Diagnostic Ultrasound Shows Reversal of Supraspinatus Muscle Atrophy Following Arthroscopic Rotator Cuff Repair.

PURPOSE: Prospective study to assess ultrasonography (US) utility as an imaging tool for supraspinatus muscle atrophy diagnosis, establishing if there is any relationship between repairing supraspinatus tears and its eventual muscular recovery. METHODS: Observational study. SELECTION CRITERIA: adults with a full-thickness reparable supraspinatus tear confirmed arthroscopically. Clinical and imaging data pre- and postoperatively with 12 months of follow-up were recorded, including demographic data, Constant scale, Patte classification, repair type, and supraspinatus muscle belly US images in both shoulders, recording height, diameter, echogenicity (mean number of pixels between 0-black and 255-white), and central tendon pennate angle (PA). RESULTS: In total, 110 supraspinatus tears underwent arthroscopic repair (2015-2018). Mean age was 61 ± 8 years (46-77). We detected a correlation between atrophy and age in terms of echogenicity and PA (P = .01). Echogenicity improved from 54.5 to 51.0 (P = .365) and slightly deteriorated on the contralateral side from 51.6 to 52.9 (P = .351). Supraspinatus echogenicity compared to trapezius muscle reduced from 0.43 to 0.36 (P < .001). PA augmented from 5.8 to 8.6 (P < .001). Mean PA on the contralateral side was 8.6 preoperatively. Patte II cases showed the most significant improvement in terms of imaging evaluation of atrophy. Although Patte III cases almost did not improve in terms of atrophy, they improved clinically. We observed improvement after surgery in Constant score from 35 to 85 (P < .001). Minimal clinically important differences for Constant and visual analog scale were 44.45 ± 12.87 and 6.54 ± 1.41, respectively. Recurrence of symptoms was 13%, related to worse results of PA and echogenicity compared to nonrecurrences. CONCLUSIONS: Supraspinatus atrophic muscle changes after repair can be reversed. It can be quantified using US imaging (histogram, histogram ratio and echogenicity reduction, pennate pattern, and PA augmentation). Patte II cases showed the best results after repair, demonstrated by US. The faster the repair, the better the results without being influenced by repair type. The bigger the tear and retraction, the more echogenicity and less PA, with worse clinical and US results. LEVEL OF EVIDENCE: Level III, prospective therapeutic study.

First Metatarsophalangeal Arthrodesis After Failed Distal Chevron Osteotomy for Hallux Valgus.

BACKGROUND: The purpose of this study was to compare the clinical outcomes after first metatarsophalangeal (MTP) joint arthrodesis for hallux rigidus between patients who underwent primary arthrodesis and those who had had a prior surgery for hallux valgus. METHODS: Our design was a retrospective cohort study comparing 29 patients who underwent primary arthrodesis (primary group) and 34 patients with hallux rigidus after hallux valgus surgery (secondary group). The clinical assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) score and a visual analog scale (VAS) for pain. Radiological evaluation was also performed. Overall, the mean postoperative follow-up was 3.4 (range, 2-5) years. RESULTS: At final follow-up, AOFAS and VAS pain scores significantly improved in both groups (P = .001). However, the mean AOFAS (P = .001) and VAS pain (P = .008) scores were significantly better in the primary group than in the secondary group. Radiologically, there were no significant differences between the groups in any angle after arthrodesis. Revision surgeries were not required in the primary group. In the secondary group, there was 1 revision due to deep infection, and 3 other patients required dorsal plate removal. Excluding plate removal, the Kaplan-Meier survival at 3 years was not significantly different between groups (P = .775). CONCLUSION: Although arthrodesis of the first MTP joint was an effective procedure for hallux rigidus, the clinical outcomes in patients who had prior hallux valgus surgery were worse than those for patients who underwent primary surgery for hallux rigidus. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Xantoma del tendón de aquiles bilateral: debut de xantomatosis cerebrotendinosa / Bilateral achilles tendon xanthoma: cerebrotendinous xanthomatosis debut

OBJETIVO Presentación de un inusual caso de xantomatosis cerebrotendinosa en un paciente de edad cuya primera manifestación fueron xantomas bilaterales del tendón de Aquiles. MATERIAL Y MÉTODOS Mujer de 62 años, que presenta tumoraciones, que presenta tumoraciones sólidas y polilobuladas, en la cara posterior de ambos tendones de Aquiles de 8 años de evolución. El diagnóstico se realizó mediante el hallazgo de hiperlipidemia y estudio genético. Se realió la exóresis quirúrgica parcial de las tumoraciones. RESULTADOS A los 5 años de la cirugía del pie izquierdo y 4 años del pie derecho la paciente estaba asintomática. Presentaba una fuerza para la flexión plantar bilateral de 5/5, pudiendo caminar y subir escaleras sin molestias. Presentaba una escala AOFAS de 85 y 90 puntos en el pie izquierdo y derecho, respectivamente. No hubo recidivas. DISCUSIÓN Los xantomas son depósitos de colesterol en el tejido conectivo de la piel, tendones o fascia, como resultado de una hiperlipoproteinemia. La importancia del caso radica en su sospecha diagnóstica, ya que la xantomatosis cerebrotendinosa suele manifestarse en pacientes de menos de 30 años de edad y en los que se ha recomendado la resección radical de las tumoraciones, e incluso del tendón, debido a las frecuentes recidivas. CONCLUSIÓN En pacientes de mayor edad con lesiones que infiltran el tendón, se puede optar por un tratamiento menos agresivo con un buen resultado clínico.

OBJETIVE Presentation of an unusual case of cerebrotendinous xanthomatosis in an elderly patient whose first manifestation was bilateral Achilles tendon xanthomas. MATERIAL AND METHODS 62-year-old woman presenting solid and polylobed tumors on the posterior aspect of both Achilles tendons for eight years. The diagnosis was made by means of hyperlipidemia and a genetic study. Surgical partial excision of the tumors was performed. RESULTS Five years after surgery on the left foot and four years after the right foot, the patient was asymptomatic. Bilateral plantar flexion force was 5/5, The patient was able to walk and climb stairs without discomfort. AOFAS score was 85 and 90 on the left and right feet, respectively. There were no recurrences. DISCUSSION Xanthomatosis is a genetic alteration with deposits of cholesterol in connective tissue of the skin, tendons or fascia, because of hyperlipoproteinemia. The importance of the present case lies in its diagnostic suspicion, since cerebrotendinous xanthomatosis manifests usually in patients under 30 years of age and in whom radical resection of tumors, and even of the tendon, has been recommended due to frequent recurrences . CONCLUSION In older patients with tumors that infiltrate the tendon, a less aggressive treatment can be chosen with a good clinical result.

Fractura del tubérculo medial de la apófisis posterior del astrágalo / Medial tubercle's fracture of posterior process of talus

OBJETIVO Mostrar una fractura infrecuente del tubérculo posteromedial del astrágalo diagnosticado y tratado de manera aguda mediante osteosíntesis con tornillo Acutrak® (2014 Acumed® LLC). MATERIAL Y MÉTODOS Varón de 28 años, que acude a Urgencias tras torcedura de tobillo con dolor al mover tobillo y hallux y tumefacción en cara interna. En Urgencias pasó desapercibida. En consulta a la semana refería sensación de que se le engancha el primer dedo con la flexoextensión. Se observa fractura del tubérculo medial de la apófisis posterior del astrágalo con desplazamiento >3mm y clínica de posible interposición del flexor hallucis longus. Se decidió tratamiento quirúrgico con tornillo Acutrak®. Se inmovilizó con férula 3 semanas y descarga 6 semanas. RESULTADOS A los 8 meses balance articular completo, sin dolor ni limitación para las ABVD y sin clínica de atrapamiento del flexor del hallux. Como complicación aguda, se verificó infección de herida quirúrgica que se trató con antibióticos. DISCUSIÓN Ese tipo de fracturas son infrecuentes. El mecanismo lesional suele ser dorsiflexión-pronación. Es importante un diagnóstico temprano y para ello es necesario una alta sospecha diagnóstica. Para su diagnóstico, son necesarias radiografías anteroposterior y lateral y si no se visualiza la lesión, proyección oblicua con 30°- 40° de rotación externa. En casos agudos resulta de utilidad la TAC y en casos crónicos la RM. CONCLUSIÓN Aunque generalmente el tratamiento es conservador, en ocasiones puede ser necesario la cirugía mediante osteosíntesis o exéresis del fragmento cuando la fractura provoca impingement.

OBJECTIVE Show an infrequent fracture of the posteromedial tubercle of the talus diagnosed and treated acutely by Acutrak® screw (2014 Acumed® LLC) osteosynthesis. MATERIAL AND METHODS A 28-year-old man attended the Emergency Department after spraining his ankle with pain when moving his ankle and hallux and swelling on the internal face. In the ER it went unnoticed. A week later in the clinic, he refered to the sensation that the first finger is hooked with the flexion extension. A fracture of the medial tubercle of the posterior process of the talus is observed with a displacement of > 3 mm and clinical signs of possible interposition of the hallucis longus . Surgical treatment with Acutrak® screw was made. He was immobilized with a splint for 3 weeks and discharge for 6 weeks. RESULTS At 8 months complete joint balance, without pain or limitations for BADL and without hallux flexor entrapment symptoms. As an acute complication, surgical wound infection that was treated with antibiotics. DISCUSSION These types of fractures are rare. The injury mechanism is usually dorsiflexion-pronation. Early diagnosis is important and a high diagnostic suspicion is required. Anteroposterior and lateral radiographs are necessary for its diagnosis and if the lesion is not visualized, oblique projection with 30°- 40° external rotation. CT is useful in acute cases and MRI in chronic cases. CONCLUSION Although the treatment is conservative, surgery may sometimes be necessary by means of osteosynthesis or excision of the fragment when the fracture causes impingement.