Allograft tendons are a safe and effective option for revision ACL reconstruction: a clinical review.

Revision anterior cruciate ligament reconstruction remains a challenge, especially optimising outcome for patients with a compromised knee where previous autogenous tissue has been used for reconstruction. Allograft tissue has become a recognized choice of graft for revision surgery but questions remain over the risks and benefits of such an option. Allograft tendons are a safe and effective option for revision ACL reconstruction with no higher risk of infection and equivalent failure rates compared to autografts provided that the tissue is not irradiated, or any irradiation is minimal. Best scenarios for use of allografts include revision surgery where further use of autografts could lead to high donor site morbidity, complex instability situations where additional structures may need reconstruction, and in those with clinical and radiologic signs of autologous tendon degeneration. A surgeon needs to be able to select the best option for the challenging knee facing revision ACL reconstruction, and in the light of current data, allograft tissue can be considered a suitable option to this purpose.Level of evidence IV.

Randomized controlled trial comparing the effectiveness of the ultrasound-guided galvanic electrolysis technique (USGET) versus conventional electro-physiotherapeutic treatment on patellar tendinopathy.

BACKGROUND: Patellar tendinopathy has a high prevalence rate among athletes. Different therapeutic options can be found in the current literature, but none of them has been clearly established as the gold standard. The purpose of this study is to compare, in a randomized controlled trial, the clinical efficacy of eccentric exercise combined with either an ultrasound-guided galvanic electrolysis technique (USGET) or conventional electrophysiotherapy to treat patellar tendinopathy. METHODS: Sixty patients diagnosed with patellar tendinopathy were randomized into two groups. Group 1 (n = 30) received electrophysiotherapy treatment consisting of ultrasound, laser and interferential current techniques. Group 2 (n = 30) received USGET. Both groups did the same standardized eccentric exercise program. Periodic assessments of the subjects were carried out with the Victorian Institute of Sport Assessment-Patella (VISA-P) score. An analysis of means and a survival study were performed. RESULTS: There were statistically significant differences in the VISA-P between the baseline and final follow-up in each treatment group. Group 1 (conventional electrophysiotherapy) went from 52.5 ± 18.8 to 61.9 ± 13.7 (in VISA-P < 90 subgroup) and from 69.1 ± 9.1 to 95.2 ± 2.5 (in VISA-P > 90 subgroup). Group 2 (USGET) went from 51.4 ± 17.9 to 63.3 ± 14.3 (in VISA-P < 90 subgroup) and from 66.3 ± 13.1 to 97.1 ± 1.7 (in VISA-P > 90 subgroup). There were statistically significant correlations between the baseline and final score in the VISA-P > 90 subjects upon completing the study but no statistically significant correlations between subjects with VISA-P < 90. The mean number of sessions applied was 22.6 ± 2.5 in Group 1 and 3.2 ± 0.9 in Group 2. The success probability in Group 1 was 36.1% versus 72.4% in Group 2. The difference was statistically significant. CONCLUSION: The results obtained with the combination of USGET and eccentric exercise reported better outcomes than with the conventional electrophysiotherapy techniques in the treatment of patellar tendinopathy.

[High recurrence and good functional results after arthroscopic resection of pigmented villonodular synovitis]. / Alta recidiva y buenos resultados funcionales tras la resección artroscópica de la sinovitis villonodular pigmentaria de la rodilla.

INTRODUCTION: Pigmented villonodular synovitis (PVS) is a synovial proliferation disorder of uncertain aetiology, with some controversy as regards its proper treatment. The purpose of the study was to evaluate the functional outcome and recurrence rate in a series of patients diagnosed with both the diffuse and the localised type of PVS and treated by arthroscopic resection. MATERIAL AND METHODS: Twenty-four patients diagnosed with PVS were retrospectively assessed. There were 11 cases with the diffuse type, and 13 cases with the localised type of PVS. They were followed-up for a median of 60 months (range, 34-204). They underwent arthroscopic synovectomy, and were functionally evaluated with IKDC, WOMET, and Kujala scores. RESULTS: There was recurrence in 8 out of 13 (61.5%) cases with the diffuse type of PVS. Two of these patients were treated with radiation. One patient underwent surgical resection with an open procedure due to extra-articular involvement. The remaining 5 patients underwent a second arthroscopic resection, and no recurrence was subsequently observed. Cases with localised PVS did not recur after a single arthroscopic resection. IKDC, WOMET and Kujala scores improved by 30.6, 37.4 and 34.03 points, respectively. DISCUSSION: Pigmented villonodular synovitis treated by arthroscopic resection showed good functional results at mid-term follow-up. A single arthroscopic resection was sufficient to treat the localised PVS, whereas the diffuse type of PVS required a second arthroscopic resection in most cases, due to its high rate of recurrence.

Clinical results after ultrasound-guided intratissue percutaneous electrolysis (EPI®) and eccentric exercise in the treatment of patellar tendinopathy.

PURPOSE: To investigate the outcome of ultrasound (US)-guided intratissue percutaneous electrolysis (EPI(®)) and eccentric exercise in the treatment of patellar tendinopathy during a long-term follow-up. METHODS: Forty patients with patellar tendinopathy were prospectively evaluated over a 10-year follow-up period. Pain and function were evaluated before treatment, at 3 months and at 2, 5 and 10 years using the Victorian Institute of Sport Assessment-Patella (VISA-P) score, the Tegner score and Blazina's classification. According to VISA-P score at baseline, patients were also dichotomized into Group 1 (<50 points) and Group 2 (≥50 points). There were 21 patients in Group 1 and 19 in Group 2. Patient satisfaction was measured according to the Roles and Maudsley score. RESULTS: The VISA-P score improved globally by 41.2 points (p < 0.01) after a mean 4.1 procedures. In Group 1, VISA-P score improved from 33.1 ± 13 to 78.9 ± 14.4 at 3-month and to 88.8 ± 10.1 at 10-year follow-up (p < 0.001). In Group 2, VISA-P score improved from 69.3 ± 10.5 to 84.9 ± 9 at 3-month and to 96.0 ± 4.3 at 10-year follow-up (p < 0.001). After 10 years, 91.2 % of the patients had a VISA-P score >80 points. The same level (80 % of patients) or the Tegner score at no more than one level lower (20 % of patients) was restored, and 97.5 % of the patients were satisfied with the procedure. CONCLUSION: Treatment with the US-guided EPI(®) technique and eccentric exercises in patellar tendinopathy resulted in a great improvement in knee function and a rapid return to the previous level of activity after few sessions. The procedure has proved to be safe with no recurrences on a long-term basis. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

[Molecular repair mechanisms using the Intratissue Percutaneous Electrolysis technique in patellar tendonitis]. / Mecanismos moleculares de reparación mediante la técnica Electrólisis Percutánea Intratisular en la tendinosis rotuliana.

OBJECTIVE: To investigate the molecular mechanisms of tissue response after treatment with the Intratissue Percutaneous Electrolysis (EPI(®)) technique in collagenase-induced tendinopathy in Sprague-Dawley rats. METHODS: Tendinopathy was induced by injecting 50 µg of type i collagenase into the patellar tendon of 24 Sprague Dawley rats of 7 months of age and weighting 300 g. The sample was divided into 4 groups: the control group, collagenase group, and two EPI(®) technique treatment groups of 3 and 6 mA, respectively. An EPI(®) treatment session was applied, and after 3 days, the tendons were analysed using immunoblotting and electrophoresis techniques. An analysis was also made of cytochrome C protein, Smac/Diablo, vascular endothelial growth factor and its receptor 2, as well as the nuclear transcription factor peroxisome proliferator-activated receptor gamma. RESULTS: A statistically significant increase, compared to the control group, was observed in the expression of cytochrome C, Smac/Diablo, vascular endothelial growth factor, its receptor 2 and peroxisome proliferator-activated receptor gamma in the groups in which the EPI(®) technique was applied. CONCLUSIONS: EPI(®) technique produces an increase in anti-inflammatory and angiogenic molecular mechanisms in collagenase-induced tendon injury in rats.

[Fracture of the carpal scaphoid in children. Case report and literature review]. / Fractura de escafoides carpiano en el niño. A propósito de un caso y revisión de la bibliografía.

OBJECTIVE: To conduct a bibliographic review of the infrequent fractures of the carpal scaphoid in pediatric cases based on a clinical case. The diagnosis is usually a difficult one and treatment should be stringent in order to minimize the chance of delayed healing or pseudoarthrosis. MATERIAL AND METHODS: Ten year-old child with a carpal scaphoid fracture visible in the plain films. The patient did not comply with treatment and removed the cast at three weeks. Despite this healing occurred without any clinical sequelae. DISCUSSION: This case is especially infrequent given the excellent result obtained despite the fact that the immobilization period was considerably shorter than the minimum recommended.

Knee joint infection after ACL reconstruction: prevalence, management and functional outcomes.

PURPOSE: Septic arthritis after an ACL reconstruction is a rare but serious complication. Functional outcomes of these patients have not been studied in depth in large series. The aim of this study was to determine the prevalence and management of knee joint infection following ACL reconstruction and to assess the functional outcomes. METHODS: A retrospective assessment of knee joint infections occurring after arthroscopically assisted ACL reconstructions done from 2006 to 2009 in two hospitals by the same surgical team is presented. Patients with signs and symptoms of joint infection along with blood and synovial effusion laboratory parameters suggestive of infection were considered as septic arthritis. All the patients were treated with antibiotic therapy according to antibiotic sensitivity and had at least one arthroscopic lavage. Final outcomes were assessed and compared with a control group using the KT-1000 arthrometer, functional testing and radiological examination. RESULTS: Fifteen (1.8 %) out of 810 patients included in the study were considered as a joint infection. Microbiology showed that coagulase-negative Staphylococcus was present in 10 patients, Staphylococcus Aureus in three patients (2 MSSA and 1 MRSA) and Propinebacterium sp. in one patient. In one patient, the micro-organism was unknown. At a mean follow-up of 39.3 ± 13 months, the Lysholm score was 77.7 ± 15.3, the IKDC score was 70.4 ± 19.5, and the KT-1000 compared to the non-injured contralateral knee showed a mean difference of 1.3 ± 2 mm. Functional outcomes in the control group were slightly better than those obtained in the infected group (Lysholm score; 90.7 ± 9.4, p = 0.007. IKDC score; 86.6 ± 6.8, p = 0.004). All but one patient retained their reconstructed ACL. CONCLUSIONS: The prevalence of septic arthritis after an ACL reconstruction in this series was 1.8 %. Arthroscopic lavages along with antibiotic treatment led us to preserve all but one graft. Functional outcomes in the infected patients were not as good as those obtained in patients without infection.

[Occipital condyle fracture: clinical case and a review of the literature]. / Fractura del cóndilo occipital. Reporte clínico y revisión de la literatura.

OBJECTIVE: We present a case report of an occipital condyle fracture, a rarely seen injury in patients of any age, and particularly so in paediatric patients. The objective of this article is to inform about this lesion, such often going unnoticed, but should be especially looked for in cranial trauma cases with neck pain. An X-ray may be normal and diagnosis is best made by using computed tomography imaging. Treatment should depend on whether the fracture is stable or not. MATERIAL AND METHODS: We report on two patients, 17 and 40 -year-old males who presented with an impacted right occipital condyle fracture following a motorbike accident. Cervical immobilization was carried out with a hard collar. RESULTS: Good results were obtained and there were no secondary effects of a neurological or functional nature. CONCLUSION AND CLINICAL RELEVANCE: In conclusion, the knowledge of this condition, its correct diagnosis and the correct treatment choice is crucial to the avoidance of brachial plexus injuries and other important sequelae.

Fractura del cóndilo occipital. Reporte clínico y revisión de la literatura / Occipital condyle fracture: clinical case and a review of the literature

Objetivo. Llamar la atención sobre la existencia de la fractura del cóndilo occipital y la facilidad con la que pasan desapercibidas durante la atención del paciente politraumatizado. Es una lesión poco frecuente, especialmente en pacientes adolescentes, y debe tenerse en cuenta ante un traumatismo craneal con dolor cervical por sus potenciales consecuencias si estas fracturas no se tratan correctamente. La exploración radiográfica puede parecer normal, debiendo hacer el diagnóstico mediante tomografía computarizada. El tratamiento de elección depende de la estabilidad de la fractura. Material y método. Dos pacientes varones de 17 y 40 años involucrados en sendos accidentes de motocicleta, presentaron una fractura impactada del cóndilo occipital. En ambos casos se realizó tratamiento conservador con collar cervical rígido. Resultados. Se obtuvieron buenos resultados funcionales sin secuelas neurológicas. Conclusión y relevancia clínica. El conocimiento y sospecha de esta infrecuente entidad y su correcto diagnóstico y tratamiento es crucial para conseguir un buen resultado funcional, para así evitar potenciales lesiones neurológicas asociadas (AU)

Objective. We present a case report of an occipital condyle fracture, a rarely seen injury in patients of any age, and particularly so in paediatric patients. The objective of this article is to inform about this lesion, such often going unnoticed, but should be especially looked for in cranial trauma cases with neck pain. An X-ray may be normal and diagnosis is best made by using computed tomography imaging. Treatment should depend on whether the fracture is stable or not. Material and methods. We report on two patients, 17 and 40 -year-old males who presented with an impacted right occipital condyle fracture following a motorbike accident. Cervical immobilization was carried out with a hard collar. Results. Good results were obtained and there were no secondary effects of a neurological or functional nature. Conclusion and clinical relevance. In conclusion, the knowledge of this condition, its correct diagnosis and the correct treatment choice is crucial to the avoidance of brachial plexus injuries and other important sequelae (AU)

Reparación artroscópica anatómica de las luxaciones agudas acromio-claviculares / Arthroscopic anatomic repair of acute acromioclavicular joint dislocations

Objetivo: Describir la técnica quirúrgica asistida por artroscopia para el tratamiento de las lesiones agudas acromio-claviculares (AC), basada en la reconstrucción anatómica córaco-clavicular (CC), y presentar los resultados clínicos preliminares. Material y método: Fueron tratados 12 pacientes de luxación AC, con edad media de 31 (19-45) años, con técnica artroscópica mediante reconstrucción con doble dispositivo de suspensión córaco-clavicular (Zip-tight). Seguimiento de entre tres y 12 meses. El tiempo medio entre lesión y cirugía fue de ocho días. Tres luxaciones fueron tipo III de Rockwood, dos tipo IV y siete tipo V. El diagnóstico se basó en radiografías ántero-posteriores y Alexander outlet. La evaluación clínica funcional se realizó con test SF-36, DASH y escala visual analógica (EVA) para el dolor. Resultados: Se obtuvo mejoría en todos los valores estudiados: DASH 79,4 (556 - 89) pre a 3,8 (1,9 - 9,5) post, SF36-físico 29,9 (17 - 43) pre a 56,1 (53 -60) post, SF36-mental 44,2 (27 - 52) pre a 55,4 (44 - 57) post. EVA 8,1 (6-9) pre a 1,3 (0-2) post. El grado de satisfacción fue de 8,5 sobre 10. Los resultados radiográficos fueron satisfactorios en 11 casos, en otro había pérdida de reducción menor al 50% sin repercusión clínica. No se presentaron complicaciones. Conclusión: La técnica presentada para estabilización de luxaciones AC en fase aguda mediante dos dispositivos de suspensión córaco-clavicular anatómicos es una técnica artroscópica segura, con alta demanda para el cirujano y baja tasa de complicaciones que obtiene óptimos resultados a corto plazo en pacientes seleccionados (AU)

Objective: Describe the arthroscopically assisted surgical technique to treat acute acromio-clavicular injuries based on anatomic coracoclavicular (CC) reconstruction and present the preliminary clinical results. Material and methods: After AC dislocation, 12 patients were treated with the anatomic arthroscopic reconstruction technique using a dual coracoclavicular suspension device. Follow-up was from 3 to 12 months 8Xip-tight). The mean time between injury and surgery was 8 days. Three dislocations were Rockwood type III, 2 type IV and 7 type V. The mean age was 31 years (19-45). Diagnosis included antero-posterior and Alexander outlet radiographs. Clinical evaluation was performed with the SF-36 test, DASH and the visual analog scale (VAS) for pain. Results: Improvement was observed in all values studied. DASH 79.4 (556-89) pre to 3.8 (1.9-9.5) post, SF36- physical 29.9 (17-43) pre to 56.1 (53-60) post, SF36- mental 44.2 (27-52) pre to 55.4 (44-57) post. VAS 8.1 (6-9) pre to 1.3 (0-2) post. The degree of satisfaction was 8.5 over 10. Radiographic results were satisfactory in 11 cases. In one case, there was a loss of reduction of less than 50% that had no clinical impact. No complications such as tunnel fractures, infection or intolerance of material occurred. Conclusion: The technique for stabilization of acute AC dislocations with two anatomically configured CC suspension devices is safe but demanding. However, the complication rate is low and short-term results are optimum in selected patients (AU)

Fractura aislada del cuerpo del hueso ganchoso. A propósito de un caso / Isolated fracture of the body of the hamate bone. About a case

Objetivo. Mostrar mediante un caso clínico que las fracturas del hueso ganchoso son muy poco frecuentes, mucho menos aún las que afectan al cuerpo del mismo sin fracturas asociadas de otros huesos del carpo. Debido a su infrecuencia y a la inespecificidad de sus manifestaciones clínicas, suelen ser de difícil diagnóstico. Material y método. Presentamos el caso de un varón de 24 años, que sufrió fractura conminuta aislada del cuerpo del hueso ganchoso. Fue tratado de forma conservadora, obteniéndose una recuperación ad integrum sin déficit funcional. Conclusiones. Es importante considerar este tipo de fracturas ante un traumatismo directo sobre la mano. Es recomendable la realización de una tomografia computerizada (TC) para caracterizar correctamente la fractura y valorar las posibles lesiones asociadas. La decisión terapéutica depende del grado de conminución de la fractura, de su estabilidad y de la afectación articular (AU)

Objective. To demonstrate, through a clinical case, that fractures of the hamate bone are very infrequent and even more so those that affect its body without there being fractures of the other associated carpal bones. Due to its infrequency and to the non-specificity of its clinical manifestations, they are usually difficult to diagnose. Material and methods. We present a case of a 24 year old male who suffered an isolated comminuted fracture of the body of the hamate bone. It was treated conservatively and full recovery without any functional deficit was obtained. Conclusions. It is important to consider this type of fracture when confronted with a direct traumatism to the hand. Performing computed tomography (CT) is recommended in order to correctly identify the fracture and assess any possible associated lesions. The therapeutic decision depends on the degree of comminution of the fracture, its stability and any joint involvement (AU)

The risks and benefits of thrombolytic therapy in acute aortic and mitral prosthetic valve dysfunction: report of a case and review of the literature.

A patient with acute thrombosis of a St. Jude mitral prosthesis was treated with streptokinase with initial success. Subsequent recurrent thrombosis and embolism prompted operative revision. Because the use of thrombolytic agents in this setting is somewhat controversial, we searched the literature for all reports of aortic or mitral prosthetic valve dysfunction treated this way. The cases of 58 patients treated 62 times were reviewed for efficacy of therapy and morbidity. Thrombolytic therapy may be useful in patients with prosthetic valve thrombosis causing critical hemodynamic compromise. It is frequently the only treatment needed. Further, it may help reduce operative risk for those patients in whom complete resolution is not possible. The incidence of systemic embolism is 18%, however, neurological events are usually limited and transient.

First-degree trifascicular block unmasked by sinus arrhythmias. Report of a case studied with intracardiac electrocardiography.

A case is presented in which first-degree block in all three fascicles of the intraventricular conduction system results in a QRS complex with no specific features of fascicular block. During spontaneous sinus arrhythmia the typical features of RBBB and LAH appear at the longest sinus cycles. This is associated with shortened P-R and H-Q intervals. During shorter sinus cycles, near equalization of delay in each fascicle is associated with delay in His-Purkinje conduction but loss of the typical features of bifascicular block as the ventricular myocardium becomes activated more synchronously. Documentation of the changing patterns of ventricular activation is provided by His bundle electrocardiography.

Cystic thymoma simulating contrictive pericarditis. The role of echocardiography in the differential diagnosis.

A case is presented of a 60-year-old woman with fatigue, dyspnea, and chest pain. A chest x-ray film revealed an abnormal cardiac silhouette. Echocardiography revealed a large, echo-free area with well-demarcated, discrete borders adjacent to the right heart border. This structure decreased in size with inspiration and did not show pulsatile cardiac motion. Cardiac catheterization confirmed the extracardiac nature of the lesion and also showed a "constrictive" pattern with equalization of diastolic pressures. Surgical exploration revealed a large cystic thymoma. With removal of the tumor, intracardiac pressures returned to normal.