? A systematic review of current concepts.

BACKGROUND: Snapping hip syndrome (SHS) is characterized by snapping sensation and pain and affects up to 10% of the general population. External snapping hip syndrome (ESHS), the most common form, is often due to repetitive movements in sports or anatomical predispositions. Conservative treatment includes physiotherapy and corticosteroid injections, while surgery is considered if conservative measures fail. Open surgical techniques carry several risks, while modern arthroscopic techniques offer less invasive options, such as endoscopic iliotibial band release (ITB) and gluteus maximus tenotomy. MATERIALS AND METHODS: A systematic review was conducted adhering to the PRISMA guidelines. Relevant studies were searched in four databases: Pubmed, Scopus, Embase, and Medline. The selected articles were evaluated according to the criteria of levels of evidence. The Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) was used to analyze the retrospective studies. This paper was registered in the International Prospective Registry of Systematic Reviews (PROSPERO). RESULTS: Out of 9 included studies, 403 patients with 689 hips underwent endoscopic treatment. ITB release and his variations were the main surgical techniques. Gluteus maximus tenotomy was also used in some studies. Postoperative rehabilitation protocols varied. Patients generally experienced significant improvements in symptoms and functional outcomes, with low rates of recurrence (1.02%) and revision (0.15%). Complications were minimal. CONCLUSIONS: Endoscopic treatment of ESH shows favorable results, improving functional outcomes and returning patients to pre-injury activity levels. Long-term efficacy and costeffectiveness need to be evaluated, emphasizing the importance of large-scale prospective randomized trials to clarify surgery's benefits in refractory ESH cases.

Manifestaciones extraarticulares en pacientes con artritis reumatoide

Introducción : La artritis reumatoide (AR) es una enfermedad inflamatoria crónica, autoinmune, caracterizada por poliartritis crónica, aditiva, simétrica, que puede cursar con manifestaciones extraarticulares (MExA) asociadas a una mayor morbimortalidad. Objetivo: de describir las MExA más frecuentes en AR. Métodos: se realizó un estudio descriptivo, transversal y retrospectivo de revisión de historias clínicas de pacientes diagnosticados con AR, durante el periodo diciembre 2011-enero 2022. Resultados: Participaron 150 pacientes con AR, con una edad promedio de 53,7±12,5 años, el sexo predominante fue el femenino con 84,6%, el tiempo de evolución de la AR fue de 7,2±8,9 años; en cuanto a las características serológicas, 91,1% tenía Factor reumatoideo positivo y 76,9% tenía anticuerpos contra péptidos cíclicos citrulinados positivo. Tanto al ingreso, como en la última consulta los pacientes presentaron alguna manifestación extraarticular (MExA), 61,3% y 70%, respectivamente, siendo las más frecuentes la anemia de los trastornos crónicos (al ingreso 44,6% y en última consulta 50,6%), seguida de nódulos reumatoideos (al ingreso con 8% y en la última consulta 9,3%). Conclusiones: Las MExA se presentaron en 70% de los pacientes, siendo las más frecuentes la anemia y los nódulos reumatoideos. Estos datos muestras los cambios que han tenido la frecuencia de estas MExA en esta enfermedad a través del tiempo.

Introduction: Rheumatoid arthritis (RA) is a chronic inflammatory, autoimmune disease, characterized by chronic, additive, symmetrical polyarthritis, which can present with extra-articular manifestations (ExAM), associated with greater morbidity and mortality. Objective: to describe the most frequent ExAM in RA. Methods: a descriptive, cross-sectional and retrospective study was carried out to review the medical records of patients diagnosed with RA, during the period December 2011-January 2022. Results: 150 patients with RA participated, with an average age of 53.7±12.5 years, the predominant sex was female with 84.6%, the evolution time of RA was 7.2±8.9. years; Regarding serological characteristics, 91.1% had positive Rheumatoid Factor and 76.9% had positive antibodies against cyclic citrullinated peptides. Both upon admission and at the last consultation, patients presented some extra-articular manifestation (ExAM), 61.3% and 70%, respectively, with the most frequent being chronic anemia (at admission 44.6% and at last consultation 50.6%), followed by rheumatoid nodules (at admission with 8% and at the last consultation 9.3%). Conclusions: ExAM occurred in 70% of patients, the most frequent being anemia and rheumatoid nodules. These data show the changes in the frequency of ExAM in the disease over time.

Quantitative MRI Analysis of Patellofemoral Joint Cartilage Health 2 Years After Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis.

BACKGROUND: The addition of an iliotibial band-based lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction (ACLR) has been shown to reduce failure rates. However, there are concerns as to the potential overconstraint of tibiofemoral kinematics that may increase the risk of cartilage degradation. To date, no clinical study has investigated the effect of LET on patellofemoral joint articular cartilage health. HYPOTHESIS: It was hypothesized that at 2 years postoperatively, (1) the addition of LET at the time of ACLR would have no effect on cartilage health on magnetic resonance imaging (MRI), and (2) higher cartilage relaxation values would be associated with worse patient-reported and functional outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A subset of patients from the STABILITY 1 randomized controlled trial were included. All patients underwent primary ACLR with a hamstring autograft. Patients were randomized to either LET augmentation or not. Cartilage status in the patellofemoral joint between the ACLR group and ACLR+LET group was compared using 2-year postoperative quantitative MRI and the ACL osteoarthritis scores of both the surgical and the contralateral nonsurgical knees. Objective functional outcomes and patient-reported outcome measures (PROMs) were attained. RESULTS: A total of 92 patients (43 patients in the ACLR group; mean age, 18.9 ± 3.2 years; 60.5% female; and 49 patients in the ACLR+LET group; mean age, 18.7 ± 3.2 years, 63.3% female) were included. No significant differences were seen in the mean values (ms) for adjusted T1ρ/T2 relaxation times in the medial patella (47.8/42.2 vs 47.3/43.2), central patella (45.5/42.5 vs 44.1/42.7), lateral patella (48.2/43.5 vs 47.3/43.0), medial trochlea (54.7/50.9 vs 56.4/50.9), central trochlea (53.3/51.1 vs 53.1/52.0), and lateral trochlea (54.9/52.1 vs 53.9/52.6) between the ACLR and ACLR+LET groups. No difference in overall ACL osteoarthritis scores was observed (P = .99). An increase in medial patellar T2 relaxation times was associated with a decreasing International Knee Documentation Committee score (P = .046), Knee injury and Osteoarthritis Outcome Score (KOOS) Symptoms subscale score (P = .01), and total KOOS (P = .01). CONCLUSION: There was no statistical difference in patellofemoral cartilage health between knees 2 years after primary ACLR with hamstring tendon autograft with or without LET. Statistically significant correlations were found between quantitative MRI relaxation times, functional outcome scores, and PROMs; however, the correlations were weak and the clinical significance is unknown. REGISTRATION: NCT02018354 (ClinicalTrials.gov identifier).

Lateral Extra-Articular Tenodesis and Anterolateral Procedures.

The treatment of rotational instability has been an intriguing challenge since the era of modern anterior cruciate ligament (ACL) surgery. Lateral extra-articular procedures (LEAPs) have emerged as a solution to this problem, particularly in high-risk populations. Several studies have shown significant benefits of combining LEAPs with ACL reconstruction, including reduced graft failure rates, improved knee stability, improved rotational stability, and higher return-to-play rates. These findings have led to an in-depth evaluation of LEAPs as lateral extra-articular tenodesis and anterolateral ligament reconstruction and their potential role in improving outcomes after ACL reconstruction.

Revision Anterior Cruciate Ligament Reconstruction and Associated Procedures.

Failure of anterior cruciate ligament reconstruction (ACLR) is a common yet devastating complication due to inferior clinical outcomes associated with revision ACLR. Identifying the cause and associated risk factors for failure is the most important consideration during preoperative planning. Special attention to tunnel quality, concomitant injuries, and modifiable risk factors will help determine the optimal approach and staging for revision ACLR. Additional procedures including lateral extra-articular tenodesis and osteotomy may be considered for at-risk populations. The purpose of this review is to explore causes of ACLR failure, clinical indications and appropriate patient evaluation, and technical considerations when performing revision ACLR.

Avoiding Graft Failure: Lessons Learned from the Stability Trial.

The Stability Study was a multicenter, pragmatic, parallel groups, randomized clinical trial comparing hamstring tendon autograft anterior cruciate ligament reconstruction with or without the addition of lateral extra-articular tenodesis in young patients at high risk of graft failure. Having recruited 618 patients with a 5% loss to follow up, we were able to demonstrate a clinically and statistically significant reduction in clinical failure and graft rupture at 2 years postoperative. No differences in patient-reported outcomes (PROs) were demonstrated between groups; however, patients who experienced an adverse event had significantly worse PROs than those who did not.