Fracturas del maleolo posterior del tobillo, clasificación y visión de tratamiento / Fractures of the Ankle Posterior Malleolus, Classification and Treatment Vision

Introducción: Las fracturas del maleolo posterior son comunes y son resultado de lesiones por rotación del tobillo que se ignoran debido a la reducción espontánea de estos fragmentos después de la reducción abierta del maléolo lateral. La tendencia actual es realizar la corrección anatómica de la articulación y evitar un escalón intraarticular. Objetivo: Revisar el estado actual de los conocimientos y clasificación de las fracturas del maleolo tibial posterior y las tendencias de su tratamiento. Métodos: Se realiza una revisión de la literatura en PubMed de los trabajos publicados en inglés entre los años 2011-2021, con los siguientes términos de búsqueda: fracturas del maleolo tibial posterior, clasificación de las fracturas del maléolo tibial posterior", tratamiento de las fracturas del maleolo tibial posterior". También se revisaron artículos accesibles de forma libre, o a través del servicio ClinicalKey e Hinari. Conclusiones: La reposición anatómica del maleolo tibial posterior en fracturas de tobillo permite alcanzar mejores resultados. Las clasificaciones y el abordaje posterolateral contribuyen a lograrlo(AU)

Introduction: Fractures of the posterior malleolus are common and resulting from rotational injuries of the ankle, which are ignored due to the spontaneous reduction of these fragments after open reduction of the lateral malleolus. The current trend is to perform the anatomical correction of the joint and to avoid an intra-articular step. Objective: To review the current state of knowledge and classification of posterior tibial malleolus fractures and treatment trends. Methods: A review was carried out of the PubMed literature of papers published in English in the period 2011-2021; the search terms adopted were posterior tibial malleolus fractures, posterior tibial malleolus fracture classification, reatment of fractures of the posterior tibial malleolus. Articles freely accessible or through Clinical Key and Hinari service were also reviewed. Conclusions: The anatomical repositioning of the posterior tibial malleolus in ankle fractures allows to achieve better results. The classifications and the posterolateral approach help to achieve this(AU)

Tendoscopía en disfunción del tendón tibial posterior Estadío I: 8 años de seguimiento / Tendoscopy in stage I Posterior Tibial dysfunction: 8 years follow up

Cuando fracasa el tratamiento conservador en el Estadio I de Disfunción del Tendón Tibial posterior (DTTP), se debe indicar sinovectomía y debridamiento del tendón. En este estudio evaluamos la evolución con 8 años mínimo de seguimiento, de los pacientes con esta patología tratados vía tenoscópica. Este es un estudio retrospectivo de pacientes operados entre el año 2008 y el año 2011. En ese período de tiempo se intervinieron 11 pacientes con esta patología. Sólo 9 de los 11 pacientes operados pudieron ser evaluados. 7 pacientes mejoraron su sintomatología según el VAS y no progresaron a estadio II. En 3 pacientes se evidenció lesión tendinosa durante la tendoscopía y ameritaron reparación a cielo abierto. La sinovectomía tendoscópica del TTP es un procedimiento quirúrgico efectivo para tratar a los pacientes con DTTP Estadio I, rebeldes a tratamiento conservador(AU)

When conservative treatment fails for Stage I Posterior Tibial tendon dysfunction (PTTD), synovectomy and tendon debridement is indicated. In this study we evaluate tendoscopic treatment results for this pathology with a minimum of 8 years follow up. This is a retrospective study of patients after tendoscopic surgery performed between 2008 and 2011. 9 of the 11 patients were available for evaluation. 7 improved their symptoms according to VAS scale, and did not progress to stage II. In 3 patients tendon tear was visualized during tendoscopy and needed open repair. PTT tendoscopy is an effective surgical treatment to treat Stage I PTTD, failing to conservative treatment(AU)

Estimulación del nervio tibial posterior en el tratamiento de la retención urinaria posparto. Reporte de dos casos / Posterior tibial nerve stimulation in the management of postpartum urinary retention. Report of two cases

Resumen OBJETIVO: Reportar dos casos de pacientes con el efecto de la estimulación del nervio tibial posterior en la retención urinaria posparto. CASOS CLÍNICOS: Caso 1: Paciente de 41 años, con dos cesáreas previas, sobrepeso (IMC 28 kg/m2), con 33 semanas de embarazo, hipertensión arterial crónica y preeclampsia sobreagregada asociada con datos de déficit neurológico. En el puerperio tardío tuvo dificultad para miccionar y dolor suprapúbico. Con base en la urodinamia se diagnosticó: disinergia detrusor-esfínter y se trató con estimulación del nervio tibial posterior durante 20 minutos cada semana con duración de fase de 200 µs y frecuencias de 10 Hz durante 12 sesiones. Los parámetros urodinámicos mejoraron y se restablecieron las micciones espontáneas, se redujo la frecuencia del cateterismo limpio intermitente y el efecto continuó a 31 meses de seguimiento. Caso 2: Paciente de 38 años, primigesta, IMC 21 kg/m2 , con antecedente de hipotiroidismo subclínico. A los cinco días de puerperio tuvo retención urinaria de 2000 mL; se le colocó una sonda Foley a drenaje contínuo y, posteriormente, un tapón con vaciado cada 2 horas. No obstante lo anterior tuvo nuevos episodios de retención urinaria que ameritaron el inicio del cateterismo limpio intermitente, 5 en 24 horas y estimulación del nervio tibial posterior con corriente bifásica asimétrica. Se consiguió una mejoría subjetiva del 100% y cambios urodinámicos. Las micciones espontáneas se reiniciaron sin requerir cateterismo limpio intermitente, fue dada de alta luego de un año de seguimiento. CONCLUSIÓN: De acuerdo con los desenlaces del estudio, la estimulación del nervio tibial posterior podría ofrecer una alternativa de tratamiento prometedora en pacientes con retención urinaria posparto.

Abstract OBJECTIVE: Case report of the effect of posterior tibial nerve stimulation on postpartum urinary retention. CASE REPORT: Case 1: 41-year-old patient, with two previous cesarean sections, overweight (BMI 28 kg/m2), 33 weeks of pregnancy, chronic arterial hypertension and over-aggregated preeclampsia associated with data of neurological deficit. In the late puerperium she had difficulty urinating and suprapubic pain. Based on urodynamics, detrusor-sphincter dyssynergia was diagnosed and she was treated with posterior tibial nerve stimulation for 20 minutes every week with phase duration 200 µs and frequency 10 Hz during 12 sessions. Urodynamic parameters improved and spontaneous micturition was restored, the frequency of intermittent clean catheterization was reduced, and the effect continued at 31 months follow-up. Case 2: 38-year-old primigravida patient, BMI 21 kg/m2, with a history of subclinical hypothyroidism. Five days postpartum she had urinary retention of 2000 mL; a Foley catheter was placed for continuous drainage and, subsequently, a plug with emptying every 2 hours. Notwithstanding the above, she had new episodes of urinary retention that warranted the initiation of intermittent clean catheterization, 5 in 24 hours and stimulation of the posterior tibial nerve with asymmetric biphasic current, she had a subjective improvement of 100% and urodynamic changes. Spontaneous urination resumed without requiring intermittent clean catheterization, she was discharged after one year of follow-up. CONCLUSION: According to the study outcomes, posterior tibial nerve stimulation could offer a promising treatment alternative in patients with postpartum urinary retention.

Análise da eletroestimulação transcutânea e percutânea do nervo tibial para tratamento da bexiga hiperativa em Parkinsonianos: revisão sistemática / Analysis of transcutaneous and percutaneous tibial nerve electrostimulation for treatment of overactive bladder in Parkinsonians: systematic review

Parkinson é uma doença de sintomas motores e não motores, podendo incluir neste último, a bexiga neurogênica, que se caracteriza por sintomas de urgência, com ou sem urge-incontinência, normalmente acompanhada de polaciúria e noctúria. Objetivo: Analisar a eletroestimulação transcutânea e a percutânea do nervo tibial para tratamento da bexiga hiperativa em Parkinsonianos. Metodologia: Foram incluí­dos todos os artigos que mencionaram o tratamento da bexiga hiperativa, com eletroestimulação transcutânea e percutânea do tibial posterior, em pacientes com Parkinson. Realizou-se a busca de março a novembro de 2017, nas bases de dados US National Library of Medicine (MEDLINE), Scientific Eletronic Library Online (SciELO), Physiotherapy Evidence Database (PEDro), Biblioteca Virtual em Saúde (BVS) e Google acadêmico, sem limites de data. Foram utilizados como descritores contidos nos Descritores em Ciências da Saúde (DeCS) as palavras-tí­tulo: bexiga hiperativa, Parkinson e eletroestimulação transcutânea e percutânea do tibial posterior. Foram utilizados como descritores contidos no Medical Subject Headings (MeSH) as palavras-tí­tulo: overactivity bladder, Parkinson"™s disease, electrical stimulation transcutaneous, percutaneous electrical stimulation. Resultados: Dos 8 artigos recuperados, 1 estava duplicado e 2 foram excluí­dos por não estarem disponí­veis, restando cinco artigos: 2 ECRs, 2 experimentais e 1 estudo piloto. Conclusão: a terapia de eletroestimulação tibial, tanto transcutânea, quanto percutânea, se mostra benéfica para tratamento da bexiga hiperativa, em pacientes com Parkinson, porém, se faz necessário a realização de novos estudos, principalmente os de intervenção, para padronização do método. (AU)

Parkinson's disease is a disease of motor and non-motor symptoms, and may include neurogenic bladder, which is characterized by urgency symptoms, with or without urge incontinence. Objective: To analyze the transcutaneous and percutaneous electrostimulation of the tibial nerve for treatment of overactive bladder in Parkinsonians. Methodology: All articles mentioning the treatment of overactive bladder, with transcutaneous and percutaneous electrostimulation of the posterior tibial, were included in patients with Parkinson's disease. The search was carried out from March to November 2017, in the databases National Library of Medicine (Medline), Scientific Electronic Library Online (SciELO), Physiotherapy Evidence Database (PEDro), Virtual Health Library (VHL) and Google academic, without date limits. The descriptors included were: hyperactive bladder, Parkinson's and transcutaneous and percutaneous electrostimulation of the posterior tibial. The descriptors included in the Medical Subject Headings (MeSH) were: overactivity bladder, Parkinson's disease, electrical stimulation transcutaneous, percutaneous electrical stimulation. Results: Of the 8 articles retrieved, 1 was duplicated and 2 were excluded because they were not available, leaving five articles: 2 RCTs, 2 experimental and 1 pilot study. Conclusion: Transcutaneous and percutaneous tibial electrostimulation therapy is beneficial for the treatment of overactive bladder in patients with Parkinson disease. However, it is necessary to carry out new studies, especially interventional ones, to standardize the method. (AU)

Análisis biomecánico a través de simulación numérica de la ruptura del tendón del tibial posterior en el pie plano valgo: estudio en cadáver / Biomechanical analysis through numerical simulation of rupture of the tibial posterior tendon in valgus flat foot: a cadeveric study

Resumen: La insuficiencia del tendón del tibial posterior es la causa adquirida de dolor más común relacionada con la deformidad de pie plano valgo en adultos. El pie plano adquirido por el adulto es una deformidad sintomática muy dolorosa que resulta de un estiramiento gradual (atenuación) del tendón del tibial posterior, así como de los ligamentos que sostienen el arco de la planta del pie. El dolor progresivo en el pie plano adquirido por el adulto afecta cuatro veces más a las mujeres que a los hombres. Algunos factores que contribuyen a incrementar el riesgo del pie plano adquirido en el adulto son la diabetes, la hipertensión y la obesidad. Se piensa que la combinación de los eventos siguientes es la causa del pie plano adquirido por el adulto. La clasificación de Johnson Strom modificada por Mayerson lo evalúa en cuatro estadios. Este estudio se dividió en tres etapas: etapa 1: disección y análisis tridimensional del tendón, etapa 2: aplicación de herramientas de bioingeniería para determinar las causas de ruptura del tendón del tibial posterior y etapa 3: evaluación de 24 pacientes con enfermedad de pie plano valgo para describir la deformidad.

Abstract: The insufficiency of the posterior tibial tendon is the most common acquired cause of pain related to valgus flatfoot deformity in adults. The acquired flatfoot adult is a very painful symptomatic deformity resulting from a gradual stretching (attenuation) of the posterior tibial tendon and ligaments that support the arch of the foot. The progressive pain acquired flatfoot adult affects four times more women than men. Some factors that contribute to increased risk of acquired flatfoot in adults, are diabetes, hypertension and obesity. It is thought that the combination of the following events is the cause of acquired flatfoot adult. Johnson Strom classification modified by Mayerson evaluates in 4 stages. This study was divided into 3 stages: Stage 1: Dissection and three-dimensional analysis of the tendon, Step 2: Application of tools bioengineering to determine the causes of rupture of the tibial tendon: Stage 3: Evaluation of 24 patients with flatfoot disease valgus for describe the deformity.

The tibial nerve and its vasculature: an anatomical evaluation / El nervio tibial y su vasculatura: una evaluación anatómica

The study has contributed to evaluate the tibial nerve and its vasculature anatomically. Ten preserved cadavers (5 male, 5 female) have been used for this study. Each cadaver was injected with red latex and through incisions the tibial nerve was exposed at the level of bifurcation of sciatic nerve. The tibial nerve in 85 % cadavers was located between middle and lower thirds at upper angle of popliteal fossa; whereas, in 15 % cadavers it was present below the piriformis muscle in gluteal region. The total length of the tibial nerve was at a mean of 65.26±14.42 cm in males and 64.79±67.61 cm in females, without significantly different. Its total diameter was at a mean of 5.51±1.55 mm, with a mean of 4.11±0.88 mm at the popliteal fossa and a mean of 3.24±0.81mm at its termination deep to the flexor retinaculum in male cadavers. In female; the means were 5.11±0.21 mm, 3.97±1.78 mm and 3.14 ± 0.03 mm respectively without significance difference. It was concluded that tibial nerve has sufficient and good blood supply. Moreover, it can be utilized as allogeneic vascularized nerve graft to repair sizable nerves after limb salvage.

El estudio ha contribuido a evaluar anatómicamente el nervio tibial y su vasculatura. Se han utilizado diez cadáveres preservados (5 hombres, 5 mujeres) para este estudio. Cada cadáver fue inyectado con látex rojo y a través de incisiones el nervio tibial fue expuesto al nivel de la bifurcación del nervio ciático. El nervio tibial en el 85 % de los cadáveres se localizó entre los tercios medio e inferior en el ángulo superior de la fosa poplítea; mientras que en el 15 % de los cadáveres estaba presente debajo del músculo piriforme en la región glútea. La longitud total media del nervio tibial fue de 65,26±14,42 cm en hombres y 64,79±67,61 cm en mujeres, sin diferencias significativas. Su diámetro total se situó en una media de 5,51±1,55 mm, con una media de 4,11±0,88 mm en la fosa poplítea y una media de 3,24 ± 0,81 mm en su terminación profunda al retináculo flexor en cadáveres masculinos. En mujeres; Las medias fueron 5,11±0,21 mm, 3,97±1,78 mm y 3,14±0,03 mm, respectivamente, sin diferencia significativas. Se concluyó que el nervio tibial tiene suficiente y buen suministro de sangre. Además, se puede utilizar como injerto de nervio vascularizado alogénico para reparar nervios importantes después de la recuperación de miembros.

Transposición tendinosa del tibial posterior al centro del pie en lesiones neuromusculares. Experiencia en pacientes adultos / Adult experience with the tibialis posterior transposition to the center of the foot in neuromuscular disease

Resumen: La transferencia del tibial posterior al centro del dorso del pie es un método que se utiliza para lograr la dorsiflexión en parálisis flácida de la musculatura anteroexterna de la pierna o para contrarrestar el desequilibrio muscular del pie equino varo. Objetivo: Describir los resultados funcionales después del procedimiento quirúrgico de transposición del tibial posterior al centro del pie. Material y métodos: Estudio observacional, descriptivo, transversal y ambispectivo con una descripción del universo de trabajo en pacientes con deficiencia de la musculatura dorsiflexora del pie y afectación de la marcha en el período de Enero de 2008 a Diciembre de 2014. Resultados: Se obtuvo un total de 18 pacientes. Discusión: Creemos que este estudio podría considerarse como generador de hipótesis sobre si representa una alternativa superior a la artrodesis. Para ello proponemos continuar estudios en esta rama con mayor cantidad de evaluaciones en el preoperatorio y postoperatorio para obtener resultados más objetivos y con un grupo más amplio de individuos.

Abstract: The transfer of the posterior tibial tendon to the center of the dorsum of the foot is a method used to achieve dorsiflexion in flaccid paralysis of the anterolateral leg muscles or muscular imbalance of clubfoot. Objective: To describe functional results back to the surgical procedure for transposition of posterior tibial the center of the foot. Material and methods: The study design was observational, descriptive, transversal, ambispective with a description of the world of work patients with impaired dorsiflexora foot muscles and impaired gait in the period January 2008 to December 2014. Results: A total of 18 patients who were candidates for what this type of treatment was obtained. Discussion: We believe that this study can be estimated as generating hypotheses about whether it is a superior alternative to arthrodesis. For this plan to continue studies in this field, with an increased number of assessments both before and after surgery to have more objective results and a greater number of individuals.

Clinical features of a rare anatomical variation of the posterior tibial and fibular arteries / Aspectos clínicos de uma variação anatômica rara das artérias tibial posterior e fibular

Abstract The posterior tibial artery normally arises from tibial-fibular trunk at the popliteal fossa, together with the fibular artery. The classic course of the posterior tibial artery is to run between the triceps surae muscle and muscles of the posterior compartment of the leg before continuing its course posteriorly to the medial malleolus, while the fibular artery runs through the lateral margin of the leg. Studies of both arteries are relevant to the fields of angiology, vascular surgery and plastic surgery. To the best of our knowledge, we report the first case of an anastomosis between the posterior tibial artery and the fibular artery in their distal course. The two arteries joined in an unusual “X” format, before division of the posterior tibial artery into plantar branches. We also provide a literature review of unusual variations and assess the clinical and embryological aspects of both arteries in order to contribute to further investigations regarding these vessels.

Resumo A artéria tibial posterior e a artéria fibular se originam do tronco tibiofibular, na fossa poplítea. A trajetória clássica da artéria tibial posterior é correr entre o tríceps sural e os músculos do compartimento posterior da perna, e, então, seguir posteriormente ao maléolo medial. Já a artéria fibular corre na margem lateral da perna, seguindo profundamente aos músculos. O estudo dessas artérias é relevante para o campo da angiologia, cirurgia vascular e cirurgia plástica. O presente trabalho é o primeiro relato de caso de uma anastomose entre ambas artérias, na porção distal de suas trajetórias. Tais artérias se anastomosaram em formato de “X”, antes da divisão da artéria tibial posterior em ramos plantares. Foi feita uma revisão de literatura das variações de tais artérias, dando ênfase ao aspecto clínico e embriológico, de modo a contribuir para novas investigações sobre esses vasos.

Changes in Femoral Posterior Condylar Offset, Tibial Posterior Slope Angle, and Joint Line Height after Cruciate-Retaining Total Knee Arthroplasty

PURPOSE: Changes in the femoral posterior condylar offset (PCO), tibial posterior slope angle (PSA), and joint line height (JLH) after cruciate-retaining total knee arthroplasty (CR-TKA) were evaluated to determine their influence on the flexion angle. MATERIALS AND METHODS: A total of 125 CR-TKAs performed on 110 patients were retrospectively reviewed. Pre- and postoperative PCO, PSA, and JLH were compared using correlation analysis. Independent factors affecting the postoperative flexion angle of the knee were analyzed. RESULTS: The PCO was 28.2+/-2.0 mm (range, 24.5 to 33.1 mm) preoperatively and 26.7+/-1.8 mm (range, 22.2 to 31.2 mm) postoperatively (r=0.807, p0.291). CONCLUSIONS: Although the PCO and JLH did not change significantly after CR-TKA, the PSA decreased by 5.5degrees with a small range of variation. Restoration of the PCO and JLH could promote optimization of knee flexion in spite of the decreased PSA after CR-TKA.

Tenodesis vs. tunelización del tendón flexor largo de los dedos en el tratamiento de la disfunción del tendón tibial posterior en estadio II / Tenodesis Vs. Tunneling of Flexor tendon length of the fingers in the treatment of Posterior Tibial Tendon Dysfunction Stage II

El tratamiento , en el estadio II de disfunción del tendón tibial posterior (DTTP) consiste en la transferencia del tendón Flexor Largo de los dedos (FLD) para suplir al tendón tibial posterior insuficiente y un procedimiento óseo para corregir la deformidad adquirida del retropié. En este estudio, evaluamos la función y eficacia de la transferencia del FLD tunelizado en el escafoide tarsiano vs la tenodesis del mismo al muñón distal del tendón tibial posterior. Material y método: Se realizó un estudio retrospectivo y comparativo de los pacientes intervenidos por esta patología en la Unidad de Pie y Tobillo del HCC, entre los años 2005 y 2012. En 27 pacientes se realizó tunelización del FLD en el escafoides tarsiano y en 49 pacientes se realizó tenodesis del FLD al muñón distal del tendón tibial posterior; en todos los pacientes se realizó un procedimiento óseo para corregir la deformidad adquirida del retropié. Se midió goniometricamente, inversión y flexión plantar del pie al año de postoperatorio en todos los pacientes y se comparó con el pie sano. Se evaluó pérdida de función ó dolor en zona de la transferencia. El análisis estadístico se realizó con t-student. Resultados: 6 pacientes presentaron DTTP bilateral y fueron descartados de este estudio. Los pacientes con tunelización del FLD en el escafoides tarsiano, presentaron una media de 62% de inversión y 86% de flexión plantar, los pacientes con tenodesis de FLD, presentaron una media de 86% de inversión y 89% de flexión plantar. Perdieron función del tendón, 1 paciente con tendón tunelizado, y 2 con tenodesis; presentaron dolor en la zona de la transferencia 2 pacientes con tenodesis del FLD. Conclusión: De nuestro estudio podemos concluir, que la tenodesis del FLD al muñón distal del tendón Tibial posterior, produce una mejor inversión del pie que la tunelización del FLD en el escafoides tarsiano(AU)

The surgical treatment of stage II posterior tibial tendon dysfunction (PTTD) is the transfer of the flexor digitorum longus tendon (FDL) to supply the posterior tibial tendon and a bone procedure to correct the acquired deformity of the hindfoot. In this study we evaluated the role and effectiveness of the FDL transfer to a tarsal scaphoid tunnel vs tenodesis of the distal stump of the posterior tibial tendon. Materials and methods: We performed a retrospective comparative study of patients with this disease in the Foot and Ankle Unit of HCC between 2005 and 2012, in 27 patients FDL tunnel was performed in the tarsal navicular and in 49 patients FDL tenodesis was performed to the distal posterior tibial tendon stump; in all patients a bone procedure was performed to correct acquired deformity of the hindfoot. Goniometrical measure was performed for forefoot inversion and plantar flexion at 12 months postop and compared with the healthy foot. Pain or loss of function in the transfer zone was evaluated. Statistical analysis was performed using T-student. Results: 6 patients had bilateral and PTTD and were excluded from this study. Patients with tarsal scaphoid FDL tunnel showed a mean of 62% forefoot inversion and 86% of plantar flexion, patients with FDL tenodesis, showed an average of 86% forefoot inversion and 89% of plantar flexion. One tendon tunnel patient lost tendon function and 2 tenodesis patient lost tendon function. 2 patients with FDL tenodesis had pain in the transfer area. Conclusion: From our study we can conclude that FDL tenodesis to the distal posterior tibial tendon stump produces a better forefoot inversion than the FDL tarsal navicular tunnel(AU)

Efectividad de la electroestimulación del nervio tibial posterior para el tratamiento de la incontinencia urinaria de esfuerzo / Effectiveness of the electro-stimulation of the posterior tibial nerve for the treatment of stress urinary incontinence

La incontinencia urinaria es cualquier pérdida involuntaria de orina. El tratamiento actual consiste en ejercicios de fortalecimiento pélvico y cirugía en los casos severos. Dado que el nervio tibial posterior y músculos del piso pélvico presentan inervación común originada en las raíces sacras se plantea que la estimulación eléctrica de dicho nervio es un método terapéutico de la incontinencia urinaria de esfuerzo. Se realizó un estudio cuasi-experimental, longitudinal, analítico de tipo prospectivo en 22 mujeres entre 20 y 60 años durante el periodo de Junio a Diciembre del año 2014, las cuales cumplieron 6 semanas de terapia y se dividieron en dos grupos: el grupo A que realizó ejercicios de Kegel y Grupo B que realizaron electroestimulación del tibial posterior y ejercicios de Kegel. Las pacientes respondieron el cuestionario de incontinencia urinaria ICIQ-SF al inicio de la terapia y a la finalización. Existió una mejoría global del 26% posterior a la terapia con ejercicios de Kegel y 69% en el grupo que realizó la electroestimulación del tibial posterior al finalizar las 6 semanas de tratamiento.

Urinary incontinence consists in any involuntary loss of urine. -The current treatment consists in pelvic strengthening exercises and surgery in severe cases. Since the tibial posterior nerve and the pelvic floor muscles present common innervation originated in the sacral roots a hypothesis arises: Electrical stimulation of the nerve is a therapeutic method of urinary incontinence. A quasi-experimental, longitudinal, prospective analytical study was performed on 22 women between 20 and 60 years during the period from June to December 2014, which met six weeks of therapy and were divided into two groups: group A who performed Kegel exercises and group B who made electrostimulation of the posterior tibial nerve and Kegel exercises. The patients answered the questionnaire urinary incontinence ICIQ-SF at the start of therapy and termination. There was an overall improvement of 26% after therapy with Kegel exercises and 69% in the group that performed electrostimulation of the posterior tibial nerve at the end of 6 weeks of treatment.

Tenoscopía tibial posterior: Reporte de un caso / Posterior tibial tenoscopy: Case report

La tendinitis del tibial posterior se presenta comúnmente en pacientes con actividades deportivas. Se puede originar ya sea por exceso de uso o una sobrecarga brusca sobre el tendón. Esta tendinitis también se puede presentar en pacientes con enfermedades inflamatorias sistémicas, y se clasifica como el estadio I en la disfunción del tendón tibial posterior. El tratamiento inicial, con el que se han presentado buenos resultados, se basa en la inmovilización y rehabilitación. En los casos que no presentan mejoría del cuadro clínico o la tendinitis se asocia a una ruptura parcial del tendón, existen técnicas abiertas para realizar tenosinovectomías y revisiones del tendón para mejorar la sintomatología dolorosa. Con el advenimiento de las técnicas miniinvasivas se pueden realizar revisiones amplias del tendón con una mínima agresión o combinarlas con técnicas tradicionales si se asocian con roturas parciales. En este artículo se describe el caso clínico de un paciente femenino de 35 años con patología y dolor crónico a nivel de tibial posterior, la cual fue manejada mediante tenoscopía del tibial posterior y su evolución postquirúrgica a 24 meses. El tratamiento endoscópico y/o tenoscópico es una técnica simple y reproducible. En esta paciente encontramos excelentes resultados funcionales y cosméticos. Es necesario aumentar nuestra casuística sobre este método de tratamiento...

Posterior tibial tendinitis occurs commonly in patients involved in sports activities. It may result from either excessive use or sudden overload of the tendon. This tendinitis may also occur in patients with systemic inflammatory conditions and is classified as posterior tibial tendon dysfunction stage I. Initial treatment, which has produced good results, is based on immobilization and rehabilitation. In cases without clinical improvement or in which tendinitis is associated with partial tendon rupture, open techniques may be used to perform tenosynovectomy and tendon revisions to improve painful symptoms. With the advent of minimally invasive techniques broad tendon revisions may be done that cause minimal damage or they may be combined with traditional techniques in cases of partial rupture. This paper describes the clinical case of a 35 year-old female patient with posterior tibial pathology and chronic pain. She underwent posterior tibial tenoscopy and was followed-up postoperatively for 24 months. Endoscopic and/or tenoscopic treatment is a simple and reproducible technique. We obtained excellent functional and cosmetic results in this patient. We need larger case series of patients subjected to this treatment...

Variações anatômicas dos vasos tibiais: diagnostico diferencial de trombose venosa profunda antiga pela ecografia vascular / Anatomical variations of tibial vessels: differential diagnosis of deep vein thrombosis by vascular ultrasound

CONTEXTO: Apesar de a ultrassonografia vascular com Doppler colorido (UVDC) ser confiável na avaliação de TVP em membros inferiores, situações como variações anatômicas das veias tibiais podem limitar o diagnóstico ou mesmo induzir a um resultado falso-positivo. OBJETIVO: Apresentar uma variação anatômica das veias tibiais posteriores potencialmente responsável por resultados falso-positivos no diagnóstico da TVP antiga pela UVDC. MÉTODOS: Foram revisados exames de UVDC em pacientes com suspeita de trombose venosa profunda de membros inferiores realizados no período de janeiro a dezembro de 2012. Nestes, foram observados a presença, o número e o trajeto das veias profundas, e suas respectivas artérias. Os casos suspeitos de variação anatômica nas veias tibiais posteriores foram revisados por outro ultrassonografista vascular, para confirmação dos achados. A variação anatômica com agenesia ou hipoplasia das veias tibiais posteriores foi considerada somente quando a artéria tibial posterior também não foi identificada em toda a extensão ou nos respectivos segmentos nos quais não foram visibilizadas as veias. RESULTADOS: Foram realizados 1458 estudos pela UVDC em pacientes com suspeita de TVP em membros inferiores. Em seis pacientes (0,41%), houve agenesia parcial ou completa das veias tibiais posteriores. Cinco pacientes tiveram avaliação unilateral e um bilateral, totalizando sete membros inferiores, três membros inferiores direitos e quatro esquerdos. CONCLUSÃO: Apesar de encontrada em apenas 0,41% dos casos, o conhecimento da agenesia das veias posteriores é útil, a fim de diminuir erros diagnósticos e resultados falso-positivos para TVP em pacientes com essas variações. .

BACKGROUND: Even though color Doppler ultrasound (CDUS) imaging is reliable in assessing deep vein thrombosis (DVT) in lower extremities, anatomical variations of tibial veins may limit the diagnosis and even lead to false positive results. OBJECTIVE: To describe anatomic variations of the posterior tibial vein that may lead to false positive results in the CDUS diagnosis of chronic DVT. METHODS: CDUS scans of patients with suspected deep vein thrombosis of the lower extremities obtained from January to December 2012 were reviewed to record the presence, number and course of deep veins and arteries. Suspected anatomic variations of the posterior tibial veins were reviewed by another vascular sonographer to confirm findings. Anatomic variations, such as absence or hypoplasia of the posterior tibial veins, were recorded when the posterior tibial artery was not detected in any segments, as well as when the artery was also not visualized in the same segments. RESULTS: A total of 1458 CDUS scans of patients with suspected DVT in the lower extremities were reviewed. In six patients (0.41%), the posterior tibial veins were absent or hypoplastic. Scans were unilateral for five patients and bilateral for one, at a total of 7 lower extremities (3 right and 4 left). CONCLUSION: Although a rare condition, found in only 0.41% of the cases, awareness of posterior vein absence may help to avoid misdiagnoses and false-positive results of DVT in patients with this variation. .

Neuroestimulación del nervio tibial posterior: impacto en el score de incontinencia. Resultados iniciales / Posterior tibial nerve neurostimulation. Impact of fecal incontinence scale. Initial results

Antecedentes: La incontinencia fecal es una afección cuya causa es multifactorial y que tiene un profundo impacto en la calidad de vida. La neuroestimulación del Nervio Tibial Posterior es una opción de tratamiento de la incontinencia fecal, cuya característica es de ser mini-invasiva. Los resultados iniciales son inciertos. Objetivo: Valorar la eficacia de la neuroestimulación del Nervio Tibial Posterior en pacientes con incontinencia fecal. Material y Métodos: Se realizó un trabajo prospectivo, longitudinal, piloto, no controlado. Durante el período entre enero de 2010 a junio de 2011, 14 pacientes fueron tratados con NTP. Todos los pacientes fueron evaluados con ecografía endoanal de 360 grados y manometría anal. Cada paciente completo el score de incontinencia de Jorge-Wexner. Resultados: Todos los pacientes toleraron el procedimiento, no registrándose complicación alguna. El score de Incontinencia de Jorge-Wexner, previo al tratamiento, tuvo una media de 10,7 (DS: 3,7). En la 6ta sesión la media del score fue de 6,4 (DS: 2,5); mientras que en la sesión 12 dicho score presento un valor de 1,5 (DS: 1,5). Conclusión: La estimulación del nervio Tibial Posterior es una opción de tratamiento mínimamente invasivo y eficaz, para pacientes con incontinencia fecal.

Background: Fecal incontinence is a condition with a multifactorial cause, and that has a profound impact on quality of life. Objective: To evaluate the efficacy of the posterior tibial nerve neurostimulation in patients with fecal incontinence. Patients and Methods: We performed a prospective, uncontrolled pilot study. During the period from January 2010 to June 2011, 14 patients were treated NTP. Endoluminal ultrasound and anal manometry were also performed in each patient. All patients completed the Wexner Fecal Continence Scale, a fecal incontinence scale. Results: All patients tolerated the procedure without complications. The Jorge-Wexner incontinence score before treatment had a mean of 10.7 (SD 3.7). At the 6th session, the average score was 6.4 (SD: 2.5). While in session 12, this score had a value of 1.5 (SD 1.5). Conclusion: Percutaneous tibial nerve stimulation is a minimally invasive and effective treatment option for patients with fecal incontinence.

The Effect of Tibial Posterior Slope on Contact Force and Ligaments Stresses in Posterior-Stabilized Total Knee Arthroplasty-Explicit Finite Element Analysis

PURPOSE: The purpose of this study is to evaluate the effect of change in tibial posterior slope on contact force and ligament stress using finite element analysis. MATERIALS AND METHODS: A 3-dimensional finite element model for total knee arthroplasty was developed by using a computed tomography scan. For validation, the tibial translations were compared with previous studies. The finite element analysis was conducted under the standard gait cycle, and contact force on ultra-high molecular weight polyethylene (UHMWPE) and stresses on lateral and medial collateral ligaments were evaluated. RESULTS: The tibial translations showed similarity with previous studies. As the tibial posterior slope angle increases, the contact stress area increased and was well distributed, and the contact force on UHMWPE decreased overall. However, the maximum contact force in the case for 10degrees case was greater than those for others. The stresses on ligaments were the greatest and smallest in 0degrees and 10degrees cases, respectively. CONCLUSIONS: The higher tibial posterior slope angle leads to the lower contact stress and more extensive stress distribution overall in posterior-stabilized total knee arthroscopy. However, it does not absolutely mean the smallest contact force. The stresses on ligaments increased with respect to the smaller tibial posterior slope angle.

Inclinação tibial posterior como fator de risco para lesões dos ligamentos cruzados anterior e posterior do joelho / Tibial slope as a risk factor for injury of anterior and posterior cruciate ligaments of the knee

Objetivo: O objetivo deste estudo é avaliar a influência da inclinação posterior da tíbia proximal na incidência de lesões dos ligamentos cruzados anterior e posterior do joelho. Métodos: Foram avaliadas, retrospectivamente, as radiografias pré-operatórias na incidência em perfil com filme longo de joelho de 30 pacientes consecutivos submetidos a reconstrução do ligamento cruzado anterior e 30 pacientes submetidos a reconstrução do ligamento cruzado posterior. Para comparação de variáveis categóricas entre os grupos foi utilizado o teste não paramétrico de Quiquadrado de Pearson. Foi assumido valor de a=5% como estatisticamente significante. Resultados: Dos indivíduos com inclinação tibial, £ 4,75% pertenciam ao grupo dos pacientes com lesão do LCP e 71,4% dos indivíduos com inclinação tibial ³ 10 pertenciam ao grupo de pacientes com lesão do LCA. Conclusão: Em indivíduos com valores intermediários de inclinação tibial posterior (5 a 9 graus) parece não haver a influência desta variável nas lesões ligamentares estudadas. Já nos extremos parece haver uma relação, no entanto estudos com maior número de pacientes seriam necessários para confirmar esta hipótese.

Fratura luxação do tálus com lesão da artéria tibial posterior: relato de dois casos / Fracture dislocation of the talus associated with posterior tibial artery lesion: two case reports

Introdução: As fraturas e fraturas luxações do colo talar representam 50% das lesões do tálus. Dentre as lesões associadas estão fratura de ossos adjacentes ou danos a tecidos moles como vasos, tendões ou nervos. Relato de caso: Os autores descrevem dois pacientes do sexo masculino apresentando fratura luxação Hawkins III com desvio medial do corpo talar e a lesão da Artéria Tibial Posterior. A lesão foi diagnosticada pela exploração cirúrgica no caso 1 e através do ecodoppler realizado pelo especialista no caso 2. Os pacientes foram submetidos à redução aberta e fixação interna através da via de acesso medial. Apesar de apresentarem flictenas no pré-operatório, ambos evoluíram com boa cicatrização, sem infecção ou necrose de pele. Discussão:Em uma revisão de literatura sobre lesões de partes moles associadas a traumas do pé e tornozelo foram encontradas publicações apenas a respeito da lesão traumática do tendão tibial posterior, aneurisma e trombose da artéria tibial posterior, tendão calcâneo, ligamento talofibular anterior e tendão fibular longo. Não foi encontrado nenhum artigo que associe fratura luxação do colo talar com lesão da artéria tibial posterior.

Neuromodulación central y periférica en incontinencia fecal: presentación de 2 casos y revisión de la literatura / Central and peripheral neuromodulation for fecal incontinence: report of 2 cases and review of the literature

Fecal incontinence is a condition that creates a huge impact on quality of life, it affects up to 45 percent of patients of the elderly. Treatment is initially conservative with dietary changes, drugs and perineal biofeedback. Surgery is reserved for those who do not respond to medical treatment. The most frequently performed procedure is anal sphincteroplasty, useful in patients with proven lesions of the external anal sphincter. Other alternatives include the implantation of an artificial anal sphincter and dynamic graciloplasty, which are very expensive techniques with high rate of complications. If there is no other alternative, a permanent ostomy can be done. In recent years, less invasive techniques have been developed for the treatment of fecal incontinence. Among these, central neuromodulation or sacral root stimulation (SRS) and peripheral neuromodulation or posterior tibial nerve stimulation (PTNS) have shown promising results. The aim of this paper is to present 2 cases of patients with fecal incontinence refractory to conventional treatment (medical and surgical) that are successfully treated with central and peripheral neuromodulation respectively. We present 2 cases and a review of the literature available to date.

La incontinencia fecal (IF) es una patología que genera un enorme impacto en la calidad de vida, afectando hasta el 45 por ciento de los pacientes de la tercera edad. El tratamiento es inicialmente conservador mediante cambios dietéticos, fármacos y rehabilitación perineal. La cirugía se reserva para quienes no responden a tratamiento medico. El procedimiento efectuado con más frecuencia es la esfinteroplastía anal, de utilidad en pacientes con lesión demostrada del esfínter anal externo. En casos de IF grave, otras alternativas son la instalación de un esfínter anal artificial y/o la graciloplastía dinámica, procedimientos de alto costo y con un alto porcentaje de complicaciones. En caso de no existir otra alternativa se puede realizar una ostomía definitiva. Durante los últimos años se han desarrollado técnicas mínimamente invasivas para el tratamiento de la incontinencia fecal. Entre éstas, la neuromodulación central o de las raíces sacras (NMS) y últimamente la neuromodulación periférica o estimulación del nervio tibial posterior (ENTP) han mostrado resultados promisorios. Los objetivos de este trabajo son presentar 2 casos clínicos de pacientes con incontinencia fecal refractaria al tratamiento convencional (medico y quirúrgico) que son tratados exitosamente con neuromodulación central y periférica, respectivamente, y realizar una revisión de la literatura disponible a la fecha.

Comparación entre resultados obtenidos en la corrección de valgo tibial proximal en pacientes pediátricos con sistema de grapas y sistema de placas en el Hospital Ortopédico Infantil Caracas Venezuela 2000-2007 / Comparison of results obtained in the proximal tibial valgus correction in pediatric patients with staple system and system of plaques in the Hospital Ortopédico Infantil 2000-2007 Caracas Venezuela

Las deformidades axiales de los miembros inferiores, motivo de consulta habitual, no corregen espontáneamente si son persitentes y sginificativas. La epifisiodesis produce la corrección grudual de la deformidad en un procedimiento mínimamente invasivo, en pacientes esqueléticamente inmaduros, en genu valgum y varum, con grapas o placas y tornillos. Según las observaciones clínicas, las placas permiten un mejor resultado en tiempo más corto, menor daño a la fisis y menos riesgo de complicaciones o falla de material en comparación con las grapas. La comparación de las técnicas en engrapado y placa en la resolución de deformidades en valgo de tibia proximal en los pacientes pediátricos en el Hospital Ortopédico Infantil, durante el periodo 2000 al 2007. Estudio retrospectivo simple y comparativo, se evaluaron 36 pacientes de ambos sexos con el diagnostico de Valgo Proximal Tibial, idiopáticos o asociados a otras patologías, que fueron tratados en el Hospital Ortopédico Infantil durante 2000 al 2007 con las técnicas de grapa y placa, mediante revisión de controles pre y postoperatorios de la historia clínica, y por medición radiológica de los ángulos FDLm, TPMm y MAD en radiogrfías panorámicas pre y postoperatorias. Se estudiaron 36 pacientes de ambos sexos, (16 varones y 20 niñas), promedio de edad de 10 años +/- 3,3 años. Existen similitudes en los primeros 12 meses en esta muestra, pero a partir de ese momento la Placa alcanza los valores de corrección antes que las grapas. Según la pendiente Y, la placa se proyecta para correcciones de 6,62 mm cada 6 meses, en cambio la grapa se proyecta para correciones de 5,72 mm cada 6 meses. Los valores del ángulo se estabilizan con la placa, y en cuanto a la grapa, se continúa la corrección en sentido contrario. La pendiente Y indica que la placa corrige -1,95º cada 6 meses, y la grapa corrige -2,95º cada 6 meses hacia el varo. Según la prueba ANOVA, combinando las variables Tiempo-Material, la placa alcanza....

The axial deformities of the lower limbs, common reason for consulation, will not correct spontaneously if they are persistent and significant. Epiphysiodesis produce gradual correction of deformity in a minimally invasive procedure in skeletally immature patients in valgum and genu varum with staples or plates and screws. According to clinical observations, the plates allow a better result in shorter time, less damage to the physis and less risk of complications or failure of material compared with the staples. Comparison of stapling techniques and plaque in the resolution of valgus deformity of proximal tibian in pediatric patients at Children's Orthopedic Hospital during the period 2000 to 2007. A retrospective and comparative simple, we evaluated 36 patients of both sexes with a diagnosis of Proximal Tibial Valgus, idiopathic or associated with other diseases, which were treated at the Children's Orthopedic Hospital during the period 2000 to 2007 with the techniques staple and plate by reviewing pre-and postoperative checks of medical record, and radiological measurements of the angeles FDLm, TPMm, and MAD in pre-and postoperative panoramic radiographs. We studied 36 patients of both sexes (16 boys and 20 girls), mean age 10 +/- 3,3 years. There are similarities in the first 12 months in this sample, but from that moment on the plate reaches the values of correction rather than staples. According to the slope and The plate is projected to corrections from 6,62 mm every 6 months, however the clip is projected to corrections of 5,72 mm every 6 months. The angle values are e¡stabilized with the plate, and as for the clip, continue the correction in the opposite direction. The slope indicates that the board and fixes -1,95º every six months, and the clip fixes -2,95º every six months into varus. According to the ANOVA test, combining the time-material variables, the plate reaches the expected correction before on the staple, the period aroun 12 months would.....

Hypoplastic posterior tibial artery and the enlarged peroneal artery supplying the posterior crural region: a rare variation / Artéria tibial posterior hipoplásica e a artéria peroneal aumentada suprindo a região crural posterior: uma variação rara

Arterial variations of distal parts of lower extremities are well-documented and can be demonstrated with the help of Doppler ultrasound or by arteriography. However, absence or variation of posterior tibial artery is considered a rare finding. We present a case of hypoplastic posterior tibial artery that terminated by supplying soleus muscle. The variant arterial supply to the sole was provided by the enlarged peroneal artery that continued as the lateral plantar artery. The awareness of these variations is important to vascular surgeons while performing arterial reconstructions in femorodistal bypass graft procedures, and also to orthopedists during surgical clubfoot release.

Variações arteriais de partes distais dos membros inferiores estão bem documentadas e podem ser demonstradas com o auxílio de ultra-sonografia Doppler ou por arteriografia. Entretanto, a ausência ou variação da artéria tibial posterior é um raro achado. Apresentamos um caso de artéria tibial posterior hipoplásica que terminava suprindo o músculo solear. Esse suprimento arterial variante foi fornecido pela artéria peroneal aumentada que continuava como artéria plantar lateral. Estar consciente dessas variações é importante para cirurgiões vasculares ao realizarem reconstruções arteriais em procedimentos de derivação femorodistal, bem como para ortopedistas durante correção cirúrgica do pé torto.