Tratamiento de la inestabilidad acromioclavicular crónica / Treatment of chronic acromioclavicular joint instability

Valorar los resultados de la técnica quirúrgica asistida por artroscopía indicada para el tratamiento de la inestabilidad acromioclavicular crónica (IAC), basada en la fijación coracoclavicular (CC) no-rígida más reconstrucción CC anatómica con aloinjerto tendinoso. Se incluyó a los pacientes con IAC intervenidos entre 2008 y 2012. Las valoraciones clínicas se realizaron mediante el SF36, la EVA y el DASH, aplicados en la visita previa (VPI) a la intervención y en la última visita de seguimiento (UVS). El Constant score y la Escala de Satisfacción General (0-10) se aplicaron en la última visita de seguimiento. Se valoró el desarrollo de subluxaciones secundarias. Se incluyeron 10 pacientes. Edad media 41 años [rango 33-55]. Seguimiento medio 25.50 meses [rango 24-30].En todos los pacientes el tratamiento quirúrgico se indicó cuando el tratamiento conservador fracasó. Cuestionarios aplicados en la VPI y en la UVS: 1. SF36 físico: VPI 29.60 ± 3.41 y UVS 59.58 ± 1.98 (p = 0.000); 2. SF36 mental: VPI 46.57 ± 3.80 y UVS 56.62 ± 1.89 (p = 0.000); 3. EVA: VPI 5.17 ± 2.40 y UVS 1.67 ± 2.07 (p = 0.022); y 4. DASH: VPI 63.33 ± 23.56 y UVS 2.61 ± 1.79 (p = 0.000). El Constant score y la satisfacción general de la UVS fueron 95.56 ± 3.28 y 9.22 ± 0.67 respectivamente. No hubo subluxaciones secundarias. El tratamiento de la IAC mediante un dispositivo de suspensión CC y una reconstrucción anatómica de los ligamentos CC asistida por artroscopía, puede ofrecer una mejoría significativa de la calidad de vida de los pacientes y representa una estrategia que al contemplar una fijación CC mecánica primaria, puede minimizar las posibilidades de fracaso y desarrollo de subluxaciones secundarias.

The purpose of this paper is to assess the results obtained with the arthroscopy-assisted surgical technique for the treatment of chronic acromioclavicular joint instability (CACJI), based on non-rigid coracoclavicular (CC) fixation and anatomical CC reconstruction with a tendinous allograft. Patients with CACJI who underwent surgery between 2008 and 2012 were included in the study. Clinical assessments included SF36, VAS and DASH, applied at the preoperative visit (POV) and at the last follow-up visit (LFUV). The Constant score and the General Satisfaction Score (0-10) were applied at the last follow-up visit. Occurrence of secondary subluxations was assessed. Ten patients were included; mean age was 41 years (range 33-55). Mean follow-up was 25.50 months (range 24-30). Surgical treatment was indicated in all patients after failure of conservative treatment. Questionnaires applied at the POV and the LFUV showed the following results: 1. SF36: physical, POV = 29.60 ± 3.41 and LFUV = 59.58 ± 1.98 (p = 0.000); 2. SF36 mental, POV = 46.57 ± 3.80 and LFUV = 56.62 ± 1.89 (p = 0.000); 3. VAS: POV = 5.17 ± 2.40 and LFUV: 1.67 ± 2.07 (p = 0.022); and 4. DASH: POV = 63.33 ± 23.56 and LFUV = 2.61 ± 1.79 (p = 0.000). The Constant score and the general satisfaction at the LFUV were 95.56 ± 3.28 and 9.22 ± 0.67, respectively. There were no secondary subluxations. Treatment of CACJI with a CC suspension device and arthroscopically-assisted anatomical reconstruction of CC ligaments may provide a significant quality of life improvement to patients. It is a strategy that, upon considering primary mechanical CC fixation, may minimize the chance of failure and occurrence of secondary subluxations.

Deltoid Ligament and Tibiofibular Syndesmosis Injury in Chronic Lateral Ankle Instability: Magnetic Resonance Imaging Evaluation at 3T and Comparison with Arthroscopy

OBJECTIVE: To evaluate the prevalence of deltoid ligament and distal tibiofibular syndesmosis injury on 3T magnetic resonance imaging (MRI) in patients with chronic lateral ankle instability (CLAI). MATERIALS AND METHODS: Fifty patients (mean age, 35 years) who had undergone preoperative 3T MRI and surgical treatment for CLAI were enrolled. The prevalence of deltoid ligament and syndesmosis injury were assessed. The complexity of lateral collateral ligament complex (LCLC) injury was correlated with prevalence of deltoid or syndesmosis injuries. The diagnostic accuracy of ankle ligament imaging at 3T MRI was analyzed using arthroscopy as a reference standard. RESULTS: On MRI, deltoid ligament injury was identified in 18 (36%) patients as follows: superficial ligament alone, 9 (50%); deep ligament alone 2 (11%); and both ligaments 7 (39%). Syndesmosis abnormality was found in 21 (42%) patients as follows: anterior inferior tibiofibular ligament (AITFL) alone, 19 (90%); and AITFL and interosseous ligament, 2 (10%). There was no correlation between LCLC injury complexity and the prevalence of an accompanying deltoid or syndesmosis injury on both MRI and arthroscopic findings. MRI sensitivity and specificity for detection of deltoid ligament injury were 84% and 93.5%, and those for detection of syndesmosis injury were 91% and 100%, respectively. CONCLUSION: Deltoid ligament or syndesmosis injuries were common in patients undergoing surgery for CLAI, regardless of the LCLC injury complexity. 3T MRI is helpful for the detection of all types of ankle ligament injury. Therefore, careful interpretation of pre-operative MRI is essential.

Evolução etária do ângulo de carregamento do cotovelo: estudo clínico-radiográfico / Evolution of the carrying angle of the elbow: a clinical and radiographic study

OBJETIVO: Avaliar clínica e radiograficamente o ângulo de carregamento do cotovelo (ACC) determinando uma curva de normalidade de acordo com faixas etárias (da infância à maturidade esquelética) e comparar as medidas clínicas e radiográficas. MÉTODOS: Avaliamos 510 indivíduos (1020 cotovelos), com idades entre 1 e 18 anos, distribuídos em grupos de 30 conforme faixas etárias, com intervalo de 1 ano. Excluímos os portadores de: fraturas do cotovelo, sequelas, malformações, doenças genéticas, afecções inflamatórias e frouxidão ligamentar. Mensuramos clinicamente o ACC bilateralmente com goniômetro, onde obtivemos duas medidas por dois examinadores onde média destas foi considerada. Realizamos radiografias ântero-posteriores dos cotovelos e aferimos os ângulos formados pelos eixos do úmero e da ulna. Todos os dados foram analisados estatisticamente pelo teste t student. RESULTADOS: Determinamos uma curva de normalidade onde observamos aumento deste parâmetro conforme a progressão da idade. Não observamos diferença significante entre as medidas clínicas e radiográficas. CONCLUSÃO: A média do ângulo de carregamento para o sexo feminino foi 12,78º ± 5,35 e para o masculino 11,20º ± 4,45. Este valor aumenta progressivamente da infância até os 16 anos quando observamos estabilização. Não houve diferença estatística significante das medidas clínicas e radiográficas.

OBJECTIVE: This paper has the purpose of evaluate the elbow carrying angle by clinic and radiographic examination in normal children and determine the range of normality according to age from childhood to skeletal maturity and also check if there is a statistically significant difference between the clinical and radiographic measurements. METHODS: We evaluated 510 persons with ages varying from 1 to 18 years distributed in groups with 30 subjects according to the age group with 1-year interval. We performed radiographic examination of the elbow and measured the angle formed by the long axis of the humerus and ulna. The data were statistically analyzed using the student t-test. RESULTS: We determined a normal curve of the study population where there was an increase of this parameter with the progression of age. No statistically significant difference between the clinical and radiographic measures. CONCLUSION: The average of the elbow carrying angle was 12,78 ± 5,35 degrees for females and 11,20 ± 4,45 degrees for males. This values increase progressively from childhood until 16 years when we notice stabilization. There was no statistical difference between the clinical and radiographic measurements.

Olmsted syndrome.

Olmsted syndrome is a rare disorder characterized by symmetrical sharply marginated mutilating keratoderma of palms & soles & hyperkeratotic plaques around the body orifices, onychodystrophy, ainhum & amputation of digital phalanges, flextion deformities of the fingers, localized alopecia, leukokeratosis of the tongue, shortness of stature & laxity of large joints. Inheritance is autosomal dominant, although sporadic cases have been reported. Here we describe two cases of this rare disorder with thickened hyperkeratotic lesion over palm & soles & along with amputation of 3rd , 4th & 5th toes in one case. In one of our case (case no. 2) the immediate younger brother has got the same disease. Both of them were treated with tab. Neotegason 25 mg orally daily for 3 months & there was significant improvement after treatment.

Anterior Cruciate Ligament Tear: Reliability of MR Imaging to Predict Stability after Conservative Treatment

OBJECTIVE: The aim of this study is to evaluate the reliability of MR imaging to predict the stability of the torn anterior cruciate ligament (ACL) after complete recovery of the ligament's continuity. MATERIALS AND METHODS: Twenty patients with 20 knee injuries (13 males and 7 females; age range, 20-54) were enrolled in the study. The inclusion criteria were a positive history of acute trauma, diagnosis of the ACL tear by both the physical examination and the MR imaging at the initial presentation, conservative treatment, complete recovery of the continuity of the ligament on the follow up (FU) MR images and availability of the KT-2000 measurements. Two radiologists, who worked in consensus, graded the MR findings with using a 3-point system for the signal intensity, sharpness, straightness and the thickness of the healed ligament. The insufficiency of ACL was categorized into three groups according to the KT-2000 measurements. The statistic correlations between the grades of the MR findings and the degrees of ACL insufficiency were analyzed using the Cochran-Mantel-Haenszel test (p < 0.05). RESULTS: The p-values for each category of the MR findings according to the different groups of the KT-2000 measurements were 0.9180 for the MR signal intensity, 1.0000 for sharpness, 0.5038 for straightness and 0.2950 for thickness of the ACL. The MR findings were not significantly different between the different KT-2000 groups. CONCLUSION: MR imaging itself is not a reliable examination to predict stability of the ACL rupture outcome, even when the MR images show an intact appearance of the ACL.

Techniques in the treatment of craniovertebral instability.

The techniques of craniovertebral region stabilization introduced and used by the senior author over the last 20 years are summarized. The lateral masses of atlas and axis are strong and largely cancellous in nature and can be used for direct implantation of screws. Opening up of the joint and placement of bone graft within the joint stabilizes the region and provides a large area for bone fusion. Distraction of the facets provides an opportunity to treat a range of congenital craniovertebral anomalies. The technique of exposure of the lateral mass of the atlas and axis and the atlantoaxial joint is technically relatively complex and needs precise understanding of anatomy of the vertebral artery and training with cadavers.

Ullrich congenital muscular dystrophy and Bethlem myopathy: clinical and genetic heterogeneity

Ullrich congenital muscular dystrophy (UCMD), due to mutations in the collagen VI genes, is an autosomal recessive form of CMD, commonly associated with distal joints hyperlaxity and severe course. A mild or moderate involvement can be occasionally observed. OBJECTIVE: To evaluate the clinical picture of CMD patients with Ullrich phenotype who presented decreased or absent collagen VI immunoreactivity on muscular biopsy. RESULTS: Among 60 patients with CMD, two had no expression of collagen V and their clinical involvement was essentially different: the first (3 years of follow-up) has mild motor difficulty; the second (8 years of follow-up) never acquired walking and depends on ventilatory support. A molecular study, performed by Pan et al. at the Thomas Jefferson University, demonstrated in the first a known mutation of Bethlem myopathy in COL6A1 and in the second the first dominantly acting mutation in UCMD and the first in COL6A1, previously associated only to Bethlem myopathy, with benign course and dominant inheritance. CONCLUSION: Bethlem myopathy should be considered in the differential diagnosis of UCMD, even in patients without fingers contractures; overlap between Ullrich and Bethlem phenotypes can be supposed.

A distrofia muscular congênita (DMC) com hiperextensibilidade articular distal (fenótipo Ullrich) associa-se a mutações nos genes do colágeno VI e corresponde a um grave quadro congênito de herança autossômica recessiva e curso progressivo, ocasionalmente mostrando menor gravidade. OBJETIVO: Avaliar o quadro clínico dos pacientes com DMC tipo Ullrich que apresentam imunoexpressão baixa ou ausente do colágeno VI na biópsia muscular. RESULTADOS: Entre 60 pacientes com DMC, dois mostravam imunomarcação negativa do colágeno VI. Mostravam-se clinicamente essencialmente diferentes: o primeiro, com 8 anos de idade e três de seguimento mostra leve dificuldade motora; o segundo, com 14 anos de idade e 8 de seguimento, não deambula e apresenta insuficiência respiratória. O estudo molecular, realizado na Thomas Jefferson University por Pan et al., revelou no primeiro, no gene COL6A1, mutação típica da miopatia de Bethlem, que tem curso benigno e herança autossômica dominante; e no segundo a primeira mutação de efeito dominante e do gene COL6A1, previamente associado apenas à miopatia de Bethlem. CONCLUSÃO: A miopatia de Bethlem deve constar no diagnóstico diferencial da DMC tipo Ullrich, mesmo na ausência das típicas contraturas dos dedos; pode existir sobreposição dos fenótipos Ullrich e Bethlem.