Conceptos actuales en osteotomías en doble nivel alrededor de la rodilla / Current concepts in double-level osteotomies around the knee

Con la osteotomía en un solo nivel, se puede lograr la corrección del eje de la extremidad en pacientes con deformidades combinadas femoral y tibial, pero de forma simultánea generará una alteración patológica de oblicuidad de la interlínea articular, lo que conducirá a elongación ligamentaria, inestabilidad, degeneración condral y, en última instancia, comprometerá su sobrevida y los resultados funcionales. En virtud del análisis de la literatura más reciente, podemos concluir que existe un número significativo de pacientes que requieren de un procedimiento combinado para lograr un objetivo biomecánico óptimo. La finalidad de una osteotomía en doble nivel alrededor de la rodilla consiste en restablecer la anatomía normal, descargar el compartimiento afectado, normalizar los ángulos mecánicos y la orientación de la interlínea articular. Los ejes fisiológicos pueden restablecerse a través de un análisis preoperatorio exhaustivo, respetando principios biomecánicos y fijación estable con placas bloqueadas. Es un procedimiento demandante y con indicaciones en evolución, que progresivamente se ha instaurado como una alternativa de tratamiento justificada en estudios clínicos y biomecánicos para el manejo de deformidades severas alrededor de la rodilla.

With single-level osteotomy, correction of the limb axis in patients with combined femoral and tibial deformities can be achieved. This correction, however, will generate a pathological alteration in the joint line oblicuity, leading to ligament elongation, instability, joint degeneration and, ultimately, it will compromise the longevity and functional results of the correction. By analyzing the most recent literature, we can conclude that there is a significant number of patients who require a combined procedure to achieve an optimal biomechanical goal. The purpose of a double-level osteotomy around the knee is to restore normal anatomy, unload the affected compartment, normalize the mechanical angles and the orientation of the joint line. Physiological axes can be reestablished by means of a thorough preoperative analysis, observing the biomechanical principles and stable fixation with locked plates. It is a demanding procedure with increasing indications, which has progressively been established in clinical and biomechanical studies as a justified treatment alternative for the management of severe deformities around the knee.

Does the GMFCS level influence the improvement in knee range of motion after rectus femoris transfer in cerebral palsy?

The aim of this study was to evaluate the influence of the Gross Motor Function Classification System (GMFCS) on the outcomes of rectus femoris transfer (RFT) for patients with cerebral palsy and stiff knee gait. We performed a retrospective review of patients seen at our gait laboratory from 1996 to 2013. Inclusion criteria were (i) spastic diplegic cerebral palsy, (ii) GMFCS levels I-III, (iii) reduced peak knee flexion in swing (PKFSw<55°), and (iv) patients who underwent orthopedic surgery with preoperative and postoperative gait analysis. Patients were divided into two groups according to whether they received a concurrent RFT or not at the time of surgery: non-RFT group (185 knees) and RFT group (123 knees). The primary outcome was the overall knee range of motion (KROM) derived from gait kinematics. The secondary outcomes were the PKFSw and the time of peak knee flexion in swing (tPKFSw). We observed a statistically significant improvement in KROM only for patients in the RFT group (P<0.001). However, PKFSw and tPKFSw improved in both groups after surgery (P<0.001 for all analyses). In the RFT group, the improvement in KROM was observed only for patients classified as GMFCS levels I and II. In the non-RFT group, no improvement in KROM was observed in any GMFCS level. In this study, patients at GMFCS levels I and II were more likely to benefit from the RFT procedure.

Distal femoral dome varus osteotomy: surgical technique with minimal dissection and external fixation.

UNLABELLED: The results obtained when employing distal femoral varus osteotomy are variable. Our objective was to describe a surgical technique involving minimal dissection, semicircular osteotomy with external fixation for valgus angular deformities, and early weight bearing. DESIGN: Series of cases. SETTING: Orthopedic Referral Trauma Center. PATIENTS: Sixteen patients with valgus angular deformities of >12°. INTERVENTION: Wedge varus osteotomy, minimal dissection with external fixation using a standard system, multidirectional Newfix. Main outcome measurements included pain, surgical time, knee flexion and extension angles, and assessment of knee function based on the Hospital Special Surgery knee rating scale (HSSkrs). RESULTS: Of 16 patients, 14 were evaluated to the end of the study. When we compared preoperative values with those obtained postoperatively at a mean of 24±2.1months, pain measurement was reduced from 7 to 2.1 (p=0.002), angle of flexion was reduced from 105.4±14.6° to 105.3±11.1° (p=0.06), and angle of extension, from -1.67 to -1.25° (p=0.6), while HSSkrs assessment increased from 67.5±2.7 to 79.4±5 (p=0.003). Two patients were excluded from the study, one due to infection that developed along the trajectory of a screw, and the other patient underwent complete arthroplasty of the knee, which was performed to combat the pain that was not being alleviated. CONCLUSIONS: The technique improves function and reduces pain while facilitating early rehabilitation in 83% of cases.

Miscellaneous non-inflammatory musculoskeletal conditions. Jaccoud's arthropathy.

Jaccoud's arthropathy (JA) is a condition characterised clinically by 'reversible' joint deformities such as swan neck, thumb subluxation, ulnar deviation, 'boutonniere' and hallux valgus, along with an absence of articular erosions on a plain radiograph. JA was initially described in patients with rheumatic fever (RF), but as this disorder has become rare the main clinical entity associated to JA at present is systemic lupus erythematosus (SLE). JA has also been described in other connective tissue diseases, infections and neoplasia. In general, its prevalence in either SLE or RF is around 5%. The etiopathogenic mechanisms of JA are not known, but some authors have suggested an association with hypermobility syndrome. Several studies have attempted to identify an association of different antibodies with JA in SLE patients, but their findings do not allow for the drawing of any definite conclusions. Newer imaging techniques such as magnetic resonance and high-performance ultrasonography have revealed the presence of small erosions in joints of a few patients with JA. Presently, the therapy for JA is conservative and based on the use of non-hormonal anti-inflammatory drugs, low doses of corticosteroids, methotrexate and antimalarials. The role of surgery through either the realignment of soft tissue around the joint--or more aggressive procedures such as arthrodesis, silastic implant and arthroplasty--needs to be proven.

Jaccoud arthropathy in systemic lupus erythematosus: analysis of clinical characteristics and review of the literature.

Jaccoud arthropathy (JA) was initially described in patients with rheumatic fever and later in several other rheumatologic conditions, particularly systemic lupus erythematosus (SLE). In patients with the latter disorder, a prevalence of about 5% has been observed. We conducted the current study to describe a series of patients with SLE with JA, followed at the Hospital Santa Izabel, Salvador, Brazil, during the year 2006. We reviewed the literature on JA, with emphasis on the histologic, clinical, radiologic, and therapeutic aspects of the condition. Twenty-one patients with JA were identified, corresponding to a prevalence of 3.47% in the population of 606 patients with the diagnosis of SLE attended in our service. Twenty patients were women, and the mean age was 40.2 +/- 8.8 years (range, 24-55 yr). The most frequently found joint deformities were swan neck and thumb subluxation, both identified in 14 patients. Ulnar deviation was seen in 8, boutonniere deformity in 3, and hallux valgus in 2 patients. We found no difference in the clinical or laboratory features in SLE patients with or without JA. The patients with JA presented a trend toward a lower quality of life compared with the patients with SLE without JA, but without statistical significance.

Luxación traumática de la cadera en niños. Reporte preliminar de 10 casos / Traumatic dislocation of the hip in children. Preliminary report of 10 cases

Se presenta una serie de 10 niños con luxación traumática de la cadera que se distribuyeron en 3 grupos de acuerdo con su edad. Grupo I (edad 0 a 5 años) 3 pacientes; grupo II (6 a 10 años) un paciente y grupo III (11 a 16 años) 6 pacientes. El grado de lesión fue graduado como leve, moderado o severo. Se identificaron lesiones severas en 7 casos principalmente en el grupo III; 9 sufrieron luxación posterior y sólo hubo una luxación anterior. Todos fueron seguidos por más de un año después de la lesión. Se encontraron lesiones asociadas en 3. El tiempo entre el accidente y la reducción fue en menos de 4 horas en 7 casos. Se encontró un buen resultado en 8 y malo sólo en 2, con limitación en los arcos de movimiento de la cadera. No se encontró artrosis degenerativas o necrosis avascular. Las complicaciones se presentaron en un caso depués de reducción abierta y osteosíntesis por una fractura del acetábulo desplazada. Se realizó evaluación radiográfica (AP de pelvis y AP en posición de rana) y en 3 casos valoración con resonancia magnética (RM)

Rehabilitacion del enfermo com lepra

En el presente trabajo, después de una breve introduccion sobre la rehabilitacion del enfermo con lepra, se hace referencia a generalidades de la enfermedad, como: origen de la enfermedad en México, número de enfermos en la Republica Mexicana (se consideran de 50 a 60,000), clasificacion, y dos grupos: indeterminado y dimorfo. Se estudiam las incapacidades físicas y psicosociales que la enfermedad produce a las personas afectadas; las físicas de localizacion en las manos, pies y cara, principalmente y las incapacidades psicosociales desde el punto de vista de como afectam a la persona y sus familiares en los diferentes aspectos: psiquico, economico y social