Is Previously Implanted Osteosynthesis Material an Obstacle for the Use of Customized Guides?: A Case Report.

CASE: We present the case of a 46-year-old patient with asymmetric deformity in the posterior tibial slope after previous high tibial osteotomy surgeries with the presence of a medial osteotomy plate. A customized cutting guide was designed to fit on the plate to perform a single surgery and avoid possible soft-tissue complications after multiple surgeries. CONCLUSIONS: The presence of a previous internal fixation device may affect the manufacture of 3-dimensional cutting guides. However, in this case, the previously placed osteosynthesis plate was used as an aid for creating the guide.

Inestabilidad femoropatelar. Controversia y evidencia / Patellofemoral instability. Controversy and evidence

La inestabilidad rotuliana se debe a una alteración del mecanismo extensor de la rodilla, que involucra a diferentes estructuras anatómicas. La anamnesis, la exploración física y las pruebas complementarias son cruciales para determinar el manejo adecuado. Una las estructuras anatómicas más importantes es el ligamento patelofemoral medial (LPFM), siendo su reconstrucción la técnica quirúrgica más empleada para resolver el problema de la inestabilidad. Existen diversas formas de realizar la reconstrucción del LPFM y se pueden añadir otros gestos quirúrgicos según las alteraciones anatómicas del paciente.(AU)

Patellofemoral instability is due to a disorder of the knee extensor mechanism which involves several anatomic structures. Medical history, clinical examination and radiological assessment are essential to determine the right handling. One of the most important anatomic structures is the medial patellofemoral ligament (MPFL), and its reconstruction is the most practiced surgical technique to solve the instability problem. There are different options to carry out the MPFL reconstruction and some other surgical options can be used depending on the anatomic alterations of the patient.(AU)

Double Level Osteotomy Assisted by 3D Printing Technology in a Patient with Blount Disease: A Case Report.

CASE: We describe the case of a 26-year-old patient diagnosed with Blount disease. She underwent a medial oblique supracondylar biplanar closing-wedge osteotomy of the distal femur followed by a medial oblique biplanar opening-wedge osteotomy of the proximal tibia. 3D printed cutting guides were used for the procedures. At 18 months after surgery, the patient is pain-free and walks without aids. CONCLUSIONS: Using 3D printed guides allowed for accurate correction of the deformity and reduced the risk of damaging critical structures. These guides could be an appropriate alternative for the surgical treatment of patients with Blount disease.

Fibular-Lengthening Osteotomy in Patient with Progressive Valgus Deformity After an Ankle Fracture.

BACKGROUND The fibular fracture requires an anatomical reduction. When a malunion occurs, it can lead to a valgus deformity with an opening of the ankle mortise. CASE REPORT This case deals with a 23-year-old patient with pain and limited movement in the right ankle, caused by a fracture healed in an incorrect position, with shortening of the fibula and progressive displacement of the valgus, after surgery 12 months earlier for an ankle fracture. The patient underwent a corrective procedure consisting of extemporaneous lengthening of the fibula, with interposition of autologous bone graft and fixation using a compression plate. Six months after surgery, the patient did not present pain or limited movement, and was able to return to his habitual sporting activity. CONCLUSIONS Fibular-lengthening osteotomy is a procedure indicated for patients with malunion fracture of the distal fibula, with shortening and progressive valgus deformity. This surgery allows the restoration of the joint surface, reduces stress on the cartilage and prevents the development of arthropathy of the ankle.

Internal Hemipelvectomy and Reconstruction Assisted by 3D Printing Technology Using Premade Intraoperative Cutting and Placement Guides in a Patient With Pelvic Sarcoma: A Case Report.

CASE: We describe the case of a 75-year-old patient diagnosed with high-grade epithelioid hemangioendothelioma in the left hemipelvis. She underwent an internal hemipelvectomy, followed by reconstruction with a tumor prosthesis with iliac anchorage using 3D-printed cutting and placement guides. Eighteen months postoperatively, she is pain-free and walks without appliances. CONCLUSIONS: Using 3D-printed guides could be an appropriate alternative for patients with aggressive bone tumors in the pelvic area that require hemipelvectomy and reconstruction using a prosthesis with iliac anchorage. 3D-printed cutting guides allow precise resection with appropriate margins, could reduce the risk of injuring critical structures, and facilitate proper prosthetic component positioning.

Extensor Mechanism Allograft in Osteosarcoma of the Patella: A Case Report.

CASE: A 24-year-old female diagnosed with fibroblastic osteosarcoma of the patella underwent a total patellectomy and surgical reconstruction with a large bone-tendon allograft of the extensor mechanism and adjuvant chemotherapy. At 5 years' postoperative, the patient has adequate disease control and excellent joint function. CONCLUSIONS: Reconstruction with an extensor mechanism allograft is an appropriate alternative for patients with malignant patella tumors without tumor contamination of the joint, allowing for satisfactory knee function and disease control.

Lesiones del ángulo posterolateral de la rodilla / Posterolateral corner injuries of the knee

El ángulo posterolateral (APL) de la rodilla presenta una anatomía compleja que permite mantener la estabilidad frente al varo, la rotación externa y la traslación posterior. Las lesiones del APL suelen pasar desapercibidas. Se relacionan con accidentes de tráfico y deportivos. La exploración física resulta fundamental en el diagnóstico. La gravedad de la lesión determina el tipo de tratamiento, conservador o quirúrgico. El tratamiento quirúrgico se asocia a una alta incidencia de complicaciones, como la artrofibrosis y la pérdida de movilidad

The posterolateral corner of the knee has a complex anatomy that allows maintaining stability against varus, external rotation and posterior translation. These injuries usually go unnoticed. They are related to traffic accidents and sports. The physical examination is fundamental in the diagnosis. The severity of the injury determines the type of treatment, conservative or surgical. Operative treatment is associated with a high incidence of complications, such as arthrofibrosis and loss of mobility

Knee Viscosupplementation: Cost-Effectiveness Analysis between Stabilized Hyaluronic Acid in a Single Injection versus Five Injections of Standard Hyaluronic Acid.

Given the wide difference in price per vial between various presentations of hyaluronic acid, this study seeks to compare the effectiveness and treatment cost of stabilized hyaluronic acid (NASHA) in a single injection with standard preparations of hyaluronic acid (HA) in five injections in osteoarthritis (OA) of the knee. Fifty-four patients with knee osteoarthritis (Kellgren-Lawrence Grade II and III) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain score greater than 7, with a homogeneous distribution of age, sex, BMI, and duration of disease, were included in this study. Patients were randomized into two groups: Group I was treated with NASHA (Durolane®) and Group II with HA (Go-ON®). Patient's evolution was followed up at the 1st, 2nd, 4th, 8th, 12th, and 26th week after treatment. A statistically significant improvement in WOMAC score was observed for patients treated with NASHA versus those who received HA at Week 26. In addition, the need for analgesia was significantly reduced at Week 26 in the NASHA-treated group. Finally, the economic analysis showed an increased cost of overall treatment with HA injections. Our data support the use of the NASHA class of products in the treatment of knee OA.

Intra-Articular Injections of Platelet-Rich Plasma versus Hyaluronic Acid in the Treatment of Osteoarthritic Knee Pain: A Randomized Clinical Trial in the Context of the Spanish National Health Care System.

Intra-articular injection of platelet-rich plasma (PRP) has been established as a suitable treatment for knee osteoarthritis. Here, we present a double-blind randomized controlled clinical trial, conducted in a public Hospital of the Spanish National Health Care System, to evaluate the efficacy of injecting autologous PRP versus hyaluronic acid (HA) in knee osteoarthritis. PRP was manufactured in Malaga's Regional Blood Center (Spain). Patients that met the eligibility criteria were randomized into a PRP group or a HA group. Pain and functional improvements were assessed pre- and post-treatment (three and six months follow-up) using the Visual Analogue Scale (VAS); the Knee and Osteoarthritis Outcome System (KOOS) scale and the European Quality of Life scale (EUROQOL). Both groups presented pain reduction at six months. The VAS scores for the PRP group improved by at least 50% from their initial value, particularly at three months following the final infiltration, with results resembling those of the HA group at six months. PRP was more effective in patients with lower osteoarthritis grades. Both treatments improved pain in knee osteoarthritis patients without statistically significant differences between them. However, PRP injection was proved to improve pain three months after the final infiltration and to be more effective in lower osteoarthritis grades.

El implante de condrocitos autólogos en la red sanitaria pública de Andalucía. Resultados tras 6 años de circuito asistencial / The autologous chondrocyte implantation in the public health system of Andalusia. Results after 6 years of care circuits

Objetivo: Evaluar los resultados del Implante de Condrocitos Autólogos (ICA) con parche de periostio y difundir los circuitos asistenciales existentes al respecto en Andalucía. Material y método: Desde su autorización ofi cial en 2005, el Banco de Tejidos y el Hospital Virgen de la Victoria de Málaga, llevan a cabo los ICA del sistema sanitario público andaluz. Se han operado 16 pacientes entre 2006-2013 con seguimiento medio 47,6 meses (6 meses-6 años), de hospitales públicos de toda Andalucía, gestionados por los servicios de admisión de los hospitales origen y destino. Se seleccionaron pacientes fi siológicamente jóvenes (< 50 años) con lesiones condrales sintomáticas, únicas, >2cm2, en rodillas estables y sin desalineación. El ICA fue utilizado como procedimiento de rescate de fracaso de microfracturas, salvo en osteocondritis disecante. Para valorar los resultados se utilizaron la escala de Cincinnati y la Short Form 36 (SF-36). Se realizó un análisis descriptivo y test no paramétricos para buscar correlaciones y comparar resultados. Resultados: En los 15 pacientes con más de un año de seguimiento: 14 hombres (87,5%) y 2 mujeres (14,5%), de edad media 28,2 años (min 17 max 43), la lesión asentó en los cóndilos femorales, más en el interno (81,2%) y tamaño 2,7cm2(2-4,2). Encontramos mejoría signifi cativa (p<0,001), tanto en actividades de la vida diaria (89,3% limitación preoperatoria -preop- y 9% postoperatoria -postop-), como en las deportivas (90,2% preop - 38% postop) y en la exploración de la rodilla (67,7% hallazgos patológicos preop y 13,3% postop). La escala de calidad de vida SF-36 mejoró en todas las dimensiones sobre todo la salud mental (p> 0,01). El grado de satisfacción de los pacientes fue alto o muy alto en 12 de los 15 casos (80%) y bajo en los 3 restantes. Conclusiones: El ICA mejora la calidad de vida y la funcionalidad de la rodilla con lesiones condrales en cóndilo femoral. La selección de casos y la colaboración con el Banco de Tejidos, permite crear circuitos asistenciales para tratar pacientes de otras provincias del Sistema Sanitario Público de Andalucía. Es necesario ampliar la experiencia en este tipo de terapia, consolidando grupos de trabajo multicéntricos que aporten solidez a las conclusiones (AU)

Objective: To asses the results of Autologous Chondrocyte Implantation (ACI) whith periosteal patch and To propagate the care circuits existing about in Andalusia. Material and Methods: From its offi cial licence in 2005, the tissue bank and the Virgen de la Victoria Hospital from Málaga, performed the ACI in the Andalusian public health system. 16 patients has been operated between 2006-2013, whith medium followup 47,6 months (6 months-6 years), from public hospitals throughout Andalucia, managed by hospital admission source and destination. Physiologically younger patients were selected (<50 años), with singles, > 2cm2 symptomatics chondral lesions, in stables and well aligned knees. ACI was used as rescue procedure after microfracture´s failure except osteochondritis dissecans. To assess the results the Concinnati score and the Short Form 36 (SF-36)score were used. A descriptive analysis was performed and non-parametric tests were used to establish correlations and compare results. Results: In 15 patients with more than one year of follow-up: 14 men(87.5%) and 2women (14.5%), medium age 28.2 years old (min 17 max 43), the lesion was located into de femoral condyle, mostly in the internal one (81,2%) with medium size 2,7cm2(2- 4,2). We founded signifi cant improvement (p<0,001), both daily activities ( 89,3% preop. limitatión - 9% postop), as in the sports (90,2% preop limitatión - 38% postop) and the exploration of the knee (67,7% hpatological fi ndings preop- 13,3%postop). The SF- 36 score improved in all categories, over all in mental health (p> 0,01). The patient satisfaction was high or very high in 12 of the 15 patients ( 80%), and low in 3 patients. Conclusions: ACI improve quality of life and knee function in femoral condyle chondral lesions. The case´s selection and the collaboration with Tissue Bank, allows us to create care circuits for treatment of patients from other provinces in the Public Sanitary Health System in Andalucia. It is necessary to increase the experience with this type of therapy, consolidating multicenter workgroups that provide strength to the conclusions (AU)

Osteoid osteoma: CT-guided radiofrequency ablation.

Osteoid osteoma is a benign bone tumour; its main symptom is pain, which is sometimes resistant to analgesic or anti-inflammatory medication. The surgical treatment consists of en bloc excision or curettage of the lesion. Several alternative methods have been proposed, among which CT guided-percutaneous radiofrequency ablation. We report on ten patients who were diagnosed clinically and radiologically as presenting an osteoid osteoma and were treated with this technique, with more than two years follow-up. Results were uniformly excellent. The pain was relieved and the rate of post-operative complications was very low. We recommend percutaneous CT-guided radiofrequency ablation for the treatment of this lesion.

Comparison of initial mechanical properties of 4 hamstring graft femoral fixation systems using nonpermanent hardware for anterior cruciate ligament reconstruction: an in vitro animal study.

PURPOSE: To compare the initial mechanical characteristics of 4 systems used to fix tendons to the femur during anterior cruciate ligament reconstruction. METHODS: A total of 32 porcine femurs were used to study the following fixation systems: Bioabsorbable interference screw (Stryker, Kalamazoo, MI), Bio-Transfix Cross-pin (Arthrex, Naples, FL), Biosteon Cross-pin (Stryker), and a fixation technique based on wrapping the graft around the femoral condyle itself, thus allowing it to be fixed in place without the use of any hardware. The mechanical characteristics of each system were obtained by a preconditioned failure tensile test. RESULTS: The yield load values (990.9 +/- 242.6 N for Bio-Transfix, 905.1 +/- 158.8 N for Biosteon Cross-pin, 684.4 +/- 119.7 N for the without-hardware system (WHS), and 369.4 +/- 120.1 N for the interference screw) revealed significant differences between the techniques that used cross-pins and the other 2 techniques (P < .006) on the one hand, and between the without hardware technique and the interference screw (P < .004) on the other. The stiffness of the 2 cross-pin fixation systems (117.6 +/- 22.5 N for Bio-Transfix and 112.6 +/- 22.5 N for Biosteon) was greater (P < .01) than those of the other systems (79.4 +/- 15.2 N for the WHS and 68.5 +/- 13 N for the interference screw). CONCLUSIONS: The initial biomechanical properties of the 2 cross-pin fixation systems proved to be superior to those of the other 2 systems studied. The WHS fixation system exhibited better mechanical properties than its interference screw counterpart. CLINICAL RELEVANCE: The better initial mechanical characteristics encountered using the Bio-Transfix and Biosteon Cross-pin systems indicate that these systems are better equipped to bear the loads generated by aggressive rehabilitation. The WHS fixation system provides an alternative to interference screw fixation.