Un método 3D para estimar el efecto de osteotomías desrotadoras sobre alteraciones torsionales de fémur / A 3D method to estimate the effect of derotational osteotomies over femoral maltorsion

Introducción y objetivos: La medición precisa de la torsión femoral es esencial para el diagnóstico, indicación y planificación preoperatoria de las osteotomías desrotadoras femorales en pacientes con inestabilidad patelofemoral o dolor anterior de rodilla. Se han descrito múltiples métodos de medición, con valores muy diferentes entre ellos y ninguno de ellos permite establecer la magnitud de la osteotomía necesaria para devolver la torsión a valores normales. El objetivo del presente trabajo es desarrollar un método de medición que permita no solo el diagnóstico de pacientes con alteraciones torsionales, sino también establecer la magnitud de la osteotomía necesaria durante la cirugía. Material y métodos: Se seleccionaron 30 pacientes sin antecedentes de patología patelofemoral que disponían de una tomografía completa de miembros inferiores por otros motivos, siendo considerados así pacientes normales. Se calculó su torsión femoral mediante los métodos de Jeanmart y de Murphy por dos radiólogos independientes. Por otra parte, dos cirujanos ortopédicos independientes realizaron la medición de la torsión mediante el método 3D propuesto. Se evaluó el comportamiento normal de los datos y se definió la variabilidad intra- e interobservador del método 3D mediante su coeficiente de correlación intraclase y mediante el gráfico de Bland-Altman, realizando una comparación cuantitativa y cualitativa respectivamente con los métodos clásicos. Se estableció el intervalo de confianza de los valores normales con el nuevo método 3D y finalmente, se analizó al patrón de regresión lineal entre los métodos de Jeanmart y Murphy con el método de medición 3D. Resultados: La media de torsión femoral con el método 3D fue de 12,74° (DE 5,96°, IC 95%: 11,67 a 13,82°). Con el método de Jeanmart, esta fue de 12,84° (DE 8,60°, IC 95%: 11,28 a 14,39°) y de 15,87° (DE 10,68°, IC 95%: 13,94 a 17,80°) con el método de Murphy.(AU)

Introduction and objectives: Accurate measurement of femoral torsion is essential to diagnosing, correct surgical decision-making, and the preoperative planning of derotational osteotomies in a subgroup of anterior knee pain patients and patellofemoral instability. Several measurement techniques have been described with great variability in the magnitude of the values. Moreover, none of them can predict the effect of rotational osteotomy on the femoral version value. The purpose of the present work is to develop a method to reliably measure femoral torsion as well as to evaluate the effects of osteotomy on the femoral version angle. Material and methods: 30 patients without previous signs neither symptoms of patellofemoral pain or patellofemoral instability and with a lower limbs CT were selected. Their femoral torsion was measured using the classic Jeanmart and the Murphy's method by two independent radiologists. Independently, two orthopedic surgeons measured femoral torsion with the 3D method described in this study. The intraclass coefficient correlation and the Bland–Altman tests were used to analyze qualitatively and quantitatively the intraobserver and interobserver variability of the method regarding the Jeanmart's and Murphy's method. The confidence interval of the Normal values of the new method were defined and a lineal regression analysis between the 3D-Jeanmart's and 3D-Muphy's methods was performed. Results: The mean femoral version with the 3D method was 12.74° (SD 5.96°, 95% CI: 11.67° to 13.82°). With Jeanmart's method, it was 12.84° (SD 8.60°, 95% CI: 11.28° to 14.39°) and 15.87° (SD 10.68°, 95% CI: 13.94° to 17.80°) with Murphy's method, being these differences not statistically significant. Both interobserver and intraobserver agreement of the 3D method were high.(AU)

[Translated article] A 3D method to estimate the effect of derotational osteotomies over femoral maltorsion / Un método 3D para estimar el efecto de osteotomías desrotadoras sobre alteraciones torsionales de fémur

Introducción y objetivos: La medición precisa de la torsión femoral es esencial para el diagnóstico, indicación y planificación preoperatoria de las osteotomías desrotadoras femorales en pacientes con inestabilidad patelofemoral o dolor anterior de rodilla. Se han descrito múltiples métodos de medición, con valores muy diferentes entre ellos y ninguno de ellos permite establecer la magnitud de la osteotomía necesaria para devolver la torsión a valores normales. El objetivo del presente trabajo es desarrollar un método de medición que permita no solo el diagnóstico de pacientes con alteraciones torsionales, sino también establecer la magnitud de la osteotomía necesaria durante la cirugía. Material y métodos: Se seleccionaron 30 pacientes sin antecedentes de patología patelofemoral que disponían de una tomografía completa de miembros inferiores por otros motivos, siendo considerados así pacientes normales. Se calculó su torsión femoral mediante los métodos de Jeanmart y de Murphy por dos radiólogos independientes. Por otra parte, dos cirujanos ortopédicos independientes realizaron la medición de la torsión mediante el método 3D propuesto. Se evaluó el comportamiento normal de los datos y se definió la variabilidad intra- e interobservador del método 3D mediante su coeficiente de correlación intraclase y mediante el gráfico de Bland-Altman, realizando una comparación cuantitativa y cualitativa respectivamente con los métodos clásicos. Se estableció el intervalo de confianza de los valores normales con el nuevo método 3D y finalmente, se analizó al patrón de regresión lineal entre los métodos de Jeanmart y Murphy con el método de medición 3D. Resultados: La media de torsión femoral con el método 3D fue de 12,74° (DE 5,96°, IC 95%: 11,67 a 13,82°). Con el método de Jeanmart, esta fue de 12,84° (DE 8,60°, IC 95%: 11,28 a 14,39°) y de 15,87° (DE 10,68°, IC 95%: 13,94 a 17,80°) con el método de Murphy.(AU)

Introduction and objectives: Accurate measurement of femoral torsion is essential to diagnosing, correct surgical decision-making, and the preoperative planning of derotational osteotomies in a subgroup of anterior knee pain patients and patellofemoral instability. Several measurement techniques have been described with great variability in the magnitude of the values. Moreover, none of them can predict the effect of rotational osteotomy on the femoral version value. The purpose of the present work is to develop a method to reliably measure femoral torsion as well as to evaluate the effects of osteotomy on the femoral version angle. Material and methods: 30 patients without previous signs neither symptoms of patellofemoral pain or patellofemoral instability and with a lower limbs CT were selected. Their femoral torsion was measured using the classic Jeanmart and the Murphy's method by two independent radiologists. Independently, two orthopedic surgeons measured femoral torsion with the 3D method described in this study. The intraclass coefficient correlation and the Bland–Altman tests were used to analyze qualitatively and quantitatively the intraobserver and interobserver variability of the method regarding the Jeanmart's and Murphy's method. The confidence interval of the Normal values of the new method were defined and a lineal regression analysis between the 3D-Jeanmart's and 3D-Muphy's methods was performed. Results: The mean femoral version with the 3D method was 12.74° (SD 5.96°, 95% CI: 11.67° to 13.82°). With Jeanmart's method, it was 12.84° (SD 8.60°, 95% CI: 11.28° to 14.39°) and 15.87° (SD 10.68°, 95% CI: 13.94° to 17.80°) with Murphy's method, being these differences not statistically significant. Both interobserver and intraobserver agreement of the 3D method were high.(AU)

[Translated article] A 3D method to estimate the effect of derotational osteotomies over femoral maltorsion.

INTRODUCTION AND OBJECTIVES: Accurate measurement of femoral torsion is essential to diagnosing, correct surgical decision-making, and the preoperative planning of derotational osteotomies in a subgroup of anterior knee pain patients and patellofemoral instability. Several measurement techniques have been described with great variability in the magnitude of the values. Moreover, none of them can predict the effect of rotational osteotomy on the femoral version value. The purpose of the present work is to develop a method to reliably measure femoral torsion as well as to evaluate the effects of osteotomy on the femoral version angle. MATERIAL AND METHODS: 30 patients without previous signs neither symptoms of patellofemoral pain or patellofemoral instability and with a lower limbs CT were selected. Their femoral torsion was measured using the classic Jeanmart and the Murphy's method by two independent radiologists. Independently, two orthopedic surgeons measured femoral torsion with the 3D method described in this study. The intraclass coefficient correlation and the Bland-Altman tests were used to analyze qualitatively and quantitatively the intraobserver and interobserver variability of the method regarding the Jeanmart's and Murphy's method. The confidence interval of the Normal values of the new method were defined and a lineal regression analysis between the 3D-Jeanmart's and 3D-Muphy's methods was performed. RESULTS: The mean femoral version with the 3D method was 12.74° (SD 5.96°, 95% CI: 11.67°-13.82°). With Jeanmart's method, it was 12.84° (SD 8.60°, 95% CI: 11.28°-14.39°) and 15.87° (SD 10.68°, 95% CI: 13.94°-17.80°) with Murphy's method, being these differences not statistically significant. Both interobserver and intraobserver agreement of the 3D method were high. CONCLUSION: The method presented in this study allows for the reliable quantification of femoral torsion in a reproducible way. This method can be applied in several open access 3D image programmes what makes its implementation in the healthcare centres possible from now on.

A 3D method to estimate the effect of derotational osteotomies over femoral maltorsion. / Un método 3D para estimar el efecto de osteotomías desrotadoras sobre alteraciones torsionales de fémur.

INTRODUCTION AND OBJECTIVES: Accurate measurement of femoral torsion is essential to diagnosing, correct surgical decision-making, and the preoperative planning of derotational osteotomies in a subgroup of anterior knee pain patients and patellofemoral instability. Several measurement techniques have been described with great variability in the magnitude of the values. Moreover, none of them can predict the effect of rotational osteotomy on the femoral version value. The purpose of the present work is to develop a method to reliably measure femoral torsion as well as to evaluate the effects of osteotomy on the femoral version angle. MATERIAL AND METHODS: 30 patients without previous signs neither symptoms of patellofemoral pain or patellofemoral instability and with a lower limbs CT were selected. Their femoral torsion was measured using the classic Jeanmart and the Murphy's method by two independent radiologists. Independently, two orthopedic surgeons measured femoral torsion with the 3D method described in this study. The intraclass coefficient correlation and the Bland-Altman tests were used to analyze qualitatively and quantitatively the intraobserver and interobserver variability of the method regarding the Jeanmart's and Murphy's method. The confidence interval of the Normal values of the new method were defined and a lineal regression analysis between the 3D-Jeanmart's and 3D-Muphy's methods was performed. RESULTS: The mean femoral version with the 3D method was 12.74° (SD 5.96°, 95% CI: 11.67° to 13.82°). With Jeanmart's method, it was 12.84° (SD 8.60°, 95% CI: 11.28° to 14.39°) and 15.87° (SD 10.68°, 95% CI: 13.94° to 17.80°) with Murphy's method, being these differences not statistically significant. Both interobserver and intraobserver agreement of the 3D method were high. CONCLUSION: The method presented in this study allows for the reliable quantification of femoral torsion in a reproducible way. This method can be applied in several open access 3D image programs what makes its implementation in the healthcare centers possible from now on.

[Patellofemoral pain]. / Patellofemorale Schmerzen.

We review the current status of knowledge in the field of pathogenesis of anterior knee pain in the young patient. Emphasis is placed on newer findings. We have developed what we call the "neural model" as an explanation for the genesis of anterior knee pain. According to our studies we hypothesize that periodic short episodes of ischemia in the lateral retinaculum could be implicated in the pathogenesis of anterior knee pain by triggering neural proliferation of nociceptive axons (substance P-positive nerves), mainly in a perivascular location. Our findings are compatible with the tissue homeostasis theory widely accepted currently to explain the genesis of anterior knee pain.

Neuroanatomic basis for pain in patellar tendinosis ("jumper's knee"): a neuroimmunohistochemical study.

Chronic patellar tendinosis or "jumper's knee" is a frequent source of persistent and often recurrent anterior knee pain in active, young people. Seventeen pathologic specimens retrieved during surgery for jumper's knee were evaluated by means of immunohistochemical (S-100) analysis. The patellar tendon-bone junction and the Hoffa fat pad adjacent to the inferior pole of the patella are structures that have a nerve supply that can be a potential source of nociceptive output resulting in the perception of pain at any given moment. In this study, pathologic neural changes also were observed. In eight cases, free nerve endings showed a histologic pattern of "nerve sprouting" in the patellar tendon-bone junction. Vascular innervation was seen in seven cases. S-100 positive fibers were observed within the muscular layer of medium and small arteries. These findings show an increase in vascular innervation. Lastly, neuromatous changes were observed in four cases, demonstrating a clear relationship with pain. These observations provide a neuroanatomic basis for pain in active, young patients with jumper's knee.

Extensive osteolytic cystlike area associated with polyethylene wear debris adjacent to an aseptic, stable, uncemented unicompartmental knee prosthesis: case report.

We present the case of a patient who after uncemented unicompartmental knee arthroplasty developed a large osteolytic cystlike area in the lateral aspect of the tibial metaphysis, contralateral to a well-fixed tibial component at revision surgery. The lesion contained fibrotic soft tissue, evidence of a foreign-body giant cell reaction and polyethylene particles, but no metal wear debris, infection, or malignancy. This case demonstrates that there is a direct communication between the joint cavity and the cyst.

Neural growth factor expression in the lateral retinaculum in painful patellofemoral malalignment.

We studied 7 samples of lateral retinaculae excised at the time of surgical realignments. They were obtained from patients with isolated symptomatic patellofemoral malalignment resistant to conservative treatment and were evaluated with immunohistochemistry and immunoblotting. We found that neural growth factor is higher in patients with pain than in those with instability as the main symptom. Neural growth factor is related to neural proliferation in vessels and perivascular tissue and to the release of neuroceptive transmitters, such as substance P. We postulate that both mechanisms are involved in the pathogenesis of pain in isolated symptomatic patellofemoral malalignment.

Immunohistochemical analysis for neural markers of the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment. A neuroanatomic basis for anterior knee pain in the active young patient.

We evaluated 13 lateral retinacula excised at the time of Insall proximal realignments or isolated lateral retinacular releases performed in patients with isolated symptomatic patellofemoral malalignment recalcitrant to nonoperative treatment. Evaluation was performed by means of conventional histologic and immunohistochemical analysis for neural markers (S-100 protein, neurofilament protein, substance P, and neural growth factor). The observations reported here provide a neuroanatomic basis for anterior knee pain syndrome in active young patients with isolated symptomatic patellofemoral malalignment and support the clinical observation that the lateral retinaculum may have a key role in the origin of this pain as a result of increased neural growth factor production, which induces proliferation of nociceptive axons, mainly in a perivascular location.

Localized pigmented villonodular synovitis as a rare cause of chronic anterolateral ankle pain in an equestrienne.

An unusual case of localized pigmented villonodular synovitis of the ankle as a rare cause of chronic anterolateral ankle pain in a 16-year-old horsewoman is presented. Intra-articular nodular forms of pigmented villonodular synovitis can only be diagnosed arthroscopically, macroscopic and microscopic aspects being typical. We believe that this lesion is more likely a reactive process secondary to repetitive microtrauma rather than a true neoplasm. Our patient presented with pathology in the left ankle, the side by which one mounts and dismounts a horse, forcing, in both activities, ankle dorsiflexion. Moreover, an English saddle was used by our patient, upon which one rides with the ankle maintained in dorsiflexion. At arthroscopy, the soft-tissue mass was seen to be entrapped in the joint between the talus and the tibia at dorsiflexion of the ankle. This had caused a slowly progressive enlargement of the lesion because of fibrosis resulting from reactive inflammation associated with this repetitive microtrauma, thus causing irritation, pain, and synovitis due to impingement.

Simultaneous bilateral anterior cruciate ligament tears in a female beginner skier.

We present a case of simultaneous bilateral ACL tears in a woman injured while skiing for the first time. We discuss the role of intercondylar notch stenosis as a high-risk factor for tearing the ACL, the injury mechanism, prevention measures, and the therapeutic strategy.

Pathogenesis of anterior knee pain syndrome and functional patellofemoral instability in the active young.

Although it is universally accepted that patellofemoral malalignment is the main cause of anterior knee pain and functional patellar instability in the active young, the question remains to be answered: what is the mechanism whereby patellofemoral malalignment produces pain and instability? Currently, there are two theories to explain the origin of pain and instability in patients with patellofemoral malalignment: the neural theory and the mechanical theory. Both theories are not exclusive, but complementary. We believe it is the neural factor that precipitates the symptoms in patients with certain mechanical anomalies who also subject the knee to overuse.

Healing of the patellar tendon donor defect created after central-third patellar tendon autograft harvest. A long-term histological evaluation in the lamb model.

Patellar tendon donor defect (PTDD) healing after patellar tendon autograft (PTA), was evaluated in 12 lambs (24 knees), by means of conventional histology, immunohistochemistry and image analysis. The results of this study indicate that the PTDD is replaced by a tissue that does not assume the histological characteristics of a normal patellar tendon. Both the Hoffa fat pad (HFP) and the paratenon play an important role in the healing process, although qualitative and quantitative chronological differences were found, which supports the concept of a "two-time process". The HFP initiates the repair process, and is the main active proliferative tissue compartment during the first week. Once the process is established, the paratenon and, in particular, its synovial lining, starts proliferative activity and virtually substitutes that of the HFP, which rapidly loses activity in a few days. Moreover, donor-site morbidity after PTA could be the result of histological changes in the patellar tendon and environs in only a few cases. We have found inflammatory and neural changes in the refilled PTDD that could explain the anterior knee pain after PTA. Likewise, we have observed loss of Golgi corpuscles in the refilled PTDD, which could lead to proprioceptive loss after ACL reconstruction with PTA. Finally, we have observed shrinkage of the PTDD scar that could contribute to the etiopathogenia of a patella infera.

Quantitative analysis of nerve changes in the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment. A preliminary study.

Neural damage in 16 lateral retinacula excised at the time of Insall proximal realignments or isolated lateral retinacular releases performed in patients with symptomatic patellofemoral malalignment was evaluated by means of conventional histology and immunohistochemical and morphometric analyses. A relationship between clinical and histologic findings was found. An increase in the proportion of innervated tissue was correlated with anterior knee pain syndrome. We found a significant relationship between total neural area and pain. The group with moderate pain had the highest number of nerves and the highest neural area. In reference to total neural area and pain, there was a significant difference only between the patients with moderate pain and those with light pain, but not between patients with severe pain and those with moderate pain. The group with severe pain also showed a high neural area, although with a lower number of nerves. The severe-pain group had the largest nerves (24% of nerve fibers surpassing 25 microns diameter) in a zonal disposition, in which there were groups of nerve fibers in some fields and no nerve fibers in others. The group with moderate pain had an increase in medium and small nerve fibers (mean diameter, 18 microns), predominantly of tiny perivascular fibers. Moreover, we believe that instability in patients with patellofemoral malalignment can be explained in part because of loss of proprioception due to neural damage.

Osteoblastic osteogenic sarcoma in a 13-month-old girl.

Osteosarcoma is exceptional in early periods of life. Therefore osteosarcomas involving the bones of the hand are extremely rare. We present a case of an osteogenic sarcoma involving the second metacarpal bone of a 13-month-old girl who has been remaining free of disease, after treatment--radial amputation and chemotherapy pre- and postoperative--, for a period of 10 years in the follow-up.

Intra-articular osteoid osteoma of the humerus with synovitis simulating chronic monoarthritis of the elbow in a recreational tennis player.

We present a case of intra-articular osteoid osteoma of the humerus simulating chronic monoarthritis of the elbow in an 18-year-old male right-handed recreational tennis player. CT revealed a well-defined nidus in the coronoid fossa. Microscopic examination of the synovium showed a lymphofollicular synovitis that resembled the synovitis in rheumatoid arthritis.

The value of MRI in the evaluation of the ACL deficient knee and in the post-operative evaluation after ACL reconstruction.

To evaluate the usefulness of magnetic resonance imaging (MRI) in the exploration of the anterior cruciate ligament (ACL) deficient-knee, a total of twenty-five patients with chronic instability of the knee joint and who underwent both MRI and arthroscopy were studied prospectively. Twenty-three of these patients underwent an intra-articular reconstruction of the ACL with bone-patellar tendon-bone autografts. For the ACL lesions MRI had a sensitivity of 95.8%, a specificity of 100% and a diagnostic accuracy of 97.7%. Associated bowing of the PCL was seen in 20 cases of the study group. For the associated meniscal lesions MRI had a sensitivity of 77.7%, a specificity of 94.7% and a diagnostic accuracy of 91.5%. In no case did MRI allow to detect the minimal cartilage irregularities observed in the arthroscopy. MRI had great accuracy for the evaluation of the anchoring points, direction of the tunnels and the state of the autografts at intra-articular level. It is concluded that MRI is a useful imaging diagnostic modality for evaluation of the ACL deficient-knee and the intra-articular reconstruction of the ACL, thereby MRI affords the surgeon better preoperative planning.

Kuntscher nailing of femoral shaft fractures in children and adolescents.

We have reviewed 29 cases of very unstable diaphyseal fractures of the femur in children and adolescents treated by Kuntscher nailing. Follow up was for at least 5 years, and in most cases until after the end of growth. There were no postoperative complications, and the mean overgrowth of the femur was 7.06 mm. There was growth disturbance of the proximal femur in one case, but this did not interfere with function. We believe that Kuntscher nailing is indicated in children and adolescents with unstable high velocity fractures of the femoral shaft.

The value of high resolution CT in the diagnosis of meniscal lesions of the knee.

We report on 50 patients who had meniscal pathology and were given computed tomographic (CT) scans. Our diagnostic accuracy was approximately 92%. We believe that CT is a good method of screening these patients prior to using a much more expensive method, such as magnetic resonance imaging or diagnostic arthroscopy.