Acute haematogenous septic arthritis of a lumbar facet joint in an otherwise healthy adolescent / Artritis séptica hematógena aguda de una articulación facetaria lumbar en un adolescente sano

Facet joint septic arthritis is a rare cause of spinal infection in children with only four cases reported. The transmission pathway is believed to be haematogenous in 72% of cases. The authors present the case of a 13-year-old boy hospitalised for acute lumbosciatalgia, limp and fever, with pain upon palpation of the paravertebral muscles, a positive Laségue signal and elevated serum inflammatory markers. The initial lumbar computerised tomography (TC) scan revealed no abnormalities in the interapophyseal joints. After improving on treatment with analgesics and antibiotics, he was readmitted one month later due to clinical deterioration, and septic arthritis of left facet joint L3-L4 was confirmed by magnetic resonance imaging (MRI). The patient experienced a full recovery after treatment with systemic antibiotics (cefotaxime-cloxacilin) and rehabilitation

La artritis séptica facetaria es una infección raquídea excepcional en niños, con solo cuatro casos publicados. Se cree que en el 72% de los casos el mecanismo de transmisión es hematógeno. Se presenta el caso de un varón de 13 años que fue hospitalizado por lumbociatalgia aguda, cojera y fiebre, con contractura y dolor a la palpación de la musculatura paravertebral, signo de Laségue positivo y elevación de los marcadores séricos inflamatorios. La tomografía axial computarizada (TAC) inicial no mostró anomalías en las articulaciones interapofisarias lumbares. Tras haber mejorado con analgésicos y antibióticos, el paciente reingresó un mes más tarde por deterioro clínico de los síntomas, y la resonancia magnética (RMN) mostró artritis séptica de la articulación interfacetaria izquierda de L3-L4. El paciente obtuvo una recuperación completa con tratamiento antibiotico (cefotaxima-cloxacilina) y rehabilitación. Se requiere un alto grado de sospecha para poder diagnosticar esta localización anatómica como manifestación de lumbociática y/o cojera en niños. Se requiere TAC o, preferiblemente, RMN para confirmar el diagnóstico

Acute haematogenous septic arthritis of a lumbar facet joint in an otherwise healthy adolescent.

Facet joint septic arthritis is a rare cause of spinal infection in children with only four cases reported. The transmission pathway is believed to be haematogenous in 72% of cases. The authors present the case of a 13-year-old boy hospitalised for acute lumbosciatalgia, limp and fever, with pain upon palpation of the paravertebral muscles, a positive Laségue signal and elevated serum inflammatory markers. The initial lumbar computerised tomography (TC) scan revealed no abnormalities in the interapophyseal joints. After improving on treatment with analgesics and antibiotics, he was readmitted one month later due to clinical deterioration, and septic arthritis of left facet joint L3-L4 was confirmed by magnetic resonance imaging (MRI). The patient experienced a full recovery after treatment with systemic antibiotics (cefotaxime-cloxacilin) and rehabilitation. A high index of suspicion is necessary to diagnose this localization as a manifestation of lumbosciatalgia and/or limp in children. CT-scan or, preferably, MRI is mandatory to confirm this diagnosis.

Distal radial torus fracture in an adult. A new type of occult wrist fracture? / Fractura en rodete distal de radio en adulto. ¿Un nuevo tipo de fractura oculta de muñeca?

Torus or buckle fractures typically affect children who have suffered indirect minor wrist injuries. They are axial compression-type metaphyseal fractures of cortical and cancellous bone, which are stable and their treatment therefore consists in immobilisation of the joint for three to four weeks. We present an atypical case of distal radius torus fracture in a 19-year-old adult male, which has not been previously reported in adults and can be considered a new type of occult fracture. Knowledge of this possibility is mandatory to be able to make a differential diagnosis of wrist sprain in adults, and avoid performing superfluous complementary tests due to the persistence of pain and functional incapacity

Las fracturas en rodete afectan típicamente a niños que sufren un traumatismo leve indirecto en la muñeca. Son fracturas metafisarias por compresión axial del hueso cortical y esponjoso que son estables y que, por tanto, su tratamiento consiste en inmovilizar la articulación durante un periodo de tres a cuatro semanas. Presentamos un atípico caso de fractura distal de radio en rodete en un hombre de 19 años, que no ha sido previamente descrita en adultos y puede ser considerada un nuevo tipo de fractura oculta. El conocimiento de esta posibilidad es esencial para poder realizar el diagnóstico diferencial con un esguince de muñeca en adultos, y evitar la realización de pruebas complementarias innecesarias ante la persistencia del dolor y de incapacidad funcional

Distal radial torus fracture in an adult. A new type of occult wrist fracture?

Torus or buckle fractures typically affect children who have suffered indirect minor wrist injuries. They are axial compression-type metaphyseal fractures of cortical and cancellous bone, which are stable and their treatment therefore consists in immobilisation of the joint for three to four weeks. We present an atypical case of distal radius torus fracture in a 19-year-old adult male, which has not been previously reported in adults and can be considered a new type of occult fracture. Knowledge of this possibility is mandatory to be able to make a differential diagnosis of wrist sprain in adults, and avoid performing superfluous complementary tests due to the persistence of pain and functional incapacity.

[Effects on the elbow of radial head resection following isolated radial head fracture in young patients]. / Efectos sobre el codo de la resección de la cabeza radial por fractura aislada de la cabeza del radio en pacientes jóvenes.

BACKGROUND: Radial head resection has been a widely used procedure in cases of non-reconstructable radial head fracture. Some authors propose the use of radial head arthroplasty. The purpose of this study was to evaluate the long-term outcome of radial head resection for isolated fracture, without instability at the time of the fracture, and its radiological and functional repercussions at the elbow level. METHODS: We reviewed 44 clinical records with acute resection of the radial head following isolated radial head fracture, with absence of associated injuries, younger than forty, with a minimum follow-up of 15 years. Information was collected on elbow pain, biomechanical function, flexion and extension elbow strength and elbow instability compared with the non-affected side. A radiological study was conducted on all patients to determine the presence of degenerative changes, calcifications and measurement of the carrying angle. Outcomes were evaluated with Disabilities of the Arm, Shoulder and Hand score as an instrument to measure the patient's perceived disability. RESULTS: The group under study is made up of ten women and thirty-four men, with an average age at the time of fracture of 28.6 years (ranging from 15-40) and an average time since the fracture or follow-up time of 28.5 years (ranging from 16-38). The affectation was on the dominant side in thirty cases (23 right-handed and 7 left-handed). Thirty-nine patients (88.6%) had no elbow pain, and in all other cases was mild or moderate. Loss of mobility and strength was 1.5% for flexo-extension, 3.5% for prono-supination, 7.9% for flexion strength and 3.5% for extension strength. We appreciated four cases of valgus instability and two of postero-lateral instability. The average DASH score was 6.9 points. Radiographic changes of arthritis were present in 93.3% and 54.4% of calcifications. The mean increase of carrying angle was 7.7º compared with non-affected gide (ranking from 0.9-15.8º). CONCLUSION: Radial head resection for isolated fracture in young patients presents satisfactory results, with very low losses of elbow mobility and strength. Despite the high presence of osteoarthritic changes or lower clinical signs of instability, elbow pain and disability are very low. Our conclusion, based in these results, is that radial head resection is still a useful surgical procedure for isolated fractures even in young patients.

[Idiopatic chondrolysis of the hip. Long-term follow-up of a case]. / Condrolisis idiopática de cadera. Evolución a largo plazo.

Idiopathic chondrolysis of the hip is a very rare disease occurring during adolescence. Pain and limp are the most common symptoms and are a consequence of an accelerated loss of the articular cartilage with a lower range of move-ment producing rigidity in the last instance. The natural history is unpredictable and varies between complete and spon-taneous recovery and the ankylosis. The current recommended treatment is conservative, restricting the surgical option for residual stiffness. A clinical case of an eleven year old patient is presented. He consulted for a 2 year, torpid course of left groin pain with limp and rigidity. He received treatment with rest, discharge, analgesics and rehabilitation without any improvement initially. He was treated conservatively with NSAIDS, extremity discharge periods, soft traction in the hospital and at home and rehabilitation, recovering mobility and normal gait 6 years after the beginning of the symptoms. Twelve years after the onset of the symptoms the patient leads a normal life without symptoms and has a symmetric range of motion of both hips.

Condrolisis idiopática de cadera. Evolución a largo plazo / Idiopatic chondrolysis of the hip. Long-term follow-up of a case

La condrolisis idiopática de cadera es una rara condición que se presenta durante la adolescencia. Se caracteriza por dolor y cojera producidos por una pérdida acelerada del cartílago articular con una disminución del grado de movilidad llegando a rigidez. La historia va desde la resolución espontánea completa a la anquilosis. El tratamiento recomendado actualmente es el conservador. Se presenta el caso clínico de un paciente de 11 años de edad con un cuadro clínico de 2 años de evolución tórpida de dolor inguinal izquierdo acompañado de cojera y rigidez. Se instauró reposo, descarga, analgésicos y rehabilitación sin mejoría inicial. Posteriormente recibió tratamiento conservador con AINE, periodos de descarga de la extremidad, tracción blanda hospitalaria, tracción ambulatoria nocturna y rehabilitación, recuperando la movilidad y marcha normal 6 años después del inicio de los síntomas. Catorce años más tarde el paciente hace una vida normal, asintomático y con movilidad simétrica de ambas caderas (AU)

Idiopathic chondrolysis of the hip is a very rare disease occurring during adolescence. Pain and limp are the most common symptoms and are a consequence of an accelerated loss of the articular cartilage with a lower range of movement producing rigidity in the last instance. The natural history is unpredictable and varies between complete and spontaneous recovery and the ankylosis. The current recommended treatment is conservative, restricting the surgical option for residual stiffness. A clinical case of an eleven year old patient is presented. He consulted for a 2 year, torpid course of left groin pain with limp and rigidity. He received treatment with rest, discharge, analgesics and rehabilitation without any improvement initially. He was treated conservatively with NSAIDS, extremity discharge periods, soft traction in the hospital and at home and rehabilitation, recovering mobility and normal gait 6 years after the beginning of the symptoms. Twelve years after the onset of the symptoms the patient leads a normal life without symptoms and has a symmetric range of motion of both hips (AU)

Cross-cultural adaptation of the Zurich Claudication Questionnaire.Validation study of the Spanish version.

BACKGROUND: In the last few years, instruments that measure outcomes and quality of life as perceived by the patient have become tools of great clinical value. The Zurich Claudication Questionnaire is one of the main instruments for the assessment of patients suffering from lumbar spinal stenosis. Nonetheless, no valid version has been published for use in the Spanish population. METHODS: The Zurich Claudication Questionnaire was translated and cross-culturally adapted to Spanish and the psychometric characteristics of the new version were then studied. Seventy-six patients were selected who were to undergo epidural steroid injection or were seen in the Hospital Complex of Navarre Spinal Unit. RESULTS: The Spanish version of the Zurich Claudication Questionnaire shows high Cronbach alpha internal consistency values, high reproducibility, a good correlation with the most important low back condition questionnaires used worldwide and good sensitivity for detecting clinical change in patients who undergo epidural steroid injection. CONCLUSION: This study resulted in a version of the Zurich Claudication Questionnaire or Swiss Spinal Stenosis Questionnaire translated and cross-culturally adapted to Spanish, with highly reliable, valid and sensitive psychometric characteristics. These proven properties make the Zurich Claudication Questionnaire available for the Spanish population, to evaluate outcomes and health status as perceived by patients with spinal stenosis and claudication syndrome.

[Giant cell tumours in a pyramidal bone: a clinical case and a review of the literature]. / Tumor de células gigantes en hueso piramidal: caso clínico y revisión de la literatura.

Giant cell tumours (GCT) of the bone are benign, but locally invasive tumours. We present a new case of carpus GCT, involving the triquetrum. The diagnosis required a prior biopsy before doing the block resection. This treatment is the best option to avoid recurrences. We review the literature on this particular lesion in the carpus bone.

Osteometría-escapulometría glenohumeral en las inestabilidades anteriores recidivantes de hombro. Estudio etiopatogénico de uno de los estabilizadores estáticos mediante tomografía computarizada / Glenohumeral osteometry-scapulometry in anterior shoulder instabilities. Study of one of the static stabilizers through computer tomography

Se realizó un estudio escapulométrico de 98 hombros,mediante TAC: 36 con luxación anterior recidivante(LRH), 37 hombros estables contralaterales de esospacientes (HEC) y 25 hombros normales (HN). Se evaluaronseis parámetros: índice glenohumeral horizontal,índice glenohumeral vertical, inclinación glenoidea,ángulo de anteversión de la escápula, ángulo glenoideoy retroversión humeral.Encontramos diferencias estadísticamente significativasentre los grupos LRH y HEC en relación al índiceglenohumeral horizontal. Ambos grupos (LRH y HEC)mostraban diferencias significativas en comparacióncon el grupo de hombros normales (HN) en relación alíndice glenohumeral horizontal, inclinación glenoidea yángulo de anteversión de la escápula. La desproporcióncefalo-glenoidea y la inclinación anterior glenoidea sonlos factores anatómicos desestabilizantes.Nuestros resultados confirman que, aunque la etiologíade la inestabilidad anterior de hombro es multifactorial,existe una predisposición congénita anatómicaque la favorece y, en menor grado, también en el hombroestable contralateral, confirmando la existencia deuna sutil displasia congénita. Además se revelan comoparámetros relevantes en el estudio de la inestabilidadanterior: el índice glenohumeral horizontal, inclinaciónglenoidea y ángulo de anteversión de la escápula, siendodiscutido el papel de la retroversión humeral(AU)

We have carried out a scapulometric study, usingCT-scan, of 98 shoulders: 36 with recurrent anteriorshoulder dislocation (RAD), 37 stable contralateralshoulders (CSS) and 25 normal shoulders (NS). Sixparameters were evaluated: Horizontal and Verticalglenohumeral index, glenoid tilt, anteversion angle ofthe scapula, glenoid angle and humeral retroversion.We found statistically significant differences betweenthe RAD and CSS groups in the horizontal glenohumeralindex. Both the RAD and CSS groups showed significantdifferences in comparison with the NS group in the horizontalglenohumeral index, glenoid tilt and anteversionangle of the scapula. An imbalance of the head-glenoidsize and the anterior glenoid tilt are the anatomicalfactors which favour instability. The determination ofthese three parameters has great value when assessingpatients with anterior shoulder instability.Our results confirm that although the aetiology ofanterior glenohumeral instability is multifactorial, thereis an anatomical congenital predisposition which favoursinstability and this predisposition affects (to a lesser extent)the stable contralateral side, confirming the roleof subtle congenital dysplasic theory. In addition the followingwere revealed as relevant parameters in the studyof anterior instability: the horizontal glenohumeral index,glenoid tilt and angle of anteversion of the scapula; whilethe value of the humeral retroversion is under discussion(AU)

Post traumatic retroperitoneal fibrosis as a cause of low-back pain.

We present the case of a male patient with post traumatic retroperitoneal fibrosis whose main clinical expression was low-back pain. Diagnosis was established using CAT-scan and MRI, which revealed a large mass of soft tissue that almost entirely enveloped the abdominal aorta. Treatment with 40 mg of prednisone every 24 hours was established. This dose was reduced gradually, and progressive remission of clinical signs and symptoms was achieved, with a significant improvement of subsequent imaging-test results. Treatment was continued for one year. Two and a half years later the patient remains symptom-free, with no recurrence of his condition.

Valgus slipped capital femoral epiphysis.

Valgus slips of the epiphysis are rare, making radiological diagnosis difficult. A high degree of clinical suspicion is required to diagnose the condition. The patient was a 13-year, 7-month-old girl who had been suffering from pain in the left thigh for ten days. She had a limp and a positive Trendelenburg sign. Menstrual function had started when she was 12 years and 10 months old. Pain occurred with getting up from a chair. Hip radiographs revealed symmetrical, bilateral caput valgum, which was a potential cause of confusion given the valgus displacement of the proximal femoral epiphysis. Axial view showed an almost imperceptible posterior slip. The patient was diagnosed as having a valgus slipped capital femoral epiphysis (SCFE). Surgical treatment was performed using in-situ fixation with a cannulated, fully threaded percutaneous screw placed through the external cortex of the femoral neck. Non-weight-bearing for six weeks was prescribed. Although a medial approach is usually used for screw insertion using a more medial entry-point, preventing neurovascular risks, in-situ fixation (through a lateral approach) was performed more safely and distally. This was done through the outer cortex of the femoral neck (and centered in the axial view), to achieve fixation of the femoral head in the center of the femoral neck and head.

[Vertebral osteomyelitis caused by Streptococcus agalactiae in healthy adults. Description of 2 new cases]. / Osteomielitis vertebral por Streptococcus agalactiae en adultos sanos: descripción de 2 nuevos casos.

The importance of Streptococcus agalactiae as a pathogen in nonpregnant adults has been widely recognized in recent years, especially in the elderly or immunocompromised patients. Two cases of vertebral osteomyelitis caused by S. agalactiae in young patients with no known underlying diseases or predisposing factor to infection are reported. A systematic review of the literature (MEDLINE, 1976-May 2008) was performed, 10 cases previously reported in the literature of vertebral osteomyelitis due to S. agalactiae being found in adults under 65 years of age with no predisposing risk factors for infection, most of which have been reported over the last 10 years. We believe that this microbial etiology should be considered in patients of any age and immunological status. Other factors, other than increasing the number of patients with chronic diseases, explaining the increased rate of S. agalactiae infections in adults need to be studied.

Osteomielitis vertebral por Streptococcus agalactiae en adultos sanos: descripción de 2 nuevos casos / Vertebral osteomyelitis caused by Streptococcus agalactiae in healthy adults. Description of 2 new cases

La importancia de Streptococcus agalactiae como patógeno en adultos fuera del período gestacional ha quedado bien demostrada en los últimos años, afectando a pacientes de edad avanzada o con inmunodepresión. Se describen 2 casos de osteomielitis vertebral por S. agalactiae en pacientes jóvenes sin enfermedad de base conocida ni factor predisponente de infección. Se realiza una revisión sistemática de la literatura (MEDLINE, 1976-Mayo 2008), encontrando 10 casos previamente publicados de osteomielitis vertebral por S. agalactiae en adultos menores de 65 años y sin ningún factor predisponente de infección, la mayoría publicados en los últimos 10 años. Consideramos que esta etiología microbiana debe ser tenida en cuenta en pacientes de cualquier edad y estado inmunológico. Otros factores, distintos al aumento del número de pacientes con enfermedades crónicas, que expliquen el incremento en la incidencia de las infecciones por S. agalactiae en adultos deben ser estudiados (AU)

The importance of Streptococcus agalactiae as a The importance of Streptococcus agalactiae as a pathogen in nonpregnant adults has been widely recognized in recent years, especially in the elderly or immunocompromised patients. Two cases of vertebral osteomyelitis caused by S. agalactiae in young patients with no known underlying diseases or predisposing factor to infection are reported. A systematic review of the literature (MEDLINE, 1976-May 2008) was performed, 10 cases previously reported in the literature of vertebral osteomyelitis due to S. agalactiae being found in adults under 65 years of age with no predisposing risk factors for infection, most of which have been reported over the last 10 years. We believe that this microbial etiology should be considered in patients of any age and immunological status. Other factors, other than increasing the number of patients with chronic diseases, explaining the increased rate of S. agalactiae infections in adults need to be studied (AU)

[Medial dislocation of the talus. Medium term evolution]. / Enucleación medial de astrágalo abierta. Evolución a medio plazo.

Fifty-seven year old patient with open medial dislocation of the left talus, with suprasyndesmotic fracture of the fibula, due to indirect traumatism. The following were carried out: washing, cleaning the talus and the soft parts, Friedrich, reduction, fixing with Kirschner needles, suture of the deltoid ligament, and osteosynthesis of the fibula. There were neither surface nor deep post-operational infections. The patient underwent six weeks of immobilisation and spent three months on discharge. Two years later there were no radiological signs of avascular necrosis. In the osseous gammagraphy carried out 18 months after the lesion, partial avascular necrosis of the talus was observed. Three years after the lesion, the patient was able to carry out a normal life, without pain in repose but with pain whilst moving, and mobility with limitation of dorsoinflection (-20 masculine). Five and a half years after the lesion, the patient presented sinking of the talar dome due to avascular necrosis, with painful symptomatology whilst moving, and tibiofibular distal diastasis, which required ankle arthrodesis.

Enucleación medial de astrágalo abierta. Evolución a medio plazo / Medial dislocation of the talus. Medium term evolution

Paciente de 57 años con enucleación abierta medialdel astrágalo izquierdo, con fractura suprasindesmal deperoné, por traumatismo indirecto. Se realizó lavado,limpieza del astrágalo y partes blandas, Friedrich, reducción,fijación con agujas de kirschner, sutura del ligamentodeltoideo y osteosíntesis del peroné. No huboinfección superficial ni profunda postoperatoria. Permanecióseis semanas de inmovilización y tres mesesen descarga.Dos años después no había signos radiológicos denecrosis avascular. En gammagrafía ósea realizada a los18 meses de la lesión se observaba necrosis avascularparcial astragalina. Tres años después de la lesiónrealizaba vida normal, sin dolor en reposo pero sí a lamarcha y movilidad con limitación de la dorsiflexión(-20º). Cinco años y medio después de la lesión presentabahundimiento de cúpula astragalina por la necrosisavascular con sintomatología dolorosa a la marcha ydiástasis tibio-peronea distal, que requirió realizar artrodesistibio-astragalina(AU)

Fifty-seven year old patient with open medial dislocationof the left talus, with suprasyndesmotic fractureof the fibula, due to indirect traumatism. The followingwere carried out: washing, cleaning the talus and the softparts, Friedrich, reduction, fixing with Kirschner needles,suture of the deltoid ligament, and osteosynthesisof the fibula. There were neither surface nor deep postoperationalinfections. The patient underwent six weeksof immobilisation and spent three months on discharge.Two years later there were no radiological signs ofavascular necrosis. In the osseous gammagraphy carriedout 18 months after the lesion, partial avascular necrosisof the talus was observed. Three years after the lesion,the patient was able to carry out a normal life, withoutpain in repose but with pain whilst moving, and mobilitywith limitation of dorsoinflection (-20º). Five and a halfyears after the lesion, the patient presented sinking ofthe talar dome due to avascular necrosis, with painfulsymptomatology whilst moving, and tibiofibular distaldiastasis, which required ankle arthrodesis(AU)

Subluxación primaria recidivante medial de rótulas. Revisión a largo plazo de un caso asociado a síndrome de desalineación torsional severa / Primary recurrent medial subdislocation of both patellae. Long-term review of an exceptional case of miserably malalignment syndrome

Presentamos una revisión a largo plazo de una chica de 11 años de edad con subluxación medial recidivante de ambas rótulas de varios meses de evolución asociado a síndrome de desalineación torsional severa. No ha sido descrito ningún caso de luxación o subluxación medial de rótulas hasta el momento. Había sufrido luxación medial de la rótula derecha tres años antes tras un salto, reducida por ella misma y no inmovilizada, seguida de 10 episodios de subluxación y tres de luxaciones mediales. Acudió a consulta por imposibilidad a la deambulación por subluxación persistente o habitual y al dolor fémoro-rotuliano, principalmente en la rodilla derecha. Presentaba subluxación medial habitual de rótulas, con desplazamiento rotuliano medial, amiotrofia cuadricipital, inestabilidad medial evidente de ambas rótulas. El test de supresión medial era positivo. Mostraba anteversión femoral excesiva de caderas (RI: 90º, RE: 30º), genu varum, torsión tibial neutra, patella alta, surcos trocleares displásicos con hipoplasia del cóndilo medial y rótulas displásicas (Wiberg tipo III). Se realizó osteotomía femoral subtrocantérea desrotatoria y realineación proximal rotuliana bilateral. Tras la cirugía recuperó la estabilidad rotuliana bilateral, marcha y carrera normales, con tests de Smillie y aprehensión (-), y movilidad de cadera de RE: 65º, RI: 50º. Quince años tras la cirugía la paciente aquejaba dolor antero-lateral de la rodilla derecha en la deambulación prolongada, al subir y bajar escaleras y la sedestación prolongada, que se diagnosticó de síndrome de hiperpresión rotuliana externa

We present a long-term review of a girl aged 11 years and 4 months with medial primary recurrent subluxation of both patellae of several months evolution associated with miserably malalignment syndrome. Not one case of medial recurrent dislocation of the patellae has been described previously. Three years previously following a jump she had suffered a right patellar luxation - self-reduced and not immobilised - followed by 10 subsequent episodes of subluxation and three more medial luxations. She could hardly walk autonomously due to persistent or habitual subluxation and patellofemoral pain, mainly in the right knee. Physical examination revealed habitual medial subluxation of both patellae, with clear medial patellar displacement, quadriceps amyotrophy and medial instability. The medial subluxation suppression test was positive. She showed excessive femoral anteversion of the hips (IR: 90º, ER: 30º), genu varum, neutral tibial torsion, patella alta, dysplastic trochlear grooves with medial condyle hipoplasia and both patellae were dysplastic (Wiberg type III). We performed a derotation subtrochanteric femoral osteotomy and bilateral proximal patellar realignment. Following surgery, bilateral stability of both sides permitted normal walking and running, as well as apprehension and the Smillie test (-), with a hip mobility of 65º ER and 50º IR. Fifteen years after the surgery the patient complains of antero-external knee pain in the right knee during prolonged walking, in getting up and down stairs and when in a prolonged sitting position, diagnosed as excessive lateral pressure syndrome

[Primary recurrent medial subdislocation of both patellae. Long-term review of an exceptional case of miserably malalignment syndrome]. / Subluxación primaria recidivante medial de rótulas. Revisión a largo plazo de un caso asociado a síndrome de desalineación torsional severa.

We present a long-term review of a girl aged 11 years and 4 months with medial primary recurrent subluxation of both patellae of several months evolution associated with miserably malalignment syndrome. Not one case of medial recurrent dislocation of the patellae has been described previously. Three years previously following a jump she had suffered a right patellar luxation - self-reduced and not immobilised - followed by 10 subsequent episodes of subluxation and three more medial luxations. She could hardly walk autonomously due to persistent or habitual subluxation and patellofemoral pain, mainly in the right knee. Physical examination revealed habitual medial subluxation of both patellae, with clear medial patellar displacement, quadriceps amyotrophy and medial instability. The medial subluxation suppression test was positive. She showed excessive femoral anteversion of the hips (IR: 90 degrees, ER: 30 degrees), genu varum, neutral tibial torsion, patella alta, dysplastic trochlear grooves with medial condyle hipoplasia and both patellae were dysplastic (Wiberg type III). We performed a derotation subtrochanteric femoral osteotomy and bilateral proximal patellar realignment. Following surgery, bilateral stability of both sides permitted normal walking and running, as well as apprehension and the Smillie test (-), with a hip mobility of 65 degrees ER and 50 degrees IR. Fifteen years after the surgery the patient complains of antero-external knee pain in the right knee during prolonged walking, in getting up and down stairs and when in a prolonged sitting position, diagnosed as excessive lateral pressure syndrome.