Reconstrucción por técnica de Chevron reverso y transferencia tendinosa con técnica no convencional en Hallux Varus Iatrogénico Severo / Reconstruction by reverse Chevron technique and tendon transfer with unconventional technique in severe iatrogenic Hallux Varus

El Hallux Varus Iatrogénico es una complicación de la cirugía correctiva del Hallux Valgus muy poco frecuente. El tratamiento incluye la intervención de los tejidos blandos, y óseos. El propósito de este trabajo es mostrar los resultados clínico-radiológicos del tratamiento quirúrgico del Hallux Varus Iatrogénico Flexible Severo empleando la combinación de técnicas de reconstrucción alternativas en una paciente femenina de 59 años de edad. Se realizó liberación medial de la capsula articular MTF y abductor, osteotomía de Chevron reverso, artrodesis interfalángica izquierda, transferencia tendinosa del extensor largo de Hallux hacia plantar con botón artesanal. De acuerdo a la Escala AOFAS aumentó de 30 a 90 puntos. Se logró la corrección estable de la deformidad en varo y la consolidación de la osteotomía. El Hallux Varus Iatrogénico es una complicación poco frecuente considerada una deformidad mal tolerada, con pocos casos reportados y pocos reportes. Se debe hacer un enfoque de tratamiento paso a paso para abordar todos los elementos involucrados en el Hallux Varus iatrogénico. La corrección quirúrgica del Hallux Varus iatrogénico severo con técnicas de reconstrucción no convencionales tipo Chevron reverso y transferencia tendinosa con botón plantar, es una excelente opción terapéutica de acuerdo a los resultados obtenidos en este caso(AU)

Iatrogenic Hallux Varus is a very rare complication of Hallux Valgus corrective surgery. The treatment includes the intervention of soft tissues and bones. The purpose of this paper is to show the clinical-radiological results of the surgical treatment of Severe Flexible Iatrogenic Hallux Varus using the combination of alternative reconstruction techniques in a 59-year-old female patient. Medial release of the MTF and abductor joint capsule, reverse Chevron osteotomy, left interphalangeal arthrodesis, tendon transfer of the long extensor of Hallux to plantar with artisanal button was performed. According to the AOFAS Scale, it increased from 30 to 90 points. Stable correction of the varus deformity and consolidation of the osteotomy were achieved. Iatrogenic Hallux Varus is a rare complication considered a poorly tolerated deformity, with few reported cases and few reports. A step-by-step treatment approach must be taken to address all the elements involved in iatrogenic Hallux Varus. Surgical correction of severe iatrogenic Hallux Varus with unconventional reconstruction techniques such as reverse Chevron and plantar button tendon transfer is an excellent therapeutic option according to the results obtained in this case(AU)

Kinematics and Plantar Pressure Analysis of Varus Femur and Varus Tibia / 医用生物力学

Objective To compare the differences in kinematic parameters and plantar pressures for two types of knee varus with tibial and femoral origins in gait analysis, so as to provide biomechanical theoretical basis for different types of genu varus. Methods Twenty-six patients with unilateral knee osteoarthritis (KOA) varus genu were enrolled, with 13 from femoral and 13 from tibial sources. Using Noraxon MyoMotion three-dimensional (3D) motion capture system and Footscan plantar pressure test system, the gait of the subjects during natural walking was measured, the temporal and spatial parameters of the gait, the kinematics parameters of lower limb joints and plantar pressures were collected, to make comparative analysis between the two groups. Results The range of knee flexion and extension of tibial varus, the peak of hip abduction, the range of motion (ROM) of hip adduction and abduction and the peak of ankle pronation were larger than those of femoral lateral genu varus. The peak of knee flexion and hip adduction was smaller than that of femoral lateral genu varus. Compared with femoral varus, subjects with tibial varus had increased stress time and peak pressure on the plantar of the 4th and 5th metatarsals (P<0.05). In the 3rd metatarsal region, the impulse of healthy femoral limb was greater than that of healthy limb with tibial deformity. While in the medial calcaneal region, the impulse of healthy femoral limb was smaller (P<0.05). Conclusions There are some differences in kinematic parameters and plantar pressures between two different types of unilateral genu varus patients. The results of this study are helpful to understand the abnormal gait caused by genu varus, and provide reliable reference for postoperative rehabilitation and limb exercise for different types of genu varus.

PACS and Photoshop assisted isosceles triangle osteotomy and Kirschner wire tension buckle fixation in the treatment of cubitus varus in children / 中国骨伤

OBJECTIVE@#To investigate the clinical efficacy of picture archiving and communication system (PACS) and Photoshop assisted isosceles triangle osteotomy and Kirschner wire fixation with tension band in the treatment of cubitus varus in children.@*METHODS@#The clinic data of 20 children with cubitus varus treated with isosceles triangle osteotomy of distal humerus and Kirschner wire fixation with tension band from October 2014 to October 2019, were retrospectively analyzed. There were 13 males and 7 females, aged from 3.2 to 13.5 years old, the median age was 6.65 years old. PACS system was applied for the osteotomy design preoperatively, simulating and measuring the side length of isosceles triangle osteotomy. Then, Photoshop system was used to simulate the preoperative and postoperative osteotomy graphics, which could guide precise osteotomy during operation.@*RESULTS@#All the 20 patients were followed up for 20 to 24 months, with a median of 22.5 months. At the last follow-up, the carrying angle of the affected limb was 5 ° to 13 °, with a median of 8.3 °. The clinical efficacy was evaluated according to the Flynn elbow function score:excellent in 16 cases, good in 2 cases, and fair in 2 cases.@*CONCLUSION@#The treatment of cubitus varus in children by isosceles triangle osteotomy and Kirschner wire fixation with tension band assisted by PACS and Photoshop system has shown good clinical outcome.

Value of personalized osteotomy in primary total knee arthroplasty for severe varus knee osteoarthritis / 中国骨伤

OBJECTIVE@#To explore application value and efficacy of personalized osteotomy in primary total knee arthroplasty (TKA) for severe varus knee osteoarthritis.@*METHODS@#From June 2018 to January 2020, 36 patients (49 knees) with severe varus knee osteoarthritis were treated, including 15 males (21 knees) and 21 females (28 knees), aged from 59 to 82 years old with an average of (67.6 ± 6.5) years old;the course of disease ranged from 9.5 to 20.5 years with an average of (15.0 ± 5.0) years;11 patients (15 knees) with Kellgren-Lawrence grade Ⅲ and 25 patients (34 knees) with grade Ⅳ according to Kellgren-Lawrence grading. According to AORI clsssification of tibial bone defects, 8 patients (15 knees) were typeⅠTa and 16 patients (18 knees) were typeⅡ T2a. All patients' femor-tibial angle (FTA) was above 15°, and received primary TKA with personalized osteotomy. Thirty-three patients (45 knees) were treated with posterior-stabilized (PS) prostheses, 13 patients (15 knees) with PS prostheses combined with a metal pad and extension rod on the tibial side, and 3 patients (4 knees) with legacy constrained condylar knee (LCCK) prostheses. FTA, posterior condylar angle (PCA), medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA) before and after operation at 1 month were measured and compared by using picture archiving and communication systems (PACS). Recovery of lower limbs before and after operation at 12 months was evaluated by American Knee Society Score(KSS), and complications were observed and recorded.@*RESULTS@#All 36 patients (49 knees) were followed up from 15 to 40 months with an average of (23.46±7.65) months. FTA, MPTA were corrected from preoperative (18.65±4.28)° and (83.75±3.65)° to postoperative (2.35±1.46)° and (88.85±2.25)° at 1 month, respectively (P<0.001). PCA was decreased from (2.42±2.16)° before operation to (1.65±1.35)° at 1 month after operation, LDFA improved from (89.56 ± 3.55)° before operation to (91.63±3.38)° at 1 month after operation (P<0.05). KSS increased from (67.58±24.16) before opertion to(171.31±15.24) at 12 months after operation, 14 patients (19 knees) got excellent result, 19 (26 knees) good, and 3 (4 knees) fair.@*CONCLUSION@#Personalized osteotomy is helpful for recovery of axial alignment of lower limbs and correct placement of prosthesis, could effectively relieve pain of knee joint, recover knee joint function.

Short-term effectiveness of INBONE TM Ⅱ total ankle prosthesis arthroplasty in the treatment of moderate to severe varus-type ankle arthritis / 中国修复重建外科杂志

OBJECTIVE@#To investigate the short-term effectiveness of INBONE TM Ⅱ total ankle prosthesis arthroplasty in the treatment of moderate to severe varus-type ankle arthritis.@*METHODS@#The clinical and radiographic data of patients with moderate to severe varus-type ankle arthritis, who were admitted between May 2017 and November 2021 and treated with total ankle arthroplasty (TAA) using INBONE TM Ⅱ prosthesis, was retrospectively analyzed. A total of 58 patients (58 ankles) met the selection criteria and were included in the study. Among them, there were 24 males and 34 females, with an average age of 62.6 years (range, 41-85 years). According to the preoperative tibiotalar angle (TTA), the patients were divided into a moderate varus group (group A, TTA 5°-15°, n=34) and a severe varus group (group B, TTA>15°, n=24). There was no significant difference in gender, side, etiology, preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, ankle dorsiflexion, plantarflexion, and total range of motion, and tibial lateral surface angle (TLS) between the two groups ( P>0.05). Yet the patients in group A were younger than group B, the degrees of oesteoarthritis (Takakura stage) and ankle pain [visual analogue scale (VAS) score] were milder, and the TTA, talar tilt angle (TT), hindfoot alignment angle (HAA) were smaller while the tibial articular surface angle (TAS) was larger, showing significant differences ( P<0.05). The pre- and post-operative VAS score, AOFAS score, the occurrence of early and late complications, the radiographic parameters of the ankle (TTA, TAS, TT, HAA, TLS), ankle dorsiflexion, plantarflexion, and total range of motion were recorded and compared.@*RESULTS@#All patients were followed up 19-72 months, with an average of 38.9 months. Compared with the preoperative data, the VAS score of all patients significantly decreased ( P<0.05); the AOFAS score, ankle dorsiflexion range of motion, and total range of motion significantly increased ( P<0.05); and the TTA, TAS, TT, HAA, and TLS significantly improved at last follow-up ( P<0.05); but there was no significant difference in plantarflexion range of motion ( P>0.05). Early complications occurred in 13 patients, and only 1 patient underwent revision surgery due to a larger size of the talar component. At last follow-up, there was no significant difference in the difference of clinical parameters before and after operation between the two groups ( P>0.05); there was a significant difference in the difference of other radiographic parameters ( P<0.05) except TLS. No significant difference in the incidence of complications between the two groups was found ( P>0.05).@*CONCLUSION@#TAA using the INBONE TM Ⅱtotal ankle prosthesis is an effective treatment for moderate or severe varus-type ankle arthritis, and good clinical and radiographic results can be obtained. Correcting bony deformities and balancing soft tissue are the keys to successful surgery.

Establishment of finite element model of varus-type ankle arthritis and biomechanical analysis of different correction models for tibial anterior surface angle / 中国修复重建外科杂志

OBJECTIVE@#To establish the finite element model of varus-type ankle arthritis and to implement the finite element mechanical analysis of different correction models for tibial anterior surface angle (TAS) in supramalleolar osteotomy.@*METHODS@#A female patient with left varus-type ankle arthritis (Takakura stage Ⅱ, TAS 78°) was taken as the study object. Based on the CT data, the three-dimensional model of varus-type ankle arthritis (TAS 78°) and different TAS correction models [normal (TAS 89°), 5° valgus (TAS 94°), and 10° valgus (TAS 99°)] were created by software Mimics 21.0, Geomagic Wrap 2021, Solidworks 2017, and Workbench 17.0. The 290 N vertical downward force was applied to the upper surface of the tibia and 60 N vertical downward force to the upper surface of the fibula. Von Mises stress distribution and stress peak were calculated.@*RESULTS@#The finite element model of normal TAS was basically consistent with biomechanics of the foot. According to biomechanical analysis, the maximum stress of the varus model appeared in the medial tibiotalar joint surface and the medial part of the top tibiotalar joint surface. The stress distribution of talofibular joint surface and the lateral part of the top tibiotalar joint surface were uniform. In the normal model, the stress distributions of the talofibular joint surface and the tibiotalar joint surface were uniform, and no obvious stress concentration was observed. The maximum stress in the 5° valgus model appeared at the posterior part of the talofibular joint surface and the lateral part of the top tibiotalar joint surface. The stress distribution of medial tibiotalar joint surface was uniform. The maximum stress of the 10° valgus model appeared at the posterior part of the talofibular joint surface and the lateral part of the top tibiotalar joint surface. The stress on the medial tibiotalar joint surface increased.@*CONCLUSION@#With the increase of valgus, the stress of ankle joint gradually shift outwards, and the stress concentration tends to appear. There was no obvious obstruction of fibula with 10° TAS correction. However, when TAS correction exceeds 10° and continues to increase, the obstruction effect of fibula becomes increasingly significant.

Early effectiveness of a new minimally invasive plate in treatment of varus-type ankle arthritis / 中国修复重建外科杂志

OBJECTIVE@#To evaluate the early effectiveness of a new minimally invasive plate in the treatment of varus-type ankle arthritis.@*METHODS@#A clinical data of 15 patients with varus-type ankle arthritis who met the selection criteria between March 2021 and October 2021 were retrospectively analyzed. All the patients were treated with medial open-wedge supramalleolar osteotomy and fibular osteotomy. The osteotomies were fixed with the new minimally invasive plate. There were 7 males and 8 females with an average age of 49.8 years (range, 16-71 years). The causes of ankle arthritis included post-fracture deformity in 1 case, sprain in 8 cases, and acquired clubfoot in 1 case; and 5 cases were without obvious factors. The disease duration ranged from 1 to 12 years, with an average of 4.1 years. Comparisons were made between pre-operation and the last follow-up in the Takakura staging, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, foot function index (FFI), visual analogue scale (VAS) score, tibial anterior surface angle (TAS), tibial lateral surface angle (TLS), and talar tilt (TT).@*RESULTS@#All incisions healed by first intention. All patients were followed up 7-18 months (mean, 12.8 months). At last follow-up, the AOFAS ankle-hindfoot score, FFI, VAS score, and Takakura staging significantly improved when compared with the preoperative ones ( P<0.05). X-ray films showed that the osteotomy healed at 3 months after operation. At last follow-up, TAS significantly increased and TT decreased when compared with the preoperative ones ( P<0.05), and the difference in TLS between pre- and post-operation was not significant ( P>0.05). Complications included 1 case of intraoperative screw breakage and 2 cases of nerve injury of the affected foot. None of the patients complained of significant discomfort at the plate placement during follow-up, and no loosening of the internal fixator occurred. Eleven patients were very satisfied with the effeectiveness, while 4 were relatively satisfied.@*CONCLUSION@#The new minimally invasive plate for the varus-type ankle arthritis has good early effectiveness in relieving ankle pain, correcting deformity, improving limb alignment and ankle function, and reducing the incidence of postoperative incisional complications.

Effect of body mass index on short-term effectiveness of high tibial osteotomy in treatment of varus knee arthritis / 中国修复重建外科杂志

OBJECTIVE@#To investigate the effect of body mass index (BMI) on the short-term effectiveness of high tibial osteotomy (HTO) in the treatment of varus knee arthritis.@*METHODS@#The clinical data of 84 patients (84 knees) with varus knee arthritis treated with HTO between May 2016 and August 2020 were retrospectively analyzed. According to BMI, the patients were divided into normal group (32 patients in group A, BMI<25 kg/m 2), overweight group (27 patients in group B, BMI>30 kg/m 2), and obese group (25 patients in group C, BMI>30 kg/m 2). The BMI of groups A, B, and C were (23.35±0.89), (26.65±1.03), and (32.05±1.47) kg/m 2, respectively. There was no significant difference ( P>0.05) in gender, age, surgical side, disease duration, and preoperative Hospital for Special Surgery (HSS) score, visual analogue scale (VAS) score, knee range of motion, and hip-knee-ankle angle (HKA) between groups. The operation time, intraoperative dominant blood loss, and the decrease of hemoglobin on the 3rd day after operation were recorded and compared between groups. The improvement of knee joint function and pain status were evaluated by knee joint HSS score, knee range of motion, and VAS score before and after operation, and measuring the HKA of patients on X-ray film. During the follow-up, the X-ray films of the knee joint were reexamined to observe the position of the internal fixator and the healing of osteotomy.@*RESULTS@#All patients completed the operation successfully and were followed up 8-40 months (mean, 19.3 months). There was no significant difference in follow-up time, operation time, intraoperative dominant blood loss, and the decrease of hemoglobin on the 3rd day after operation between groups ( P>0.05). No operative complications such as severe vascular or nerve injury occurred. After operation, deep venous thrombosis of lower extremities occurred in 1 case in groups A and B respectively, and fat liquefaction of surgical incision occurred in 2 cases in group C. There was no significant difference in the incidence of perioperative complications between groups (3.1% vs. 3.7% vs. 8.0%) ( P=0.689). During the follow-up, there was no bone nonunion, plate fracture or loosening. At last follow-up, HSS score, VAS score, knee range of motion, and HKA significantly improved in the 3 groups when compared with those before operation ( P<0.05), but there was no significant difference in the differences of the above indexes between groups before and after operation ( P>0.05).@*CONCLUSION@#BMI does not affect the short-term effectiveness of HTO in the treatment of varus knee arthritis. HTO can be selected for overweight and obese patients after standard medical treatment is ineffective.

Effect of varying dietary crude protein and metabolizable energy levels on leg abnormalities and performance in broiler chickens

Background: Nutrient restriction is a common strategy to prevent metabolic disorders in fast growing broiler chickens, but limited information is available regarding the impact of diets with low protein and energy on leg abnormalities Objective: Two experiments were conducted to evaluate the effect of varying crude protein (CP) and metabolizable energy (ME) levels on gastrocnemius tendon (GTeBS) and tibia breaking strength (TiBS), gait score (GS) and valgus/varus angulation (VAng). Methods: In Experiment 1, eight-d-old Ross 308 broilers (n=90) were randomly assigned into three treatments: 13/2,900 (13% CP and 2,900 kcal ME kg-1 of diet), 17/3,000 (17% CP and 3,000 kcal ME kg-1 of diet), and 21/3,025 or control (21% CP and 3,025 kcal ME kg-1 of diet). In Experiment 2, six-d-old Ross 308 chickens (n=192) were randomly distributed into two treatments: 16/3,000; 16% CP and 3,000 kcal ME kg-1 of diet and 21/3,000 or control; 21% CP and 3,000 kcal ME kg-1 of diet. In both experiments data were analyzed as one-way ANOVA. Results: In Experiment 1, broilers in the 17/3,000 and control treatments had similar (p>0.05) GTeBS (202 and 224 N, respectively), and TiBS (338 and 332 N, respectively). Birds in the 13/2,900 treatment showed higher GS (lower walking ability; 80% of birds with score >3), and greater VAng (53% of birds with score >2) than broilers in the control treatment (0% of birds with GS score >3 and 0% of birds with VAng score >2). Experiment 2, broilers in the 16/3,000 showed similar VAng, GS and TiBS than birds in the control treatment. However, birds in the 16/3,000 treatment showed lower (-26%) GTeBS than birds in the control treatment (p<0.05). Conclusions: Feeding broilers with 16% CP and 3,000 kcal ME kg-1 of diet did not affect tibia breaking strength, gait score and valgus/varus angulation. A diet containing 16% CP or less and 2,900-3,000 kcal ME kg-1 reduces tendon and tibia breaking strength.

Antecedentes: La restricción de nutrientes es una estrategia común para prevenir trastornos metabólicos en pollos de engorde, sin embargo, se dispone de información limitada sobre el impacto de las dietas bajas en proteína y energía en las anomalías de piernas. Objetivo: Se llevaron a cabo dos experimentos para evaluar el efecto de niveles variables de proteína cruda (PC) y energía metabolizable (EM) en la fuerza de rotura del tendón del gastrocnemio (GTeBS) y tibia (TiBS), la evaluación de marcha (GS) y la angulación en valgus/varus (VAng). Métodos: En el Experimento 1, pollos de engorde Ross 308 de ocho días de edad (n = 90) se asignaron al azar en tres tratamientos: 13/2.900; 13% PC y 2.900 kcal ME kg-1 de dieta, 17/3.000; 17% PC y 3.000 kcal ME kg-1 de dieta y 21/3.025 o control; 21% PC y 3.025 kcal ME kg-1 de dieta. En el Experimento 2, pollos Ross 308 de seis días de edad (n = 192) se distribuyeron aleatoriamente en dos tratamientos: 16/3.000; 16% PC y 3.000 kcal ME kg-1 de dieta y 21/3.000 o control; 21% PC y 3.000 kcal ME kg-1 de dieta. En ambos experimentos los datos se analizaron como ANOVA de una vía. Resultados: En el Experimento 1, los pollos de los tratamientos 17/3.000 y control tuvieron GTeBS (202 y 224 N, respectivamente) y TiBS (338 y 332 N, respectivamente) similares (p>0,05). Las aves del tratamiento 13/2.900 mostraron mayor GS (menor capacidad para caminar; 80% de las aves con puntaje >3) y mayor VAng (53% de las aves con puntaje >2) que los pollos del tratamiento control (0% de aves con un puntaje GS >3 y 0% de aves con un puntaje VAng >2). En el Experimento 2, los pollos del 16/3.000 mostraron VAng, GS y TiBS similares a los de las aves del tratamiento control. Sin embargo, las aves del tratamiento 16/3.000 mostraron menor (-26%) GTeBS que las aves control (p<0,05). Conclusiones: La alimentación de pollos de engorde con 16% PC y 3.000 kcal EM kg-1 de dieta no afecta la resistencia a la ruptura de la tibia, la marcha y la angulación valgus/varus. La dieta formulada con 16% de PC o menos y 2.900-3.000 kcal de EM kg-1 reduce la resistencia a la ruptura del tendón y de la tibia.

Antecedentes: A restrição de nutrientes é uma estratégia comum para prevenir distúrbios metabólicos em frangos de corte, no entanto, há informações limitadas disponíveis sobre o impacto de dietas de baixa proteína e baixa energia nas anormalidades de pernas destas aves. Objetivo: Dois experimentos foram realizados para avaliar o efeito de diferentes níveis de proteína bruta (PB) e energia metabolizável (EM) em força de ruptura do tendão do músculo gastrocnêmio (GTeBS), forca de ruptura da tíbia (TiBS), gait score (GS) e angulação em valgus/varus (VAng). Métodos: Experimento 1, foram utilizados 308 frangos de corte machos da linhagem Ross com oito dias de idade (n = 90) distribuidos aleatoriamente em três tratamentos: dieta controle com 21% PB e 3.025 kcal EM kg-1 13/2.900; dieta con 13% PB e 2.900 kcal EM kg-1, y 17% PB e 3.000 kcal EM kg-1 . Experimento 2, foram utilizados 308 frangos de corte da linhagem Ross com seis dias de idade (n = 192) distribuídos aleatoriamente em dois tratamentos: dieta controle con 21% PB e 3.000 kcal EM kg-1 e dieta com 16% PB e 3.000 kcal EM kg-1 . Em ambos os experimentos, os dados foram submetidos a ANOVA. Resultados: Experimento 1, os frangos de corte submetidos ao dos tratamentos 17/3.000 e controle nao apresentaram diferencas significativas (p>0,05) para as variáveis GteBS (202 y 224 N, respectivamente) e TiBS (338 y 332 N, respectivamente). Os frangos submetidos ao 13/2.900 apresentaram maior frequência de GS (menor capacidade de locomocao; 80% das aves com pontuação>3) e maior VAng (53% das aves com pontuação>2) do que os frangos do tratamento controle (0% das aves com pontuação GS>3 e 0% das aves com pontuação VAng>2). Experimento 2, os frangos do 16/3.000 apresentaram VAng, GS e TiBS semelhantes aos das aves do tratamento controle. Entretanto, as aves do tratamento 16/3.000 apresentaram GTeBS mais baixo (-26%) em comparacao as aves do tratamento de controle (p<0,05). Conclusões: A dieta com 16% PB e 3.000 kcal EM kg-1 não afetou a forca de ruptura da tíbia, gaite score marcha e angulação em valgus/varus de frangos de corte. Uma dieta com níveis de 16% de PB ou menos e 2.900-3.000 kcal EM kg-1 reduziu a resistência à ruptura do tendão e a resistência de tibia de frangos de corte.

Progress in the treatment of varus-posteromedial rotation instability of the elbow / 中华创伤骨科杂志

As varus posteromedial rotatory instability (VPMRI) is not common, its injury mechanisms are complex and presents no obvious dislocation on X-ray, it may be considered as a simple coronoid fracture, likely leading to a missed diagnosis or misdiagnosis. Moreover, the treatment of VPMRI is also controversial. Conservative treatment or improper treatment can cause serious complications. Therefore, this review expounds on the injury mechanisms, anatomical structure, O'Driscoll classification, imaging examination, treatment and postoperative rehabilitation of this complicated elbow injury which is rare and difficult to treat clinically.

Neutral wedge osteotomy assisted by determination of the center of rotation of angulation at the distal humerus anatomical axis for cubitus varus deformity in children / 中华创伤骨科杂志

Objective:To evaluate the clinical outcomes of neutral wedge osteotomy assisted by determination of the center of rotation of angulation (CORA) at the distal humerus anatomical axis for cubitus varus deformity in children.Methods:From 2016 to December 2019, 20 children with cubitus varus after supracondylar fracture of the humerus were treated at Department of Orthopeadics, Children's Hospital of Wujiang District. They were 8 boys and 12 girls, aged from 4 to 12 years (average, 7.0 years). Standard anteroposterior X-ray films of bilateral humerus were taken preoperatively for measurement of Baumann angle, proximal anatomical axis (PAA) and distal anatomical axis (DAA) of bilateral humerus to determine the CORA and the varus deformity angle. A lateral closed neutral wedge osteotomy was performed around the CORA to correct the varus deformity. All children were immobilized with elbow plaster cast after operation. Elbow flexion and extension function, postoperative scar, and body surface carrying angle were recorded. The carrying angle and Baumann angle were also measured on elbow X-ray films. Elbow function was evaluated according to the modified Flynn elbow score at 24 months after operation.Results:All patients were followed up for 24 to 36 months (mean, 29.3 months). Elbow hyperextension was close to normal in 18 cases, and 5° hyperextension existed in 2 cases. The flexion was greater than 130°, averaging 133.1° (from 130° to 138°), in 15 patients. The flexion ranged from 110° to 130° in 5 patients. The Baumann angle was 99.0°±1.0° preoperatively and 76.0°±1.0° postoperatively; the carrying angle was -14.0°±1.0° preoperatively and 13.6°±1.0° postoperatively. There were significant differences between the above items between preoperation and postoperation ( P<0.05). According to the modified Flynn elbow score at 24 months after operation, the elbow function was excellent in 16 and good in 4 cases. The varus of 40° was corrected during surgery in one child. Fixation failure or correction failure occurred in none of the children before removal of the plaster or the Kirschner wire. Conclusions:In neutral wedge osteotomy assisted by determination of the CORA at the distal humerus anatomical axis, the CORA and angulation of the distal humerus inversion can be accurately determined so that the osteotomy line and the angulation correction axis can pass through the CORA to restore the humerus alignment with no displacement of the broken ends.

Application of esophageal varus extraction in the treatment of laryngopharyngeal and cervical esophageal tumors / 中华胸心血管外科杂志

Objective:To investigate the application and effect of esophageal varus extraction in the treatment of cervical tumors(laryngopharynx and cervical esophagus).Methods:A retrospective analysis was performed on 238 patients with cervical tumors(laryngopharynx and cervical esophagus) who underwent thoracic surgery in Beijing Tongren Hospital affiliated to Capital Medical University from March 2010 to March 2020. There were 135 males and 103 females, aged from 42 to 78 years, with a median age of 62 years.Surgical methods included open abdominal surgery in 96 cases and laparoscopic surgery in 142 cases. The intraoperative abdominal bleeding volume, abdominal operation time and postoperative abdominal drainage volume were analyzed. χ2 test was used to compare the clinical characteristics of the two groups, t test was used to compare the clinical indicators, and statistical software SPSS 13.0 was used to analyze. Results:No intraoperative death occurred in all patients.In the laparoscopic group, all cases successfully completed tubular gastric traction through the original esophageal bed to the neck, and completed cervical anastomosis.One patient(0.70%) was converted to thoracotomy due to aortic tear, and no post-operative bleeding occurred.No incision infection and wound liquefaction. Splenectomy was performed in 1 patient(1.04%), incision infection in 2 patients(2.08%), and fat liquefaction in 3 patients(3.12%) in the open surgery group.The intraoperative abdominal bleeding volume in the open surgery group and the laparoscopic group was(187±28)ml and(79±23)ml, respectively( t=1.836, P=0.032); the postoperative abdominal drainage volume in the two groups was(172±33)ml and(56±24)ml, respectively( t=1.964, P=0.028), and there was a significant difference between the two groups.The operation time of open operation group and laparoscopy group was(125±33) min and(118±27) min respectively( t=1.224, P=0.203), and there was no significant difference between the two groups. Conclusion:Laparoscopic esophageal varus extraction has advantages over traditional laparotomy in the treatment of laryngopharyngeal tumors and cervical esophageal tumors, such as beautiful incision, small surgical trauma, clear surgical field exposure and less postoperative complications, which conforms to the current minimally invasive treatment concept.The application of pneumoperitoneum-free suspension device solves the key links of mediastinal compression hemostasis after esophageal extubation and traction of tubular stomach to neck under pneumoperitoneum-free condition, so that laparoscopic surgery can be applied.However, such operations need to strictly grasp the indications to avoid the occurrence of serious complications.

Hallux varo. Caso clínico / Halluxvarus. Clinical case / Halluxvarus. Caso clínico

RESUMEN Introducción: hallux varo congénito es una deformidad rara, que puede estar asociada a otras deformidades. Caso clínico: paciente masculino, de 18 años de edad. Acude a consulta por presentar deformidad del pie e imposibilidad para caminar y usar calzado. Al examen físico se observa angulación medial del primer dedo del pie a nivel de la articulación metatarsofalángica y deformidad en varo de 90 grados. Se indicó rayos X del pie derecho anteposterior. Discusión: la radiografía mostró angulación en varo de la articulación metatarsofalángica derecha. El tratamiento de la deformidad es por corrección quirúrgica, y varias técnicas han sido descritas. Conclusión: se plantea Halluxvarus congénito primario del pie derecho como diagnóstico. El tratamiento de la deformidad fue quirurgico con técnina de Framer, la cual resultó ser efectiva.

ABSTRACT Introduction: congenital Hallux varus is a rare deformity that may be associated with other deformities. Clinical case: male patient, 18 years old. He goes to the consultation for presenting a foot deformity and inability to walk and wear shoes. Physical examination revealed medial angulation of the first toe at the level of the metatarsophalangeal joint and a 90-degree varus deformity. An X-ray of the anteposterior right foot was indicated. Discussion: X-ray showed varus angulation of the right metatarsophalangeal joint. Treatment of the deformity is by surgical correction, and several techniques have been described. Conclusion: primary congenital Hallux varus of the right foot is considered as a diagnosis. The deformity treatment was surgical with Framer's technique, which turned out to be effective.

RESUMO Introdução: hálux varo congênito é uma deformidade rara que pode estar associada a outras deformidades. Caso clínico: paciente masculino, 18 anos. Ele vai à consulta por apresentar deformidade no pé e incapacidade de andar e usar sapatos. O exame físico revelou angulação medial do primeiro dedo do pé ao nível da articulação metatarsofalangiana e uma deformidade em varo de 90 graus. Foi indicada radiografia do pé direito anterior. Discussão: a radiografia mostrou angulação em varo da articulação metatarsofalangiana direita. O tratamento da deformidade é por correção cirúrgica, e várias técnicas foram descritas. Conclusão: o Hálux varo congênito primário do pé direito é considerado diagnóstico. O tratamento da deformidade foi cirúrgico com a técnica de Framer, que se mostrou eficaz.

Resultados radiológicos y funcionales en fracturas de platillo tibial de alta energía / Radiological and functional results in high-energy tibial plate fractures

Resumen: Introducción: Las fracturas de platillo tibial por mecanismos de alta energía son lesiones graves que ocurren sobre una articulación de carga. Son difíciles de abordar, ya que además de afectar la estructura ósea de la pierna suelen tener lesiones de partes blandas asociadas. Objetivo: Evaluar los resultados radiológicos y funcionales de las fracturas de platillo tibial de alta energía con un mínimo seguimiento de un año. Material y métodos: Estudio retrospectivo, observacional y multicéntrico. Análisis de los resultados radiológicos y funcionales en el tratamiento de fracturas de platillo tibial de alta energía tratadas mediante reducción abierta y fijación interna (RAFI) entre 2014 y 2019. Resultados: 54 fracturas tratadas mediante RAFI. Seguimiento un año, 98.1% de consolidación en 13 semanas de promedio, 83.4% sin alteraciones del eje en plano coronal, 74% sin ensanchamiento articular postoperatorio. Escalas funcionales: Lysholm 82.1 puntos promedio y Oxford Knee Score (OKS) 39.5 puntos promedio. Conclusión: El rango de movilidad articular se redujo luego de una fractura de platillos tibiales de alta energía, pero con buenos resultados funcionales. Cuanto menor deseje y menor ensanchamiento radiográfico postoperatorio, se obtienen mejores resultados.

Abstract: Introduction: The tibial plateau fractures due to high-energy mechanisms are serious injuries that occur on a load bearing joint. These are difficult to approach because, also affect the bone structure of the leg, they usually have associated soft tissue injuries. Objective: To evaluate the radiological and functional results of high-energy tibial plateau fractures with a minimum follow-up of one year. Material and methods: Retrospective, observational and multicenter study. Analysis of radiological and functional outcomes in the treatment of high-energy tibial plateau fractures, treated by open reduction and internal fixation (ORIF) between 2014 and 2019. Results: 54 fractures treated by ORIF. Follow-up one year. 98.1% consolidation in 13 weeks on average. 83.4% without alterations of the axis in the coronal plane. 74% without postoperative joint widening. Functional scores: Lysholm 82.1 average points and Oxford Knee Score (OKS) 39.5 average points. Conclusion: The joint range of motion was reduced after a high-energy tibial plateau fracture, but with good functional results. The less off axis and less post-operative radiographic widening, the better results are obtained.

Surgical importance of radiographically aided morphometry of the proximal ulna / Importancia quirúrgica de la morfometría de la ulna proximal con examen radiográfico

This study was conducted to define the proximal ulnar morphometry with respect to dorsal and intramedullary implant design. Eighty two dry Anatolian ulnae were evaluated by both the traditional and digital morphometric analysis methods. Also the medullary cavities and cortical bone thicknesses were measured from radiographic images. The mean value of ulnar length (UL) was 25.06 cm; distance between the most prominent anterior point of the superior surface of the olecranon (MAPO) and the most posterior point of the olecranon (MPPO), distance between the MPPO and maximum anterior angulation (MAA), distance between the MPPO and the maximum varus angulation (MVA) were; 1.67 cm, 5.36 cm and 7.56 cm, respectively. The average antero-posterior diameters at midolecranon plane (MOP), MAA plane (MAAP) and MVA plane (MVAP) were; 1.78 cm, 1.68 cm and 1.41 cm; transverse diameters of same planes were; 1.96 cm, 1.65 cm and 1.51 cm, respectively. The mean olecranon angle (OA), MAA and MVA were: 113.35°, 9.12° and 13.82°; also the mean circumferences at same planes were 6.48 cm, 6.37 cm and 5.16 cm, respectively. The mean antero-posterior medullary diameter at MAAP and mean transverse medullary diameter at MVAP were; 6.83 mm and 7.22 mm, respectively. Mean anterior and posterior cortical bone thicknesses at MAAP were: 3.61 mm and 4.25 mm; the mean medial and lateral cortical bone thicknesses at MVAP were: 4.06 mm and 4.13 mm, respectively. Dorsal angulation and medullary angulation of the proximal ulna presents different architecture. Unique morphological architecture of the proximal ulna should be taken into consideration in means of surgical operations and examination of radiographic images. It can be inferred that standardized bony landmarks may helpful during the process of designing and manufacturing precurved dorsal plates and as well as variable proximal ulnar implants.

Este estudio se realizó para definir la morfometría ulnar proximal con respecto al diseño de implante dorsal e intramedular. Ochenta y dos ulnas de Anatolia secas fueron evaluadas por los métodos de análisis morfométrico tradicional y digital. También se midieron las cavidades medulares y el grosor del hueso cortical a partir de imágenes radiográficas. El valor medio de la longitud ulnar (LU) fue de 25,06 cm; distancia entre el punto anterior más prominente de la superficie superior del olécranon (SSO) y el punto más posterior (PPO), la distancia entre el PPO y la angulación anterior máxima (AAM), la distancia entre el PPO y la angulación máxima en varo (AMV) fueron; 1,67 cm, 5,36 cm y 7,56 cm, respectivamente. Los diámetros anteroposteriores medios en el plano medio del olécranon (PMO), el plano AAM (AAP) y el plano AMV fueron; 1,78 cm, 1,68 cm y 1,41 cm; los diámetros transversales de los mismos planos eran; 1,96 cm, 1,65 cm y 1.51 cm, respectivamente. El ángulo medio del olécranon (AMO), AAM y MVA fueron: 113,35 °, 9,12 ° y 13,82 °; También las circunferencias medias en los mismos planos fueron 6,48 cm, 6,37 cm y 5,16 cm, respectivamente. El diámetro medular anteroposterior medio en AMV y el diámetro medular transversal medio en AMV fueron; 6,83 mm y 7,22 mm, respectivamente. Los grosores óseos corticales anteriores y posteriores medios en AMV fueron: 3,61 mm y 4,25 mm; Los espesores medios de los huesos corticales medial y lateral en AMV fueron: 4,06 mm y 4,13 mm, respectivamente. La angulación dorsal y la angulación medular de la ulna proximal presentan una arquitectura diferente. La arquitectura morfológica única de la ulna proximal debe tenerse en cuenta en las operaciones quirúrgicas con el examen de imágenes radiográficas. Se puede inferir que los puntos de referencia óseos estandarizados pueden ser útiles durante el proceso de diseño y fabricación de placas dorsales precurvadas y también de implantes ulnares proximales variables.

Complicaciones de fracturas supracondíleas humerales en niños / Complications of supracondylar humeral fractures in children

Resumen: Introducción: Las fracturas supracondíleas representan la causa más frecuente de las lesiones del codo pediátrico (64% de la población en niños menores de ocho años). Estas fracturas pueden presentar complicaciones como: A) complicaciones previas al tratamiento: 1) neurológicas, 2) vasculares y 3) síndrome compartimental. B) complicaciones posteriores al tratamiento: 1) precoces en los primeros días tras el tratamiento: pérdida de reducción, complicaciones neurológicas, vasculares, síndrome compartimental, infección de las agujas de Kirschner, 2) complicaciones tardías en el tratamiento: deformidad angular, pérdida de movilidad, miositis osificante, necrosis avascular de la tróclea, entre otros. Objetivo: Determinar la frecuencia de las complicaciones en fracturas supracondíleas humerales en menores de ocho años. Material y métodos: Se realizó un estudio retrospectivo y observacional de cohorte en pacientes menores de ocho años en el período de Marzo de 2014 a Febrero de 2018. Resultados: Se obtuvieron 277 pacientes con los siguientes porcentajes: 3.97% presentó lesiones de cúbito varo; 1.44%, lesiones neurológicas previas al tratamiento quirúrgico; 1.44%, complicaciones neurológicas precoces al tratamiento; 0.72%, infecciones de agujas de Kirschner; 0.72%, cúbito valgo y 0.36% con pérdida de la movilidad. Conclusiones: La complicación más frecuente de las fracturas supracondíleas de húmero en este estudio fue cúbito varo y complicaciones neurológicas previas al tratamiento.

Abstract: Introduction: Supracondylar fractures represent the most frequent cause of pediatric elbow injuries, at 64%, in children under eight years old. These fractures can present complications such as: A) Complications prior to treatment: 1) neurological, 2) vascular and 3) compartment syndrome. B) Complications after treatment: 1) early, in the first days after treatment: loss of reduction, neurological, vascular, compartment syndrome, infection of Kirschner wires. 2) Late complications in treatment: Angular deformity, loss of mobility, ossifying myositis, avascular necrosis of the trochlea, others. Objective: To determine the frequency of complications in humeral supracondylar fractures in less than eight years. Material and methods: A retrospective, observational cohort study was conducted in patients under 8 years of age during the period of March 2014 to February 2018. Results: 277 patients were obtained with the following percentages: cubitus varus 3.97%, neurological lesions prior to surgical treatment 1.44%, early neurological complications to treatment 1.44%, infections of Kirschner needles 0.72%, cubitus valgus 0.72%, loss of mobility 0.36%. Conclusions: The most common complication of humerus supracondylar fractures in this study was cubitus varus and neurological complications prior to treatment.

Combination of measured resection and gap balancing technique used in femoral component rotation in total knee arthroplasty / 中国组织工程研究

BACKGROUND: Total knee arthroplasty is effective in managing end-stage knee disease. Measured resection and gap balancing are two different techniques. Both of two have advantages and disadvantages. A technique has been developed that combines the benefits of measured resection and gap balancing to optimize the clinical effect of total knee arthroplasty. OBJECTIVE: To evaluate the operation and early clinical effect in total knee arthroplasty about the combination of measured resection and gap balancing technique used in femoral component rotation. METHODS: Totally 30 patients were treated with the combination of measured resection and gap balancing technique in total knee arthroplasty from September 2016 to December 2018, including 4 males and 26 females, at the age of 46-81 years. There were 24 cases of osteoarthritis with varus and 2 cases of osteoarthritis with valgus. There were 4 cases of rheumatoid arthritis with valgus. All patients signed the informed consent. This study was approved by the Hospital Ethics Committee. Effects were evaluated by Visual Analogue Scale, Hospital for Special Surgery score, femorotibial angle and range of motion before surgery and during final follow-up. RESULTS AND CONCLUSION: (1) The incision healed in the first stage after operation. No early complications occurred, such as infection, vascular nerve injury, deep venous thrombosis of the lower extremities and periprosthetic fracture. (2) Totally 30 patients were followed up for 6-30 months. (3) Visual Analogue Scale, Hospital for Special Surgery score, range of motion and femorotibial angle were improved during final follow-up compared with those before surgery (P < 0.05). (4) Surgeons should be familiar with measured resection and gap balancing technique in total knee arthroplasty, and then use the combination of two techniques based on the specific situation of patients to obtain better soft tissue balance and prosthesis position. The combination technique is easy to master and can be operated with traditional osteotomy tools. Thus, good short-term effect can be achieved.

Change of related functions and double lower limb length after total knee arthroplasty / 中国组织工程研究

BACKGROUND: There are many reasons for poor function after knee arthroplasty. Leg length discrepancy is one of them. The extent of influence on the function of knee joint after arthroplasty has not been fully studied. OBJECTIVE: To analyze the change degree, possible influencing factors and functional changes of leg length discrepancy in patients after total knee arthroplasty. METHODS: Totally 107 patients (124 knees), including 23 males and 84 females, were included from October 2016 to September 2018, who entered the Department of Orthopedics of Affiliated Hospital of Xuzhou Medical University for total knee arthroplasty. There were 90 cases of unilateral total knee arthroplasty (90 knees) and 17 cases of bilateral total knee arthroplasty (34 knees). Three cases (6 knees) of bilateral total knee arthroplasty received separate treatment with an interval of more than 6 months, and entered the unilateral knee group. Therefore, there were 93 cases (96 knees) in the unilateral knee group, and 14 cases (28 knees) in the bilateral knee group. Patients signed the informed consent. This study was approved by the Hospital Ethics Committee. At preoperative and postoperative 10 days and 6 months, full length anteroposterior radiographs were taken, and the length of the lower limb and hip-knee-ankle angle were measured and recorded. Angle of knee flexion contracture was measured and the hospital for special surgery knee score was recorded. RESULTS AND CONCLUSION: (1) The length of patients' lower limbs was increased by the correction of deformities after total knee arthroplasty. The length of lower limbs 10 days after surgery was longer than that at 6 months after surgery. The lower limbs of 70.2% of the patients were increased 10 days after total knee arthroplasty, and 79.0% of the patients were increased 6 months after total knee arthroplasty. At 10 days and 6 months postoperatively, the postoperative corrected flexion contracture angles were positively correlated with the change of postoperative lower limb length. (3) Limb lengthening on the operative side was positively correlated with increased hospital for special surgery knee score after surgery. (4) The incidence of leg length discrepancy before and after surgery was almost equal: 45.1 % preoperatively, 55.3% 10 days postoperatively, and 46.0% 6 months postoperatively. (5) The leg length discrepancy preoperatively and 6 months postoperatively was influenced by the difference of deformities between the pair of limbs. Preoperative influencing factors were the difference of hip-knee-ankle angle and flexion contracture of both lower limbs. The difference value of flexion contracture of both lower limbs was the factor affecting the leg length discrepancy 6 months after surgery. Leg length discrepancy before surgery and 6 months after surgery was affecting the difference of hospital for special surgery knee score between lower limbs.

Advantages of individualized open wedge high tibial osteotomy in treatment of medial compartment knee osteoarthritis / 中国组织工程研究

BACKGROUND: Open wedge high tibial osteotomy can achieve significant clinical efficacy for patients with medial compartment knee osteoarthritis and genu varus. However, Fujisawa point has been recognized as a reference for the correction of lower limb alignment. Can individualized orthopedics in lower limb alignment obtain better clinical efficacy? OBJECTIVE: To explore short-term efficacy of individualized orthopedics in lower limb alignment for medial compartment knee osteoarthritis through open wedge high tibial osteotomy. METHODS: Totally 46 patients with medial compartment knee osteoarthritis treated by open wedge high tibial osteotomy from June 2016 to May 2018 in Department of Orthopedics, Wuxi People's Hospital were enrolled in this study. X-ray and MRI were used to evaluate the knee and I-III degeneration grades were classified. Patients at Grade I and II were randomly divided into individualized orthopedics group and control group with 16 cases in each group. Patients at grade III were classified as Fujisawa group with 14 cases. In the individualized orthopedics group, mild grade I and moderate grade II respectively corrected lower limb alignment to 50% and 55% of lateral tibial plateau, while control group and Fujisawa group all corrected the alignment to 62.5% point. Postoperative lower limb alignment, pre- and post-operative range of motion, femoral-tibial angle and medial proximal tibial angle of the knee were measured and evaluated. The hospital for special surgery score and the Western Ontario and McMaster Universities osteoarthritis index score were followed up before operation, 3, 6 and 12 months after operation, while postoperative self-satisfaction of patients was also compared. RESULTS AND CONCLUSION: (1) All patients were followed up for 12 months. (2) Three groups achieved satisfactory lower limb alignment. Range of motion and medial proximal tibial angle increased and femoral-tibial angle decreased at postoperative stage (P 0.05). (4) All patients were satisfied with the surgical efficacy. Postoperative self-satisfaction scores of individualized orthopedics group were superior to that of control group (P < 0.05). (5) According to the results, individualized open wedge high tibial osteotomy is benefit to obtain early functional rehabilitation of the knee through accurate correction of lower limb alignment. It can also improve patient satisfaction.

Análise do exercício agachamento com e sem o uso de physioball e banda elástica em diferentes intensidades / Analysis of the squat exercise with and without physioball and elastic band in different intensities

RESUMO O objetivo do presente estudo foi analisar a atividade mioelétrica (EMG), o tempo sob tensão (TST) e a projeção dos joelhos no exercício agachamento sem o uso de implementos (SI) e com o uso de physioball (PH) e banda elástica (BE) em diferentes intensidades de esforço. Dez homens realizaram o exercício nos três protocolos com a intensidade de 50 e 100% de 10 RM. A distância entre joelhos no protocolo controle (51,25cm) foi menor quando comparada com o SI 50% (84,38cm; p < 0,001), com o SI 100% (88,80cm; p < 0,001) e com BE 100% (67,41cm; p = 0,014). A distância entre os joelhos também foi menor para os protocolos PH 100% (53,10cm; p < 0,001) e BE 100% (67,41cm; p < 0,001) comparada ao SI 100% (88,80cm). O Vasto Medial Oblíquo (VMO) apresentou maior ativação nos protocolos SI 50% (p = 0,035) e PH 50% (p = 0,028) quando comparados ao protocolo BE 50%. A realização do agachamento com cargas submáximas parece aumentar e diminuir a ativação do VMO quando realizado com PH e BE, respectivamente.

ABSTRACT The objective of the present study was to analyze the myoelectric activity (EMG), the time under tension (TST) and the knee projection in the squat exercise without the use of implements (SI) and with the use of physioball (PH) and elastic band (EB) at different intensities of effort. Ten men performed the exercise in the three protocols with the intensity of 50 and 100% of 10 RM. The distance between knees in the control protocol (51.25 cm) was lower when compared to SI 50% (84.38 cm, p <0.001), with SI 100% (88.80 cm, p <0.001) and with EB 100% (67.41cm, p = 0.014). The distance between the knees was also lower for the protocols PH 100% (53.10cm, p <0.001) and EB 100% (67.41, p <0.001) compared to the SI 100% (88.80 cm) protocols. The Vasto Medial Oblique (VMO) presented greater activation in the SI 50% protocols (p = 0.035) and PH 50% (p = 0.028) when compared to the EB 50% protocol. The accomplishment of squatting with submaximal loads seems to increase and decrease the activation of VMO when performed with physioball and BE, respectively.