Combined femoral and tibial component total knee arthroplasty device rotation measurement is reliable and predicts clinical outcome.

BACKGROUND: The optimal total knee arthroplasty (TKA) rotational alignment and how best to obtain and measure it are debatable. The aim was to analyse the reliability of the Berger femoral, three different tibial and four different combined two-dimensional computer tomography (2D-CT) TKA component rotation measurements, and to ascertain which rotational values best predict a successful clinical outcome. METHODS: The 2D-CT scans were obtained post-operatively on 60 patients who had TKA. We determined one femoral [Berger's femoral angle (BFA)], three tibial [Berger's tibial angle (BTA), anatomical tibial angle (ATA) and bimalleolar posterior tibial component angle (BM_PTCA)] and four combined [transepicondylar posterior tibial component angle (TE_PTCA), bicondylar posterior tibial component angle (BC_PTCA, transepicondylar bimalleolar angle (TE_BM) and bicondylar bimalleolar angle (BC_BM)] TKA rotation angles. We made all measures in 23 patients twice by three observers and determined inter- and intra-observer agreement using the Bland-Altman plot method. We analysed measures of 55 patients using the area under the ROC curve (AUC) analysis to ascertain the discriminative capacity of BFA, ATA, TE_PTCA and BC_PTCA for predicting a successful clinical outcome according to the Knee Society Score (KSS) threshold. RESULTS: ATA showed the smaller inter- and intra-observer average of differences (-0.1° and 1.6°, respectively) of the studied methods followed by BFA (-0.9° and 1.4°), TE_PTCA (-2.1° and 2.7°) and BC_PTCA (-0.5° and 1.8°). BFA (-4° to 2.1° and -6.1° to 8.8°) and BC_PTCA (-4.4° to 3.4° and -7.9° to 4.4°) showed the narrower inter- and intra-observer limits of agreement. A TKA device rotation (BC_PTCA) < 0.8° of external rotation (ER) predicted a KSS and KSS knee successful outcome, and < 3.8° ER for KSS functional (AUC = 0.889; 0.907 and 0.764, respectively). BFA and ATA < 0.9° ER and < 3.9° internal rotation (IR) predicted a successful KSS knee outcome (AUC = 0.796 and 0.889, respectively). CONCLUSION: The ATA tibial component rotation measurement was the most reliable of those studied. BFA, TE_PTCA and BC_PTCA were reliable measures for TKA femoral and combined rotation. The presence of a minimal rotation between the TKA components (BC_PTCA) and a small femoral ER or tibial IR predicted a successful KSS outcome.

Measuring direct and indirect tendon parameters to characterize the proximal tendinous complex of the rectus femoris in football and futsal players.

Objective: To present unprecedented radiological parameters that characterize the angle between the direct and indirect tendons of the proximal rectus femoris (RF) and its inclinations and to evaluate the population variability according to demographic variables. Materials and methods: From September 2019 to July 2021, using MRI multiplanar reconstructions of the proximal thigh/hip, two blinded radiologists measured the direct and indirect tendon angle and the inclination of each tendon in different planes. The intra- and inter-observer agreements were assessed with Bland-Altman analysis and intraclass correlation coefficient (ICC). The correlations between radiological parameters and demographic variables were evaluated using linear regression, Student's t-test, and analysis of variance. Results: We performed 112 thigh/hip MRI scans on 91 football players of different age, gender, and disciplines (football and futsal). For observer 1 (the reference), the mean direct and indirect tendon angle was 56.74° ± 9.37, the mean indirect tendon slope was -7.90° ± 7.49, and the mean direct tendon slope was 22.16° ± 5.88. The three measurements showed inter- and intra-observer agreement (mean differences ∼0). No correlation was observed between age and the parameters. Likewise, no statistically significant differences were found for gender, dominant limb, examined limb, and sport. Conclusion: There is an inter- and intra-observer agreement in the measurements of the direct and indirect tendon angle and the inclination of each tendon. There is population variability in the proximal tendinous complex unrelated to demographic factors. These results allow further detection of morphological patterns that represent a risk factor for lesions in the RF in professional football and futsal players and other sports.

Direct Oral Anticoagulants or Standard Anticoagulant Therapy in Fragile Patients with Venous Thromboembolism.

Background The efficacy and safety of the direct oral anticoagulants (DOACs) in fragile patients (age ≥ 75 years and/or creatinine clearance levels ≤ 50 mL/min and/or body weight ≤ 50kg) with venous thromboembolism (VTE) has not been evaluated. Methods We used the RIETE database to compare the rates of the composite of VTE recurrences or major bleeding during anticoagulation in fragile patients with VTE, according to the use of DOACs or standard anticoagulant therapy. Results From January 2013 to April 2018, 24,701 patients were recruited. Of these, 10,054 (41%) were fragile. Initially, 473 fragile patients (4.7%) received DOACs and 8,577 (85%) low-molecular-weight heparin (LMWH). For long-term therapy, 1,298 patients (13%) received DOACs and 5,038 (50%) vitamin K antagonists (VKAs). Overall, 95 patients developed VTE recurrences and 262 had major bleeding. Patients initially receiving DOACs had a lower rate of the composite outcome (hazard ratio [HR]: 0.32; 95% confidence interval [CI]: 0.08-0.88) than those on LMWH. Patients receiving DOACs for long-term therapy had a nonsignificantly lower rate of the composite outcome (HR: 0.70; 95% CI: 0.46-1.03) than those on VKAs. On multivariable analysis, patients initially receiving DOACs had a nonsignificantly lower risk for the composite outcome (HR: 0.36; 95% CI: 0.11-1.15) than those on LMWH, while those receiving DOACs for long-term therapy had a significantly lower risk (HR: 0.61; 95% CI: 0.41-0.92) than those on VKAs. Conclusions Our data suggest that the use of DOACs may be more effective and safe than standard therapy in fragile patients with VTE, a subgroup of patients where the risk for bleeding is particularly high.

Lesión osteolítica cervical como presentación del síndrome SAPHO / SAPHO syndrome presenting as an osteolytic lesion of the neck

Se expone un caso de osteítis vertebral múltiple de presentación aguda con marcada afectación del estado general. Los hallazgos radiológicos, gammagráficos y de resonancia magnética obligaron al diagnóstico diferencial de un proceso neoplásico infiltrativo y de un origen infeccioso vertebral frente a la etiología inflamatoria. Por la presencia de osteítis múltiple no infecciosa, artritis esternoclavicular y la ulterior aparición de pustulosis plantar, se orientó como síndrome SAPHO. El tratamiento con infliximab consiguió la mejoría clínica, analítica y de las alteraciones radiológicas (AU)

We report a case of acute-onset multifocal vertebral osteitis with a marked impact on the patient's general health. The radiological, scintigraphic and magnetic resonance findings made it necessary to carry out a differential diagnosis to distinguish it from an infiltrative neoplastic process and determine whether it had an infectious or an inflammatory etiology. The presence of noninfectious multifocal osteitis and sternoclavicular arthritis and the subsequent development of plantar pustulosis pointed to SAPHO syndrome. Treatment with infliximab led to improvement in the clinical symptoms, laboratory values and radiological abnormalities (AU)

SAPHO syndrome presenting as an osteolytic lesion of the neck. / Lesión osteolítica cervical como presentación del síndrome SAPHO.

We report a case of acute-onset multifocal vertebral osteitis with a marked impact on the patient's general health. The radiological, scintigraphic and magnetic resonance findings made it necessary to carry out a differential diagnosis to distinguish it from an infiltrative neoplastic process and determine whether it had an infectious or an inflammatory etiology. The presence of noninfectious multifocal osteitis and sternoclavicular arthritis and the subsequent development of plantar pustulosis pointed to SAPHO syndrome. Treatment with infliximab led to improvement in the clinical symptoms, laboratory values and radiological abnormalities.

Hypophosphatemic osteomalacia induced by tenofovir in HIV-infected patients.

Tenofovir disoproxil fumarate (TDF) is an adenine analogue reverse transcription inhibitor widely used in first-line treatment of human immunodeficiency virus (HIV) infection and also in hepatitis B virus infection. Its use has been linked to sporadic Fanconi syndrome, renal failure and bone disease. We present the clinical characteristics of tenofovir-induced osteomalacia, discuss bone biopsy findings, describe predisposing factors and compare our results with other reported cases. We describe five cases of hypophosphatemic osteomalacia induced by TDF and recorded at the rheumatology service of a university hospital between 2010 and 2014. We also report the characteristics of bone biopsies of this pathology, which have not been previously described. We include a review of published cases of proximal renal tubulopathy (PRT) and osteomalacia induced by TDF (PubMed 1995-2014; keywords: osteomalacia, tenofovir, Fanconi syndrome, hypophosphatemic osteomalacia, proximal renal tubulopathy, bone biopsy). Five HIV patients who developed hypophosphatemic osteomalacia under TDF treatment (>5 years) presented increasing bone pain and a progressive inability to walk without assistance as a result of multiple insufficiency fractures. Bone biopsy performed in three patients after tetracycline labelling showed increased osteoid thickness, confirming osteomalacia. A literature review retrieved 17 publications on this condition, including 53 cases: 26 patients developed isolated PRT, 25 presented PRT and with multiple insufficiency fractures and two presented isolated bone disease, including osteomalacia and osteoporosis. Rheumatologists should be alert to this complication in patients receiving tenofovir. The main complaint reported by these patients is diffuse pain, predominantly in the lower limbs, indicating multiple stress fractures. Serum phosphate and appropriate screening for abnormal proximal tubule function should be monitored. Bone scintigraphy should be carried out in cases of limb pain before the occurrence of more severe complications.

The SAPHO syndrome: a clinical and imaging study.

The purpose of this study is to describe the clinical and radiological manifestations of patients with the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. Retrospective study (1984-2007) was performed in a single center. All patients with the SAPHO syndrome were included. Fifty-two patients were included: 26 male, mean age at diagnosis is 42±12 years. Ostearticular involvement was present before cutaneous involvement in 59.6% of patients and concomitantly in 23.5%. Anterior chest pain was the commonest clinical manifestation, it was present in 38 patients (73%), followed by peripheral arthritis in 17 patients (32%), and sacroliliac pain in 14 patients (26.9%). Cutaneous involvement was present in 33 patients (63.5%). HLA B27 antigen was present in eight patients (17.7%). Bone scintigraphy showed an increased uptake in 42 patients (93.3%). The location of the uptake was mainly in sternoclavicular and manubriosternal joints. CT scan was performed in all "hot joints" showing sclerosis, erosions, hyperostosis, and soft tissue involvement. Refractory patients were treated mainly with pamidronate. Although SAPHO syndrome is an entity that share features that fit into a variety of established disease categories, the present study has a homogenous clinical and radiological pattern that gives support to believe that the SAPHO syndrome is an isolated clinical entity.

Brown tumor of the cervical spine: a case report and review of the literature.

Brown tumors (BT) are benign focal bone lesions that may appear in the context of primary and secondary hyperparathyroidism (HPT). Involvement of the spine is exceedingly rare. We present a case of brown tumor involving the cervical spine, the third reported in the literature. In the literature review (until August 2010), we found nine cases of spinal BT in primary HPT and 14 cases in secondary HPT. Fifteen patients (65%) had evidence of spinal cord compression. A 34-year-old woman on long-term hemodialysis, with secondary HPT, presented with a 9-month history of persistent neck pain. Radiographs of the cervical spine revealed an expansive osteolytic lesion in the posterior arch of the second cervical vertebra. MR imaging revealed an expansive mass on C2 affecting the vertebral body, odontoid process, right pedicle, laminas, and spinous process; there were no signs of spinal edema. A CT-guided needle biopsy of the lesion showed destruction of trabecular bone, infiltration of the fibroblastic cells, and abundant osteoclast-like multinucleated giant cells with hemorrhage and hemosiderin pigment, and the diagnosis of brown tumor was made. Cervical pain disappeared within a few days of parathyroidectomy, and rapid remineralization of C2 was evident within a few months. BT must always be considered in the context of hyperparathyroidism and osteolytic lesions. Vertebral BT can be particularly devastating due to medullar compression symptoms. Regression or complete disappearance of these lesions after parathyroidectomy is common, but prompt surgical decompression is necessary in case of medullar compression symptoms.

Hemangioma from head to toe: MR imaging with pathologic correlation.

Hemangioma is a common benign vascular neoplasm that closely resembles normal vessels and can be found in all organs of the human body. Vascular lesions can be classified as infantile hemangiomas or vascular malformations on the basis of their natural history, location, cellular turnover, and histologic characteristics. The magnetic resonance (MR) imaging features of vascular malformations of the central nervous system depend on the pathologic subtype. Soft-tissue vascular malformations can be categorized with combined MR imaging and MR angiography as either high- or low-flow. Osseous vascular malformations commonly demonstrate a high-signal-intensity trabecular pattern at both T1- and T2-weighted MR imaging. A group of more aggressive vascular neoplasms, including hemangioendothelioma, hemangiopericytoma, and glomus tumor, have a nonspecific appearance at MR imaging. In the liver and spleen, hemangiomas are typically hyperintense at T2-weighted MR imaging, with a centripetal filling pattern after administration of gadopentetate dimeglumine. Vascular lesions can involve several organs or systems in angiomatous syndromes. MR imaging allows characterization of a hemangioma with typical features, which vary depending on anatomic location. Familiarity with these features facilitates diagnosis and management of these anomalies.

Localized renal cystic disease: imaging findings, pathologic correlation, and management approach.

A case of unilateral renal cystic disease of the kidney is reported, in which the cysts were located to the lower pole of the right kidney. The radiologic and pathologic findings are described and their differential diagnosis is discussed. Conservative treatment and imaging follow-up is proposed for this condition.