Patient-Reported Outcomes of Minimally Invasive versus Open Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Disc Disease: A Prospective Comparative Cohort Study.

Background: Comparative outcomes of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and traditional open TLIF (O-TLIF) for degenerative lumbar disc disease have been poorly studied. The purpose of this study was to prospectively compare the outcomes between MI-TLIF and O-TLIF for patients with a degenerative disc disease, focusing on the functional capacity of patients in daily life. Methods: A prospective cohort study was performed, comparing 54 patients who underwent O-TLIF and 55 patients who underwent MI-TLIF with a follow-up of 4 years. Clinical evaluation was performed using the Oswestry Disability Index (ODI), 36-item short form survey (SF-36), and a visual analog scale for pain (VAS pain). Radiological evaluation was also performed. Results: At the final follow-up, compared with O-TLIF, MI-TLIF was associated with significantly better intraoperative results, including similar operative time (p = 0.246), lower estimated blood loss (p = 0.001), and shorter hospital stay (p = 0.001). The final ODI score was significantly better in the MI-TLIF group (p = 0.031). The SF-36-physical (p = 0.023) and VAS pain (p = 0.024) scores were significantly better in the MI-TLIF group. There was no significant difference in the fusion rate (p = 0.747). Conclusions: The MI-TLIF technique is an effective and safe procedure for degenerative lumbar disc disease. Compared to traditional O-TLIF, MI-TLIF was associated with less disability and higher quality of life, with a low rate of intraoperative and postoperative complications.

Influence of sesamoid position after scarf osteotomy for hallux valgus on patient-reported outcome. A prospective cohor study.

BACKGROUND: The objective was to evaluate the influence of the postoperative sesamoid position as measured with conventional radiographs on the patient-reported outcome after scarf osteotomy. The hypothesis was that incomplete reduction of the sesamoid would result in a decreased functional outcome. METHODS: Eighty-two patients who underwent scarf osteotomy for hallux valgus were prospectively assessed for up to two postoperative years. The Self-Reported Foot and Ankle Score (SEFAS) was used to assess the quality of life, and the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale (AOFAS) for the functional outcome. A visual analogue scale (VAS) assessed pain, and Likert scale for patient satisfaction. Radiologically, hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), and sesamoid position were analyzed. According to the final sesamoid position, patients were classified as normal position (48 patients) and outlier position (34 patients). A power analysis, conventional and logistic regression statistical analysis were performed. RESULTS: At the final follow-up, significant improvements in all clinical scores were observed for both groups (p = 0.001) with no significant difference in AOFAS score (p = 0.413), but SEFAS score (p = 0.023), VAS-pain (p = 0.006), and satisfaction (p = 0.014) were significantly better in the normal group than in the outlier group. There were significant differences between groups in final HVA (p = 0.042) and IMA (p = 0.040). In multivariate analysis, only lower VAS-pain score (OR 0.4, 95% CI 0.2-0.6; p = 0.039) and normal sesamoid position (OR 2.4, 95% CI 1.6-3.2; p = 0.012) were significant predictor of patient satisfaction. CONCLUSION: At two postoperative years, normal sesamoid position as measured on weight-bearing radiographs was associated with lower pain and better patient satisfaction in patients underwent scarf osteotomy for moderate to severe hallux valgus.

Síndrome compartimental bilateral de pierna tras posición de litotomía prolongada: presentación de un caso clínico / Bilateral leg compartment syndrome after prolonged lithotomy position: clinical case report

INTRODUCCIÓN: El síndrome compartimental es una complicación infrecuente pero severa que puede aparecer ante una posición de litotomía prolongada y el uso de perneras. OBJETIVO: Presentar un caso de síndrome compartimental bilateral tras posición de litotomía prolongada asociada con el uso de perneras. MATERIAL Y MÉTODOS: Paciente varón de 43 años sometido a una cirugía urológica en posición habitual de litotomía durante un periodo de 6 horas. A las 2 horas de finalizar la cirugía, el paciente presentó dolor intenso y endurecimiento de compartimento anterior y lateral de ambas piernas, junto con una elevación de la creatina quinasa sérica (valor inicial de 109 U/L que se elevó hasta 7.689 U/L a las 12 horas) y una imposibilidad para la flexión dorsal pasiva de ambos tobillos. El paciente no sentía dolor en el resto de los compartimentos. RESULTADOS: Ante la sospecha de un síndrome compartimental anterolateral, se realizó fasciotomía bilateral urgente, y se observó una disminución de la perfusión muscular y mejoría de la misma tras apertura de la fascia. Se realizaron curas periódicas cada 48 horas, y se observó viabilidad del tejido hasta su cierre definitivo a los 4 días. A las 2 semanas, el paciente presentó fatiga ligera para la deambulación sin ayuda, con tumefacción en el compartimento lateral de ambas piernas. A los 10 meses de evolución, el paciente caminaba sin ayuda y con función muscular completa. CONCLUSIONES: El conocimiento de la asociación del síndrome compartimental y la cirugía laparoscópica prolongada es esencial para un diagnóstico precoz y un tratamiento quirúrgico inmediato, para evitar graves secuelas. Los buenos resultados de nuestro paciente se deben a la rápida actuación, ya que normalmente se suele demorar. Para evitar su aparición o disminuir su incidencia, la posición de litotomía debería limitarse a aquellos momentos de la cirugía en los que sea imprescindible, modificando la posición de las piernas cada dos horas en caso de cirugías prolongadas, para prevenir dicha complicación.

Compartment syndrome is a rare but severe complication resulting from a prolonged lithotomy position and the use of leg loops. PURPOSE: To present a case of bilateral compartment syndrome after prolonged lithotomy position associated with the use of leg loops. METHODS: A 43-year-old man underwent urological surgery in the usual lithotomy position for a 6-hour period. Two hours after the end of the surgery, the patient presented severe pain and stiffening of the anterior and lateral compartments of both legs, elevated serum creatine kinase levels (the baseline value of 109 U/L increased to 7,689 U/L at 12 hours), and inability for passive dorsiflexion of both ankles. The patient reported no pain in the other compartments. RESULTS: Suspicion of an anterolateral compartment syndrome resulted in an urgent bilateral fasciotomy; muscle perfusion was decreased, and it improved after fascial opening. Dressings were changed every 48 hours, and tissue viability was observed until the final closure at 4 days. At two weeks, the patient presented slight fatigue when walking with no assistance, in addition to swelling in the lateral compartment of both legs. Ten months after surgery, the patient walked with no assistance and with complete muscle function. CONCLUSION: Knowledge of the association between compartment syndrome and prolonged laparoscopic surgery is essential for an early diagnosis and immediate surgical treatment to avoid serious sequelae. In our patient, the good outcomes resulted from quick action, since diagnosis is often delayed. Limiting the lithotomy position to those surgical moments in which it is essential and changing the position of the legs every 2 hours during prolonged procedures can reduce the occurrence and incidence of compartment syndrome, preventing this complication.

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.

Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a prospective cohort study at a minimum five year follow-up.

PURPOSE: To evaluate prospectively the functional outcomes of tibiotalocalcaneal (TTC) arthrodesis with a contemporary retrograde intramedullary nail after a minimum follow-up of five years. METHODS: Sixty-one patients with a mean age of 51.3 (range, 18-79) years were included in the study. Functional outcome was assessed using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score (AOFAS), Short-Form 12-item Health Survey (SF12), and visual analog scales (VAS) for both pain and patient satisfaction. Radiographic evaluation was also assessed. RESULTS: The mean post-operative follow-up was 6.8 (range, 5-8) years. Mean AOFAS and SF12 scores significantly improved at the final follow-up (p < 0.001), and the mean VAS for pain significantly decreased (p < 0.001). At the final follow-up, only five (8.2%) patients gave an AOFAS score of less than 50, 52 (85.2%) were satisfied with their surgery, and 32 (52.4%) returned to their employment. There were two tibiotalar joint nonunions that required re-operations, and another patient required re-operation for screw removal. There was no deep infection. CONCLUSIONS: The retrograde intramedullary nail provided a stable TTC arthrodesis with a high union rate, acceptable functional outcomes, and a low severe complication rate. This procedure appears to offer a reliable salvage option for TTC arthrodesis in patients with severe ankle and hindfoot degeneration.

Better clinical outcomes and overall higher survival with hybrid versus cemented primary total knee arthroplasty: a minimum 15 years follow-up.

PURPOSE: To compare the clinical outcomes and survival at long-term between hybrid and cemented primary total knee arthroplasty (TKA). A better clinical outcome and survival following a follow-up as long as 15 years with the use of hybrid fixation as compared with cemented fixation was hypothesized. METHODS: Case-control study of 126 patients with a mean age of 62.4 years who underwent hybrid TKA matched with 126 patients underwent cemented TKA. Clinical outcome was assessed by the Knee Society scores (KSS) and reduced Western Ontario and MacMaster Universities questionnaire (WOMAC). Radiological assessment was made by the Knee Society method. RESULTS: The mean follow-up was 15.7 (range 15-17) years. At the final follow-up, clinical scores were significantly better in the hybrid group, although the differences were not clinically relevant. Revisions for all reasons were performed in five knees in the hybrid group and 15 knees in the cemented group (p = 0.033). In the hybrid group, there was one aseptic femoral loosening and no aseptic tibial loosening. In the cemented group, the main reasons for aseptic revisions were polyethylene wear (six knees) and tibial loosening (four knees). Cemented fixation was a significant risk factor for aseptic revision (hazard ratio 2.3; 95% CI 1.3-3.7%; p = 0.004). Survival at 15 years for aseptic reasons was 96.5% (95% CI 93.4-98.7%) in hybrid groups and 90.3% (95% CI 88.7-93.9%) in cemented group (p = 0.020). CONCLUSION: After a minimum follow-up of 15 years, hybrid fixation of primary TKA for osteoarthritis provide significantly higher clinical benefits compared with cemented fixation, but the differences were not clinically relevant. Hybrid fixation provides longer overall survival, although the femoral component survival was similar between groups. LEVEL OF EVIDENCE: III.

Successful mid- to long-term outcome after reconstruction of the extensor apparatus using proximal tibia-patellar tendon composite allograft.

PURPOSE: The purpose of the study was to assess the outcomes of extensor mechanism reconstruction with proximal tibia-patellar tendon composite allograft. METHODS: 24 consecutive patients treated with allograft-prosthetic composite for proximal tibia tumour resection and a conventional total knee arthroplasty were included. Extensor mechanism reconstruction was performed with a proximal tibia-patellar tendon composite allograft and the suture of the donor tendon to the remnant native patellar tendon. Function was evaluated by the Musculoskeletal Tumor Society score (MSTS) and range of motion. Western Ontario and MacMaster University (WOMAC) and visual analogue scale for pain also were used. RESULTS: After a mean follow-up of 11.7 (range 3-15) years, mean MSTS score was 22.4 (range 20-30), mean flexion was 94.0° (range 84°-110°), and mean extension lag was 7.2° (range 0°-18°). The mean VAS-pain was 4.3 (range 2-6), and WOMAC score was 72.4 (range 58-100). There was no failure of the reconstructed extensor mechanism. CONCLUSION: Patellar tendon reconstruction with allogeneic tissue from the proximal tibia allograft sutured to the recipient's remnant patellar tendon provides the mechanical support needed for healing of the reconstructed extensor mechanism with a substantial functional benefit to stabilize active knee extension and successful reconstruction survival at long-term. LEVEL OF EVIDENCE: III.

Prospective comparison of functional outcomes of primary reverse shoulder arthroplasty for acute fractures versus rotator cuff deficiencies.

AIMS: The purpose of this study was to determine whether there were long-term differences in outcomes of reverse shoulder arthroplasty (RSA) undertaken for acute proximal humeral fracture versus rotator cuff deficiency with a minimum follow-up of five years. METHODS: This was a prospective cohort study comparing 67 patients with acute complex proximal humeral fracture and 64 patients with irreparable rotator cuff deficiency who underwent primary RSA. In the fracture group, there were 52 (77.6%) females and 15 (22.4%) males, with a mean age of 73.5 years (51 to 85), while in the arthropathy group, there were 43 (67.1%) females and 21 (32.9%) males, with a mean age of 70.6 years (50 to 84). Patients were assessed by the Constant score, University of California Los Angeles shoulder score (UCLA), short version of the Disability of the Arm Shoulder and Hand score (QuickDASH), and visual analogue scales (VAS) for pain and satisfaction. Radiological evaluation was also performed. RESULTS: Mean follow-up was 8.4 years (5 to 11). There were no significant differences in mean absolute (p = 0.125) or adjusted (p = 0.569) Constant, UCLA (p = 0.088), QuickDASH (p = 0.135), VAS-pain (p = 0.062), or range of movement at the final follow-up. However, patient satisfaction was significantly lower in the fracture group (p = 0.002). The complication rate was 1.5% (one patient) versus 9.3% (six patients), and the revision rate was 1.5% (one patient) versus 7.8% (five patients) in the fracture and arthropathy groups, respectively. The ten-year arthroplasty survival was not significantly different (p = 0.221). CONCLUSION: RSA may be used not only for patients with irreparable rotator cuff deficiencies, but also for those with acute complex proximal humeral fractures. We found that RSA provided similar functional outcomes and a low revision rate for both indications at long-term. However, satisfaction is lower in patients with an acute fracture. Cite this article: Bone Joint J 2020;102-B(11):1555-1559.

Outcomes of Total Hip Arthroplasty for Healed Intertrochanteric Hip Fractures. A Matched Retrospective Cohort Study.

BACKGROUND: Many studies have analyzed the outcomes of total hip arthroplasty (THA) after failed intertrochanteric fracture fixation, but not after healed fracture. The objective is to investigate the influence of a prior healed intertrochanteric fracture fixation on the outcomes of a subsequent THA for osteoarthritis. METHODS: This is a matched retrospective cohort study of THA between 43 patients who suffered a prior intertrochanteric fracture successfully managed with internal fixation and 43 patients without prior hip fracture. Mean age was 73.6 vs 74.2 years. A conventional cementless THA was used in both groups. Functional outcome was assessed by the Harris hip score (HHS) and reduced Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. Radiological assessment was also performed. RESULTS: Mean follow-up was 6.6 (range, 5-8) years. The mean operative time and blood transfusion rate were significantly higher in the fracture group (P = .001), but there was no significant difference in the length of stay. HHS significantly improved in both groups. At final follow-up, HHS was significantly higher in nonfracture group (P = .008), but the rate of patients with excellent and good outcomes was similar (P = .616). Western Ontario and McMaster Universities Osteoarthritis Index score at the final follow-up was not different between groups (P = .058). Complication rate was similar between groups. There were no revisions, dislocations, or loose implants in the study group. CONCLUSION: Cementless THA provided successful functional outcomes and implant durability at medium term in patients treated for osteoarthritis following healed intertrochanteric fracture fixation, comparable to those without prior fracture who underwent primary THA. Surgical complexity and complication rate were low.

Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients.

INTRODUCTION: Treatment of the distal radius fracture in elderly remains controversial. The objective was to assess the outcomes of volar locking plate for displaced complete intra-articular distal radius fractures in elderly as compared to younger patients. HYPOTHESIS: The outcomes in elderly patients would be comparable with those in younger patients with a low rate of complications. MATERIAL AND METHODS: Non-randomised prospective comparative study between 70 patients older than 65 years and 46 younger patients with AO type-C fractures. The main outcome was Disabilities Arm, Shoulder and Hand (DASH) score. Secondary variables were Patient-Rated Wrist Evaluation (PRWE) score, range of motion, Visual Analogue Scale (VAS) for pain, and grip strength. Radiological measurements were also performed. RESULTS: The mean follow-up was 30.9 (range, 24-53) months. There were no significant differences in mean DASH, PRWE, VAS-pain, wrist motion or radiological parameters at final follow-up. Multivariate analysis showed that the functional outcomes were significantly influenced by baseline ulnar positivity greater than 3mm at baseline but not by age. DISCUSSION: The study hypothesis was confirmed. Surgical treatment with volar locking plate for displaced complete intra-articular fractures of the distal radius in elderly patients represents a safe and effective treatment alternative with similar early complication rate than in younger. LEVEL OF EVIDENCE: III, cohort study.

Minimal clinically important differences and substantial clinical benefits for Knee Society Scores.

PURPOSE: There is a paucity of literature defining the minimal clinically important difference (MCID) for the Knee Society Scores (KSS) after total knee arthroplasty (TKA), and no data on the substantial clinical benefit (SCB) for KSS have been reported. The purpose of this study was to determine MCID and SCB for the KSS in patients with primary TKA. METHODS: The median age of patients was 71.6 (range 50-88) years, and 60.3% were females 507 patients with TKA were prospectively enrolled. Patients completed the KSS before surgery and at second postoperative year. The MCID values of the KSS were estimated using anchor-based method, distribution-based method and receiver operating characteristic (ROC) curve analysis with calculation of the area under curve (AUC). SCB was estimated using ROC. RESULTS: The MCID for KSS-knee score was 7.2 points by the anchor-based method, 7.2 by the distribution-based method, and using a ROC analysis the cutoff point was 8.9 points with an AUC of 0.75. For KSS-function score, the MCID values were 9.7, 6.3, and 10.3 (AUC 0.71), respectively. SCB values were 39.7 points (AUC 0.74) for the KSS-knee score, and 38.6 (AUC 0.76) for the KSS-function score. Logistic regression showed age and Charlson index to negatively affect the changes in KSS. CONCLUSION: Different methods for MCID calculation lead to different results. With the use of ROC curve analysis, patients with an improvement of at least 9 points for KSS-knee and 10 points for KSS-function scores experience a clinically important change, whereas those who have at least an improvement of 40 points for KSS-knee and 39 points for KSS-function scores experience a substantial clinical benefit. These findings can ensure clinical improvement from the patient's perspective and also aid in interpreting results from clinical studies. LEVEL OF EVIDENCE: III.

Is Pseudo-Patella Baja Really a Serious Complication of Total Knee Arthroplasty?

BACKGROUND: The available evidence on pseudo-patella baja (PPB) is limited. The purpose of this study is to investigate prospectively the occurrence of PPB after primary total knee arthroplasty and its clinical consequences in a large series of patients with a minimum follow-up of 2 years. PPB was defined as a patella distally displaced in relationship to the femoral trochlea with absence of patellar tendon shortening (Grelsamer RP. J Arthroplasty 2002;17:66-69) due to elevation of the joint line. METHODS: This study is a prospective case series of 354 patients with a mean age of 71.7 (range 52-87) years. Clinical evaluation was performed by the Knee Society Scores (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short-Form 12-item (SF12), and range of motion. Patellar height was assessed by the Insall-Salvati and Blackburne-Peel ratios. RESULTS: The mean follow-up was 3.6 (range 2.0-6.6) years. Postoperatively, 286 (80.7%) patients had a normal patellar height, 17 (4.8%) had true patella baja (TPB), and 51 (14.4%) had PPB. There were no significant differences between the 3 groups in mean KSS-function (P = .107), range of motion (P = .408), WOMAC-pain (P = .095), WOMAC-stiffness (P = .279), or SF12-mental (P = .363). Between normal and PPB groups, there were no significant differences in mean KSS-knee (P = .903), WOMAC-function (P = .294), or SF12-physical (P = .940). However, the TPB group had significantly lower mean KSS-knee (P = .031), WOMAC-function (P = .018), and SF12-physical (P = .005) as compared with either 2 other groups. CONCLUSION: PPB was a relatively common finding, but no significant differences in terms of clinical outcomes were found as compared to patients with postoperative normal patellar height. TPB was infrequent, but these patients had significantly worse clinical outcomes than those with PPB or normal patellar height.

Prior unilateral total hip arthroplasty does not influence the outcome of ipsilateral total knee arthroplasty.

PURPOSE: To assess the influence of a prior well-functioning unilateral primary total hip arthroplasty (THA) on the functional outcome of a subsequent ipsilateral primary total knee arthroplasty (TKA). METHODS: A retrospective case-control study of 92 patients older than 60 years underwent unilateral primary TKA after a prior ipsilateral THA (THA-TKA group) and 92 matched patients underwent only TKA (TKA group). Clinical assessments were performed using the Knee Society Scores (KSS) and Harris Hip Score (HSS), quality of life by the Reduced Western Ontario and MacMaster Universities (WOMAC) and Short-Form 12 (SF-12) questionnaires. Radiological evaluation was also performed. RESULTS: Median follow-up after TKA was 7.2 (range 5-9) years. There were no significant differences between groups in baseline data at the TKA time. The mean gains in KSS were similar in both groups. At the last follow-up, there were no significant differences in WOMAC-pain or SF12-physical scores, but the WOMAC-function (p = 0.003) and SF12-mental (p = 0.018) scores were significantly better in the isolated TKA group. At the last follow-up, there were no significant differences in the radiological knee alignment or component positions. For aseptic reasons, the TKA survival at 8 years in the TKA group was 95.8 (95% CI 87.8-100%), and 96.6% (95% CI 91.8-100%) in the THA-TKA group (ns). CONCLUSION: A well-functioning unilateral THA does not influence on the functional outcome of a subsequent ipsilateral TKA. This finding can help clinicians when counseling patients with hip and knee osteoarthritis. LEVEL OF EVIDENCE: III.

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.

Altered seric levels of albumin, sodium and parathyroid hormone may predict early mortality following hip fracture surgery in elderly.

PURPOSE: To analyse a wide set of routine laboratory parameters at admission to predict mortality within 30 post-operative days in elderly patients with hip fracture, as well as calculate the critical values of those biomarkers. METHOD: Data of 994 patients older than 65 years with hip fracture were analysed of which 89 (8.2%) died within 30 post-operative days. Variables described in the literature with potential influence on early mortality were collected, including demographics, fracture type, American Society of Anesthesiologists score, Charlson's comorbidity index and pre-operative Hodkinson's mental test and the Katz index for activities of daily living. In addition, an exhaustive collection of biomarkers from routine blood testing at admission was performed. Critical levels of biomarkers were calculated by the method of area under ROC curve. RESULTS: At admission, early mortality group had significantly higher Charlson's index (p = 0.001) and lower the Katz index (p = 0.001). The surgical delay also was significantly longer in that group (p = 0.001). In univariate analyses, serum concentration at admission of total protein (p = 0.004), albumin (p = 0.001), sodium (p = 0.001), and parathyroid hormone (PTH) (p = 0.001) were significantly different between both groups. In multivariate analysis, serum albumin < 2.9 g/dL (p = 0.013), sodium < 127 mEq/L (p = 0.035) and PTH > 65 pg/mL (p = 0.005) were predictors of early mortality. The three biomarkers together accounted for 67% of the variability in early mortality. CONCLUSION: The association of altered levels at admission of serum concentration of albumin, sodium and PTH was predictor of early mortality following hip fracture surgery in elderly patients.

Outcomes and Patient Satisfaction With Arthroscopic Partial Meniscectomy for Degenerative and Traumatic Tears in Middle-Aged Patients With No or Mild Osteoarthritis.

BACKGROUND: There is controversy about the benefit of arthroscopic partial meniscectomy (APM) for degenerative lesions in middle-aged patients. PURPOSE: To compare satisfaction with APM between middle-aged patients with no or mild knee osteoarthritis (OA) and a degenerative meniscal tear and those with a traumatic tear. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A comparative prospective study at 5 years of middle-aged patients (45-60 years old) with no or mild OA undergoing APM for degenerative (n = 115) or traumatic (n = 143) tears was conducted. Patient satisfaction was measured by a 5-point Likert scale and functional outcomes by the Knee injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Univariate and multivariate regression analyses were used to identify factors correlating with patient-reported satisfaction at 5 years postoperatively. RESULTS: Baseline patient characteristics were not different between groups. At the 5-year evaluation, the satisfaction rate in the traumatic and degenerative groups was 68.5% versus 71.3%, respectively (P = .365). Patient satisfaction was significantly associated with functional outcomes (r = 0.69; P = .024). In the degenerative group, 43 patients (37.4%) had OA progression to Kellgren-Lawrence (K-L) grade 2 or 3, but only 24 patients (20.8%) had a symptomatic knee at final follow-up. Multivariate regression analysis for patient dissatisfaction at 5-year follow-up showed the following significant independent factors: female sex (odds ratio [OR], 1.6 [95% CI, 1.1-2.3]; P = .018), body mass index >30 kg/m2 (OR, 2.6 [95% CI, 1.7-4.9]; P = .035), lateral meniscal tears (OR, 0.6 [95% CI, 0.1-0.9]; P = .039), and OA progression to K-L grade ≥2 at final follow-up (OR, 1.4 [95% CI, 1.2-2.6]; P = .014). At the final evaluation, there were no significant differences between groups in pain scores (P = .648), WOMAC scores (P = .083), or KOOS-4 scores (P = .187). Likewise, there were no significant differences in the KOOS subscores for Pain (P = .144), Symptoms (P = .097), or Sports/Recreation (P = .150). Although the degenerative group had significantly higher subscores for Activities of Daily Living (P = .001) and Quality of Life (P = .004), the differences were considered not clinically meaningful. CONCLUSION: There were no meaningful differences in patient satisfaction or clinical outcomes between patients with traumatic and degenerative tears and no or mild OA. Predictors of dissatisfaction with APM were female sex, obesity, and lateral meniscal tears. Our findings suggested that APM was an effective medium-term option to relieve pain and recover function in middle-aged patients with degenerative meniscal tears, without obvious OA, and with failed prior physical therapy.

Validation of the Spanish Version of the Knee Injury and Osteoarthritis Outcome Score (KOOS) for Elderly Patients With Total Knee Replacement.

The purpose of this study was to validate the Knee Injury and Osteoarthritis Outcome Score (KOOS) for elderly patients who undergo total knee replacement (TKR). The validated Spanish versions of the KOOS and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaires were applied to 137 patients (mean age 72.3, SD 7.5 years). Test-retest data were collected with an intermediate period of 1-2 weeks. To evaluate the clinimetric properties of the KOOS, internal consistency (Cronbach's α), reproducibility (intraclass correlation coefficient [ICC]), construct validity (Spearman's correlation), responsiveness (effect sizes [ES], and standardized response mean [SRM]), and floor and ceiling effects (<15%) were assessed. As result, Cronbach's coefficients of the KOOS subscales ranged from 0.78 to 0.93, and ICC from 0.76 to 0.91. Construct validity was supported by the confirmation of the three predefined hypotheses involving expected correlations between KOOS subscale and SF-36 physical health subscales. Spearman's correlations were strong between KOOS Pain and SF-36 Bodily Pain (r = 0.81), KOOS Pain and SF-36 Physical Functioning (r = 0.67), KOOS activities of daily living (ADL) and SF-36 Bodily Pain (r = 0.69), KOOS ADL and SF-36 Physical Functioning (r = 0.74), and KOOS Sports/Recreation and SF-36 Physical Functioning (r = 0.76). Responsiveness at 1 year after TKR was large with the ES ranging from 0.81 to 2.12, and the SRM from 0.70 to 1.91. Floor and ceiling effects were low. In conclusion, the Spanish version of KOOS has successful psychometric characteristics and is a reliable and valid instrument for assessment of patient-relevant outcomes in elderly patients with advanced OA who undergo TKR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2157-2162, 2019.

A Comparison Study of the Outcomes of Ceramic-on-Ceramic Total Hip Arthroplasty in Young vs Older Patients: A Minimum 10-Year Follow-Up Prospective Matched Study.

BACKGROUND: The purpose of this study is to analyze the outcome and prosthesis survival in patients aged between 20 and 40 years who received a cementless total hip arthroplasty (THA) with a minimum follow-up of 10 years compared to older patients. METHODS: Prospective matched comparative study was conducted between 94 young patients with mean age of 37.2 (range 22-40) years and 90 older patients with mean age of 64.7 (range 60-70) years treated with ceramic-on-ceramic THA. Clinical outcomes were assessed by the Harris Hip Score, reduced Western Ontario and MacMaster University (WOMAC), and Short-Form-12 (SF12) questionnaires. Radiological evaluation was also performed. The primary outcome was the THA survival rate. RESULTS: Mean follow-up of 13.6 (range, 10-15) years. At the final follow-up, there was no significant difference between groups in Harris Hip Score (P = .356), WOMAC-pain (P = .461), SF12-physical (P = .305), or SF12-mental (P = .511), but younger group had significantly higher WOMAC-function score (P = .013). There were 7 revisions in the younger group and 4 in the older group (P = .197). The 14-year prosthesis survival for any reason was 93.2% (95% confidence interval [CI] 86.7-99.7) in the younger group and 98.3% (95% CI 95.1-100) in the older group (P = .189). For aseptic reason, the 14-year survival was 94.7% (95% CI 88.9-100) in the younger group and 98.3% (95% CI 95.1-100) in the older group (P = .332). CONCLUSION: At minimum follow-up of 10 years, THA with cementless stem and ceramic-on-ceramic bearing provides successful survival and functional outcomes in young patients between 20 and 40 years old.