Tratamiento de la inestabilidad femoropatelar objetiva. Resultados a cinco años de seguimiento / Treatment of objective patellar instability. Results after five years of follow-up

Resumen: Objetivo: Presentar los diferentes procedimientos quirúrgicos en el tratamiento de las inestabilidades femoropatelares objetivas, incluyendo la osteotomía de la tuberosidad tibial anterior y la trocleoplastía femoral. Material y métodos: Con un diseño prospectivo con seguimiento a cinco años que incluyó a 21 pacientes (21 rodillas) tratados por luxación rotuliana recidivante entre Marzo de 2010 y Agosto de 2014, tratándose de forma quirúrgica mediante dos técnicas diferentes según el tipo de inestabilidad estructural de base. Para determinarlo, se analizó el índice radiográfico de Caton-Deschamps (para la evaluación de la altura rotuliana) y parámetros tomográficos para valorar el configuración troclear y distancia desde la tuberosidad tibial anterior hasta la tróclea femoral (TT-TG) en la superposición de imágenes en el plano axial. Resultados: Hemos tenido resultados satisfactorios tanto con la transferencia de la tuberosidad tibial anterior como con la trocleoplastía. En ambos procedimientos se realizó una reconstrucción del ligamento patelofemoral medial (LPFM). Conclusiones: La recurrencia de inestabilidad es muy rara después de estos procedimientos y es más probable que ésta resulte de anomalías asociadas no diagnosticadas o subestimadas. Se requiere una planificación precisa preoperatoria para determinar la altura rotuliana, la ubicación de la tuberosidad tibial anterior y la configuración troclear para obtener resultados satisfactorios.

Abstract: Objective: To present the different surgical procedures in the treatment of objective femoropateral instability, including osteotomy of anterior tibial tuberosity and femoral trocleoplasty. Material and methods: With a prospective 5-year follow-up design that included 21 patients (21 knees) treated for relapsing patellar dislocation between March 2010 and August 2014, treated surgically using 2 different techniques depending on the type of basic structural instability. To determine this, the Caton-Deschamps X-Ray Index (for the evaluation of the patellar height) and tomographic parameters were analyzed to assess the troclear configuration and distance from the anterior tibial tuberosity to the femoral trochlea (TT-TG) in the overlapping of images in the axial plane. Results: We have had satisfactory results both with the transfer of the anterior tibial tuberosity and with the trocleoplasty. In both procedures, a reconstruction of the medial patelo-femoral ligament (LPFM) was performed. Conclusion: Recurrence of instability is very rare after these procedures and is more likely to result from undiagnosed or underestimated associated abnormalities. Precise preoperative planning is required to determine the patellar height, location of the anterior tibial tuberosity, and troclear configuration for satisfactory results.

Variz Intra-Óssea ­ um achado raro diagnosticado pela ressonância magnética / Intraosseous Varicose Vein ­ A rare finding diagnosed by magnetic resonance imaging

Introdução: As varizes são veias que após submetidas a períodos de pressão aumentada no sistema venoso periférico se tornam dilatadas, tortuosas e alongadas. Pacientes acometidos irão referir dor no membro, além de sinais de insuficiência venosa. O exame de imagem comumente utilizado é o ultrassom com Doppler, no entanto, na presença de anomalias de drenagem venosa intraóssea, deve-se preferir a ressonância magnética. Objetivo: Relatar um caso e revisar a literatura acerca desta lesão incomum. Materiais e Métodos: Revisão do prontuário do paciente no Hospital América, registro fotográfico do método diagnóstico e revisão da literatura. Resultados: Homem de 46 anos com dor e queimação constantes, além de edema na perna e no pé esquerdos há dois meses Ao exame físico apresenta edema da perna, tornozelo e pé esquerdos, com discreto aumento de temperatura ao toque, sem alteração da coloração da pele. A ressonância magnética demonstra varicosidades das veias tibiais posteriores com comunicação através de veia perfurante com varicosidade da veia intraóssea posterior da tíbia ­ variz intraóssea. Conclusão: Este relato demonstra a dificuldade de diagnosticar a variz intra-óssea que, além de ser uma lesão rara, é diagnosticada apenas pela ressonância magnética.

Introduction: Varicose veins are veins that after being submitted to high pressure on the peripheral venous system become dilated, tortuous and elongated. Patients affected will report pain and venous insufficiency signs in the area. The imaging exam commonly used is the Doppler ultrasound, however, when in front of an intraosseous venous drainage anomaly ­ intraosseous varix, magnetic resonance should be preferred. Objective: Report a case and review the literature about this uncommon lesion. Materials and Methods: We carried out a review of medical records at Hospital América, a photographic record of diagnostic methods, and a review from the literature. Results: A 46-year-old man with constant pain and burning, as well as edema in his left leg and foot for two months. On physical examination, he had edema in his left leg, ankle, and foot, with a slight increase in temperature at the touch, without changing the skin color. Magnetic resonance imaging shows varicosities of the posterior tibial veins with communication through a perforating vein with varicosity of the posterior tibial intraosseous vein - intraosseous varicose vein. Conclusion: This report demonstrates the difficulty of diagnosing intraosseous varices, which, in addition to being a rare lesion, are diagnosed only by magnetic resonance imaging.

Precisión diagnóstica de la radiografía para la medición de túneles óseos en reconstrucción de ligamento cruzado anterior / X ray diagnostic accuracy for bone tunnel measurements in anterior cruciate ligament reconstruction

OBJETIVO: Determinar la precisión diagnóstica de las radiografías de rodilla para la medición de los diámetros de los túneles tibiales y femorales en reconstrucción de ligamento cruzado anterior (RLCA). MATERIALES Y PACIENTES: Estudio retrospectivo de precisión diagnóstica en pacientes con antecedentes de RLCA. Inclusión: RLCA realizada en el mismo centro, con el mismo equipo quirúrgico, entre 2011 y 2015; uso de cualquier tipo de injerto y de fijación; estudiados con radiografía (Rx) y tomografía computada (TC) durante postop en el mismo centro. Exclusión: desfase Rx-TC > 6 meses; cirugía entre estudios radiológicos. Análisis de túneles por 3 especialistas (OsiriX). La precisión diagnóstica consideró la TC como gold standard. Se midieron las diferencias inter e intra-observador, y las variables que interfirieron en las mediciones. RESULTADOS: 22 pacientes cumplieron los criterios de selección, determinando 528 mediciones en total (Rx y TC, fémur y tibia, 3 observadores, 2 tiempos). No hubo diferencias estadísticamente significativas en la medición de los túneles femorales (p » 0.8986), pero sí en cuanto a los diámetros tibiales (p » 0.0001). El análisis de precisión diagnóstica determinó una sobrevaloración de los diámetros óseos al usar la radiografía (10,5% en fémur, 10% en tibia). Hubo diferencias estadísticamente significativas inter-observador tanto en Rx como en TC (observador más joven con el resto); sin diferencias intra-observador. CONCLUSIÓN: La Rx como método diagnóstico del diámetro de túneles óseos luego de una RLCA sobreestima los valores reales, lo que empeora cuando el observador tiene menor experiencia.

OBJECTIVE: To determine the diagnostic accuracy of knee radiographs for the measurement of tibial and femoral tunnels diameters after an anterior cruciate ligament reconstruction (ACLR). MATERIALS AND PATIENTS: A retrospective study of the diagnostic accuracy in patients with a history of ACLR. Inclusion: surgery performed in the same center, same surgical team, between 2011 to 2015; any graft and fixation; studied with radiography (X-Ray) and computed tomography (CT) during postop in the same center. Exclusion: X-Ray-CT lag > 6 months; surgery between radiological studies. Tunnel analysis by 3 specialists (OsiriX). Diagnostic accuracy considered CT as a gold standard. The inter and intraobserver differences, and the variables that interfered in the measurements, were measured. RESULTS: 22 patients achieved the selection criteria, determining 528 measurements in total (X-Ray and CT, femur and tibia, 3 observers, 2 times). There were no statistically significant differences in the measurement of the femoral tunnels (p » 0.8986), but there were differences in the tibial diameters (p » 0.0001). Analysis of diagnostic accuracy determined an overestimation of the bone diameters when using the radiography (10.5% in the femur, 10% in the tibia). There were statistically significant inter-observer differences in both X-Ray and CT (younger observer with the rest); there were no intra-observer differences. CONCLUSION: X-Ray as a diagnostic method of the diameter of bone tunnels after an ACLR overestimates the real values, which worsens when the observer has less experience.

Distrofia ósea esclerosante mixta / Mixed-sclerosing-bone-dystrophy

El término "distrofia ósea esclerosante mixta" describe la combinación de las características radiológicas correspondientes a melorreostosis, osteopoiquilosis y osteopatía estriada, como entidades individuales, que ocurren en un mismo paciente. El objetivo de esta comunicación es presentar el caso clínico de una paciente con diagnóstico de distrofia ósea esclerosante mixta y, a partir de este caso, realizar una revisión sobre el tema. (AU)

The term "mixed-sclerosing-bone-dystrophy" describes the combination of the radiological characteristics corresponding to melorheostosis, osteopoikilosis and osteopathia striata, as individual conditions, ocurring in the same patient. The aim of this communication is to present the clinical case of a patient diagnosed with mixed-sclerosing-bone-dystrophy and, based on this case, to undertake a review of this condition. (AU)

Estudio descriptivo de la irrigación de la tuberosidad tibial y cresta tibial en muestras cadavéricas de perros ( Canis lupus familiaris ), mediante repleción arterial con tinta china y medio de contraste radiográfico / Descriptive study of tibial tuberosity and tibial crest blood supply in dog carcass samples ( Canis lupus familiaris ) by arterial injection with indian ink and radiographic contrast

La ruptura del ligamento cruzado craneal corresponde a la causa más común de cojera en el canino, siendo poco clara su etiología. En la práctica el diagnóstico de la patología se realiza mediante pruebas clínicas ortopédicas, las que corresponden a la prueba de cajón y la prueba de compresión tibial. El desarrollo de diferentes soluciones quirúrgicas incorpora osteotomías a nivel de la tuberosidad tibial, proceso que presenta riesgos frente a una isquemia ósea postquirúrgica. Las descripciones de la anatomía vascular de esta zona de la articulación son escasas y permanecen pobremente representadas en los textos de anatomía. El objetivo de este estudio fue describir el origen de la irrigación de la epífisis proximal y diáfisis en su tercio proximal de la tibia en el perro, mediante la inyección de medio de contraste mezclado con tinta china a través de dos vías arteriales diferentes, incluyendo una radiografía simple previa a la inyección y otra contrastada posterior a la inyección. Se evaluó un total de 48 miembros pélvicos de perros, organizados en tres grupos. En todos los grupos se obtuvo presencia de tinción en la tuberosidad tibial, tanto por vasos originados desde la arteria poplítea, así como también por vasos originados desde la arteria femoral.

The rupture of the cranial cruciate ligament is one of the most common causes of lameness in the dog, and etiology of this disease is not yet clear. The diagnosis of the pathology is performed by clinical orthopedic tests, typically the drawer test and the tibial compression test. The development of different surgical techniques and treatments incorporate surgical osteotomies at the tibial tuberosity level, but the procedure may not be successful due to post-surgical bone ischemia. The descriptions of the vascular anatomy of this joint area are scarce and remain poorly represented in anatomical texts. The objective of this study was to describe the origin of the blood supply to the proximal epiphysis and diaphysis at its proximal third of the tibia in the dog. Contrast medium mixed with Indian ink was injected into two different arterial pathways, visualized with simple radiography prior to the injection and contrasted radiography postinjection. A total of 48 pelvic limbs of dogs were evaluated and organized in three groups based upon the arterial injection pathway. The group injected through the popliteal artery, as well as the group injected through the femoral artery, was observed to have staining in the tibial tuberosity.

Caso clínico: hipofosfatasia de la niñez. Seguimiento clínico / Clinical case: childhood hypophosphatasia. Clinical follow-up

La hipofosfatasia (HP) es una enfermedad congénita, causada por mutaciones con pérdida de función en el gen ALPL que codifica la isoenzima no específica de tejido de la fosfatasa alcalina (TNSALP). Su expresión clínica es muy variable, desde casos de muerte intraútero por alteración grave de la mineralización ósea, hasta casos solo con caída prematura de la dentición. Se presenta el caso clínico de un varón al que se le diagnosticó odontohipofosfatasia a los 30 meses por pérdida temprana de piezas dentarias y niveles anormalmente bajos de fosfatasa alcalina, sin signos de raquitismo ni deformidades óseas. Durante su seguimiento, hasta los 13 años, presentó síntomas compatibles con HP infantil leve, como cansancio al caminar, incoordinación en la marcha y dolor en miembros inferiores que aumentaban con la actividad física. Ante la aparición de edema bimaleolar y poca respuesta al tratamiento con calcitonina y antiinflamatorios, se descartaron patologías infecciosas o reumáticas o ambas y se diagnosticó, por biopsia de tibia y peroné, periostitis sin detección de cristales de pirofosfato. Los controles radiológicos durante su evolución mostraron ensanchamiento metafisario en muñeca, falta de remodelado de metacarpianos, hojaldrado perióstico en tibia y peroné e hipomineralización en metáfisis tibiales, con "lenguas radiolúcidas" características de HP. Como conclusión, la hipofosfatasia debe considerarse como una entidad clínica para descartar en niños que presentan pérdida temprana de dientes. La presencia de este cuadro clínico es en general suficiente para realizar el diagnóstico de HP de la niñez. (AU)

Hypophosphatasia (HP) is a congenital disease, caused by mutations with loss of function in the gene ALPL that encodes the non-specific tissue isoenzyme of alkaline phosphatase (TNSALP). Its clinical expression displays considerable variability, from cases of intrauterine death due to severe alteration of bone mineralization, to cases with only early loss of teeth. We report the case of a male, diagnosed as odontohypophosphatasia at 30 months of age due to early loss of teeth and abnormally low levels of alkaline phosphatase, without signs of rickets or bone deformities. During follow-up, up to 13 years of age, he presented symptoms consistent with mild infantile HP such as tiredness when walking, lack of gait coordination, and pain in lower limbs, especially after physical activity. Due to the appearance of bimalleolar edema and poor response to treatment with calcitonin and anti-inflammatory drugs, infectious and / or rheumatic pathologies were ruled out. Periostitis without pyrophosphate crystal detection was diagnosed by tibial and fibular biopsy. Radiological controls during follow up showed metaphyseal wrist enlargement, lack of remodeling of metacarpals, periosteal flaking in the tibia and fibula and hypomineralization in the tibial metaphysis, with "radiolucent tongues"; characteristic of HP. In conclusion, hypophosphatasia should be considered as a clinical entity in children who present early loss of teeth. The presentation of this clinical case is generally sufficient to make the diagnosis of childhood HP. (AU)

The diagnosis and treatment of tibial intercondylar chondroblastoma

OBJECTIVES: To investigate the diagnosis and treatment of tibial intercondylar chondroblastoma. METHODS: We retrospectively analyzed the diagnosis and treatment of 12 patients with tibial intercondylar chondroblastoma admitted to the orthopedics department from May 2011 to February 2016; among them were 4 males and 3 females aged 10-19 years, with an average age of 15.7 years. Tibial intercondylar chondroblastoma was on the left and right side in 7 and 5 cases, respectively. The preoperative average Lysholm score of the knee joint was 68 (42-87). A posteromedial approach was applied in all cases. The incisions were approximately 5-8 cm in length. Complete curettage and inactivation were performed after fenestration, and allogeneic bone grafts were transplanted. Then, the posterior cruciate ligament insertion was fixed with 5.0 suture anchors. All patients were followed up with regularly to monitor for tumor recurrence, observe bone graft healing, and reassess the Lysholm score of the knee. RESULTS: Patients were followed for 7-55 months, and the median follow-up time was 19 months. One patient experienced tumor relapse 4 months after the operation. Incision, inactivation and cementation were performed. Then, the bone was fixed with anchors. In the other 11 patients, the bone graft healed over an average period of 6.2 months (4-10 months), with good functional recovery postoperatively. The average postoperative Lysholm score of the knee was 91 (81-95). CONCLUSION: Tibial intercondylar chondroblastoma has unique clinical and imaging characteristics and can effectively be treated by curettage followed by the inactivation, transplantation and fixation of allogeneic bone grafts with suture anchors through a posteromedial approach.

Ressonância magnética na avaliação de enxerto osteocondral autógeno na cartilagem articular de coelhos / Magnetic resonance in the evaluation of autogenous osteochondral graft in articular cartilage of rabbits

Este trabalho teve o objetivo de determinar as características e a aplicabilidade do exame de ressonância magnética na avaliação de enxerto ostecondral autógeno, em formato íntegro ou macerado, associado ou não ao fator de crescimento semelhante à insulina tipo 1 (IGF-1), utilizado no reparo de lesões induzidas na cartilagem articular de coelhos. Foram utilizados 9 coelhos da linhagem Nova Zelândia, em que as 18 articulações fêmoro-tíbio-patelares foram submetidas à enxertia osteocondral autógena no sulco troclear femoral. Estas foram divididas em quatro grupos, denominados como enxerto osteocondral íntegro + IGF-1 (n=5), enxerto osteocondral íntegro + solução fisiológica (n=4), enxerto osteocondral macerado + IGF-1 (n=5) e enxerto osteocondral macerado + solução fisiológica (n=4). Os animais foram eutanasiados em 12 semanas após a cirurgia e as articulações foram submetidas ao exame de ressonância magnética utilizando um aparelho scanner de 1,5 Tesla de alto campo magnético. Além disso, amostras dos locais de enxertia foram submetidas aos exames anatomopatológicos. O exame de ressonância magnética mostrou-se eficaz como um método não invasivo para avaliação do tecido de reparação em enxertos osteocondrais na cartilagem articular do fêmur de coelhos, fornecendo dados complementares aos exames macroscópicos e histológicos. Por meio destas imagens e dos exames anatomopatológicos, foram observados resultados satisfatórios em relação ao processo de reparação dos enxertos osteocondrais autógenos na cartilagem de coelhos, independentemente de seu formato ou da adição de IGF-1.(AU)

This study aimed to determine the characteristics and applicability of magnetic resonance imaging (MRI) in the evaluation of autogenous osteochondral graft in intact or macerated format, with or without insulin-like growth factor type 1 (IGF-1) used in repair of cartilage lesions induced in rabbits. Nine New Zealand rabbits were used, in which 18 stifle joints underwent grafting procedure in the femoral trochlear groove. These were divided into four groups, referred as intact osteochondral graft + IGF-1 (n=5), intact osteochondral graft + saline solution (n=4), macerated osteochondral graft + IGF-1 (n=5) and macerated osteochondral graft + saline solution (n=4). Animals were euthanized 12 weeks after surgery and the joints were subjected to MRI using a high magnetic field scanner of 1.5 Tesla. In addition, samples of grafting sites were subjected to anatomopathological examination. The MRI was effective as a noninvasive method to evaluate the repair tissue in osteochondral grafts in articular cartilage of the femur of rabbits by providing complementary data to macroscopic and histological examinations. Through these images and anatomopathological examinations satisfactory results were observed in relation to the repair process of autogenous osteochondral grafts in cartilage of rabbits, regardless of its format or the addition of IGF-1.(AU)

Chronic recurrent multifocal osteomyelitis exhibiting predominance of periosteal reaction / Osteomielite crônica multifocal recorrente exibindo predomínio de reação periosteal

Summary Chronic recurrent multifocal osteomyelitis is an idiopathic nonpyogenic autoinflammatory bone disorder involving multiple sites, with clinical progression persisting for more than 6 months and which may have episodes of remission and exacerbation in the long term. It represents up to 2-5% of the cases of osteomyelitis, with an approximate incidence of up to 4/1,000,000 individuals, and average age of disease onset estimated between 8-11 years, predominantly in females. The legs are the most affected, with a predilection for metaphyseal regions along the growth plate. We describe the case of a female patient, aged 2 years and 5 months, with involvement of the left ulna, right jaw and left tibia, showing a predominance of periosteal reaction as main finding.

Resumo Osteomielite crônica multifocal recorrente é uma desordem autoinflamatória óssea idiopática não piogênica, envolvendo vários sítios e com evolução clínica persistindo por mais de 6 meses, podendo apresentar episódios de remissão e exacerbação em longo prazo. Representa de 2 a 5% das osteomielites, com incidência aproximada de até 4/1.000.000, com idade média de apresentação estimada entre 8 e 11 anos, predominando no gênero feminino. Os membros inferiores são os mais afetados, com predileção para regiões metafisárias junto à fise. Descrevemos um caso da doença em uma menina de 2 anos e 5 meses de idade, com acometimento de ulna esquerda, mandíbula à direita e tíbia esquerda, exibindo predomínio de reação periosteal como achado principal.

Estudio radiográfico de la asociación de antioxidantes y bifosfonatos en remodelación ósea peri-Implantaria / Radiographic antioxidants association and biphosphonates study in bone remodeling peri-implant

Estudios previos han demostrado que los bisfosfonatos son potentes inhibidores de la resorción ósea. El aceite de oliva (O) es rico en ácidos grasos monoinsaturados con potentes propiedades anti-oxidantes. El objetivo de este estudio fue estudiar el efecto del tratamiento de alendronato (AL) y pamidronato (PA) y de O sobre la regeneración tisular. Las fórmulas se dosificaron 0,5 mg/kg de peso para AL, y de 0,6 mg/kg de peso para PA. El O se administró en la dieta, 50 g/ Kg. Cincuenta y cuatro ratas macho de la línea Wistar se dividieron en 6 grupos. El grupo control (C), recibió semanalmente 0,3 ml/100g de peso corporal de solución salina vía subcutánea. El grupo (AL) recibió semanalmente por vía subcutánea en el miembro posterior izquierdo. El grupo (PA) se colocó igual que el grupo anterior. El grupo (O) fue tratado en la alimentación y en las áreas de la cirugía recibieron inyección subcutánea con solución fisiológica. El grupo (ALO) recibió tratamiento combinado con AL y O. El grupo (PAO) se trató igual al anterior. La cirugía consistió en una incisión longitudinal en las tibias realizando un defecto circular en la parte plana de cada tibia hasta llegar al hueso medular. Se tomaron radiografías a los 0, 7, 15, 30, 60 y 90 días y fueron analizadas con el Software Image Pro Plus. Los estudios estadísticos se realizaron a través del análisis de la variancia a dos y tres criterios de clasificación. Se evidencio un incremento en la densidad mineral ósea promedio (DMO) conforme avanza el tiempo en todos los grupos, siendo evidentes con PA a los 60 días. El tratamiento O mostró eficacia en la remodelación ósea, observándose un pico a los 60 días. Esto sugiere que O representa una opción terapéutica para el tratamiento de las patologías óseas.

Previous studies have shown that bisphosphonates are potent inhibitors of bone resorption. Olive oil (O) is rich in monounsaturated fatty acids with potent anti-oxidant properties. The objective of this work was to study the effect of alendronate treatment (AL) and pamidronate (PA) and O on tissue regeneration. Formulas 0.5 mg / kg for AL dosed, and 0.6 mg / kg for PA. O was administered in the diet, 50 g / kg. Fifty-four male rats Wistar were divided into 6 groups. The control group (C) received weekly 0.3 ml / 100g body weight of saline subcutaneously. The group (AL) received a weekly dose subcutaneously in the left posterior limb. The group (PA) was placed as the previous group. The group (O) was treated in food and in the areas of surgery received subcutaneousinjection with saline. The group (ALO) received combined treatment with Al and O. The group (PAO) was treated the same as before. Surgery consisted of a longitudinal incision in the warm using a circular on the flat side of each tibia until the medullary bone defect. X-rays at 0, 7, 15, 30, 60 and 90 days were taken and analyzed with Image Pro Plus Software. Statistical studies were conducted through analysis of variance to two and three classification criteria. Results: an increase in the average bone mineral density (BMD) was evident as time progresses in all groups, with PA still evident at 60 days. Or treatment showed efficacy in bone remodeling observed a peak at 60 days. Conclusions: This suggests that O represents a therapeutic option for the treatment of bone disease.

The Efficacy of Percutaneous Lateral Hemiepiphysiodesis on Angular Correction in Idiopathic Adolescent Genu Varum

BACKGROUND: Percutaneous lateral hemiepiphysiodesis of the lower extremity is a simple and excellent method to correct the angular and length problems cosmetically. However, the efficacy of percutaneous lateral hemiepiphysiodesis is not well established in the literature. The purpose of this study was to evaluate the efficacy of percutaneous lateral hemiepiphysiodesis for angular corrections in adolescent idiopathic genu varum patients with proximal tibia vara and identify the factors affecting the amount of deformity correction of the lower limb in the coronal plane. METHODS: We retrospectively reviewed 20 patients (40 lower limbs) who had percutaneous lateral hemiepiphysiodesis on the proximal lateral tibia between 1997 and 2010. Radiographic evaluations were made using (1) the hip-knee-ankle angle and (2) the length of the tibia. Furthermore, the intercondylar distance was evaluated at the level of the knee joint. Preoperative factors (gender, age, body mass index, intercondylar distance, preoperative hip-knee-ankle angle, remaining growth of tibia, and calculated correctable angle) were analyzed, as well as their correlation with the degree of the actual correction angle. RESULTS: The amount of coronal deformity of the lower limb was improved from its preoperative state. The median average of hip-knee-ankle angle improved from 8.0degrees (interquartile range [IQR], 7.0degrees to 10.0degrees) preoperatively to 3.0degrees (IQR, 2.5degrees to 4.0degrees) at the final follow-up (p < 0.001). The median percent ratio of the angular correction was 60% (IQR, 50% to 71.3%). The correlation coefficients were -0.537, 0.832, 0.791, and 0.685 for the bone age, preoperative hip-knee-ankle angle, the remaining growth of tibia, and calculated correctable angle, respectively. CONCLUSIONS: Despite the excellent cosmetic outcome of percutaneous lateral hemiepiphysiodesis on the proximal lateral tibia in adolescent idiopathic genu varum, the effect was limited in most cases. For optimum results, surgery a few months earlier is recommended, rather than at the calculated operation time.

How to Minimize Rotational Conflict between Femoral & Tibial Component in Total Knee Arthroplasty: The Use of Femoro-Tibial Axial Synchronizer (Linker)

PURPOSE: The purpose of this study was to investigate the correlation between rotational axes of femur and tibia with the use of Linker. MATERIALS AND METHODS: This study was carried out from August 2009 to February 2010 on 54 patients (106 knees), who were diagnosed with simultaneous bilateral total knee arthroplasty. With the use of postoperative computed tomography scans, it was investigated how much the rotational angle of femoral and tibial components matched. RESULTS: The tibial component was internally rotated for the femoral component at an angle of 0.8degrees. The femoral component was externally rotated for the surgical transepicondylar axis (TEA) at an angle of 1.6 (range: from 4.8degrees of internal rotation to 7.9degrees of external rotation, SD=2.2degrees), and the tibial component was externally rotated for the surgical TEA at an average angle of 0.9 (range: from 5.1degrees of internal rotation to 8.3degrees of external rotation, SD=3.1degrees). CONCLUSION: The femoro-tibial synchronizer helped to improve the orientation and positioning of both femoral component and tibial component, and also increase the correlation of the rotational axes of the two components.

How to Minimize Rotational Conflict between Femoral & Tibial Component in Total Knee Arthroplasty: The Use of Femoro-Tibial Axial Synchronizer (Linker)

PURPOSE: The purpose of this study was to investigate the correlation between rotational axes of femur and tibia with the use of Linker. MATERIALS AND METHODS: This study was carried out from August 2009 to February 2010 on 54 patients (106 knees), who were diagnosed with simultaneous bilateral total knee arthroplasty. With the use of postoperative computed tomography scans, it was investigated how much the rotational angle of femoral and tibial components matched. RESULTS: The tibial component was internally rotated for the femoral component at an angle of 0.8degrees. The femoral component was externally rotated for the surgical transepicondylar axis (TEA) at an angle of 1.6 (range: from 4.8degrees of internal rotation to 7.9degrees of external rotation, SD=2.2degrees), and the tibial component was externally rotated for the surgical TEA at an average angle of 0.9 (range: from 5.1degrees of internal rotation to 8.3degrees of external rotation, SD=3.1degrees). CONCLUSION: The femoro-tibial synchronizer helped to improve the orientation and positioning of both femoral component and tibial component, and also increase the correlation of the rotational axes of the two components.

Demineralized Bone Matrix Injection in Consolidation Phase Enhances Bone Regeneration in Distraction Osteogenesis via Endochondral Bone Formation

BACKGROUND: Distraction osteogenesis (DO) is a promising tool for bone and tissue regeneration. However, prolonged healing time remains a major problem. Various materials including cells, cytokines, and growth factors have been used in an attempt to enhance bone formation. We examined the effect of percutaneous injection of demineralized bone matrix (DBM) during the consolidation phase on bone regeneration after distraction. METHODS: The immature rabbit tibial DO model (20 mm length-gain) was used. Twenty-eight animals received DBM 100 mg percutaneously at the end of distraction. Another 22 animals were left without further procedure (control). Plain radiographs were taken every week. Postmortem bone dual-energy X-ray absorptiometry and micro-computed tomography (micro-CT) studies were performed at the third and sixth weeks of the consolidation period and histological analysis was performed. RESULTS: The regenerate bone mineral density was higher in the DBM group when compared with that in the saline injection control group at the third week postdistraction. Quantitative analysis using micro-CT revealed larger trabecular bone volume, higher trabecular number, and less trabecular separation in the DBM group than in the saline injection control group. Cross-sectional area and cortical thickness at the sixth week postdistraction, assessed using micro-CT, were greater in the regenerates of the DBM group compared with the control group. Histological evaluation revealed higher trabecular bone volume and trabecular number in the regenerate of the DBM group. New bone formation was apparently enhanced, via endochondral ossification, at the site and in the vicinity of the injected DBM. DBM was absorbed slowly, but it remained until the sixth postoperative week after injection. CONCLUSIONS: DBM administration into the distraction gap at the end of the distraction period resulted in a significantly greater regenerate bone area, trabecular number, and cortical thickness in the rabbit tibial DO model. These data suggest that percutaneous DBM administration at the end of the distraction period or in the early consolidation period may stimulate regenerate bone formation and consolidation in a clinical situation with delayed bone healing during DO.

Effect of the Starting Point of Half-Pin Insertion on the Insertional Torque of the Pin at the Tibia

PURPOSE: The authors have observed a failure to achieve secure fixation in elderly patients when inserting a half-pin at the anteromedial surface of the tibia. The purpose of this study was to compare two methods for inserting a half-pin at tibia diaphysis in elderly patients. MATERIALS AND METHODS: Twenty cadaveric tibias were divided into Group C or V. A half-pin was inserted into the tibias of Group C via the conventional method, from the anteromedial surface to the interosseous border of the tibia diaphysis, and into the tibias of Group V via the vertical method, from the anterior border to the posterior surface at the same level. The maximum insertion torque was measured during the bicortical insertion with a torque driver. The thickness of the cortex was measured by micro-computed tomography. The relationship between the thickness of the cortex engaged and the insertion torque was investigated. RESULTS: The maximum insertion torque and the thickness of the cortex were significantly higher in Group V than Group C. Both groups exhibited a statistically significant linear correlation between torque and thickness by Spearman's rank correlation analysis. CONCLUSION: Half-pins inserted by the vertical method achieved purchase of more cortex than those inserted by the conventional method. Considering that cortical thickness and insertion torque in Group V were significantly greater than those in Group C, we suggest that the vertical method of half-pin insertion may be an alternative to the conventional method in elderly patients.

Limb Lengthening in Patients with Achondroplasia

PURPOSE: Although bilateral lower-limb lengthening has been performed on patients with achondroplasia, the outcomes for the tibia and femur in terms of radiographic parameters, clinical results, and complications have not been compared with each other. We proposed 1) to compare the radiological outcomes of femoral and tibial lengthening and 2) to investigate the differences of complications related to lengthening. MATERIALS AND METHODS: We retrospectively reviewed 28 patients (average age, 14 years 4 months) with achondroplasia who underwent bilateral limb lengthening between 2004 and 2012. All patients first underwent bilateral tibial lengthening, and at 9-48 months (average, 17.8 months) after this procedure, bilateral femoral lengthening was performed. We analyzed the pixel value ratio (PVR) and characteristics of the callus of the lengthened area on serial radiographs. The external fixation index (EFI) and healing index (HI) were computed to compare tibial and femoral lengthening. The complications related to lengthening were assessed. RESULTS: The average gain in length was 8.4 cm for the femur and 9.8 cm for the tibia. The PVR, EFI, and HI of the tibia were significantly better than those of the femur. Fewer complications were found during the lengthening of the tibia than during the lengthening of the femur. CONCLUSION: Tibial lengthening had a significantly lower complication rate and a higher callus formation rate than femoral lengthening. Our findings suggest that bilateral limb lengthening (tibia, followed by femur) remains a reasonable option; however, we should be more cautious when performing femoral lengthening in selected patients.

Volume and Contact Surface Area Analysis of Bony Tunnels in Single and Double Bundle Anterior Cruciate Ligament Reconstruction Using Autograft Tendons: In Vivo Three-Dimensional Imaging Analysis

BACKGROUND: Regarding reconstruction surgery of the anterior cruciate ligament (ACL), there is still a debate whether to perform a single bundle (SB) or double bundle (DB) reconstruction. The purpose of this study was to analyze and compare the volume and surface area of femoral and tibial tunnels during transtibial SB versus transportal DB ACL reconstruction. METHODS: A consecutive series of 26 patients who underwent trantibial SB ACL reconstruction and 27 patients with transportal DB ACL reconstruction using hamstring autograft from January 2010 to October 2010 were included in this study. Three-dimensional computed tomography (3D-CT) was taken within one week after operation. The CT bone images were segmented with use of Mimics software v14.0. The obtained digital images were then imported in the commercial package Geomagic Studio v10.0 and SketchUp Pro v8.0 for processing. The femoral and tibial tunnel lengths, diameters, volumes and surface areas were evaluated. A comparison between the two groups was performed using the independent-samples t-test. A p-value less than the significance value of 5% (p < 0.05) was considered statistically significant. RESULTS: Regarding femur tunnels, a significant difference was not found between the tunnel volume for SB technique (1,496.51 +/- 396.72 mm3) and the total tunnel volume for DB technique (1,593.81 +/- 469.42 mm3; p = 0.366). However, the total surface area for femoral tunnels was larger in DB technique (919.65 +/- 201.79 mm2) compared to SB technique (810.02 +/- 117.98 mm2; p = 0.004). For tibia tunnels, there was a significant difference between tunnel volume for the SB technique (2,070.43 +/- 565.07 mm3) and the total tunnel volume for the DB technique (2,681.93 +/- 668.09 mm3; p < or = 0.001). The tibial tunnel surface area for the SB technique (958.84 +/- 147.50 mm2) was smaller than the total tunnel surface area for the DB technique (1,493.31 +/- 220.79 mm2; p < or = 0.001). CONCLUSIONS: Although the total femoral tunnel volume was similar between two techniques, the total surface area was larger in the DB technique. For the tibia, both total tunnel volume and the surface area were larger in DB technique.

In Vivo Three-Dimensional Imaging Analysis of Femoral and Tibial Tunnel Locations in Single and Double Bundle Anterior Cruciate Ligament Reconstructions

BACKGROUND: Anatomic footprint restoration of anterior cruciate ligament (ACL) is recommended during reconstruction surgery. The purpose of this study was to compare and analyze the femoral and tibial tunnel positions of transtibial single bundle (SB) and transportal double bundle (DB) ACL reconstruction using three-dimensional computed tomography (3D-CT). METHODS: In this study, 26 patients who underwent transtibial SB ACL reconstruction and 27 patients with transportal DB ACL reconstruction using hamstring autograft. 3D-CTs were taken within 1 week after the operation. The obtained digital images were then imported into the commercial package Geomagic Studio v10.0. The femoral tunnel positions were evaluated using the quadrant method. The mean, standard deviation, standard error, minimum, maximum, and 95% confidence interval values were determined for each measurement. RESULTS: The femoral tunnel for the SB technique was located 35.07% +/- 5.33% in depth and 16.62% +/- 4.99% in height. The anteromedial (AM) and posterolateral (PL) tunnel of DB technique was located 30.48% +/- 5.02% in depth, 17.12% +/- 5.84% in height and 34.76% +/- 5.87% in depth, 45.55% +/- 6.88% in height, respectively. The tibial tunnel with the SB technique was located 45.43% +/- 4.81% from the anterior margin and 47.62% +/- 2.51% from the medial tibial articular margin. The AM and PL tunnel of the DB technique was located 33.76% +/- 7.83% from the anterior margin, 45.56% +/- 2.71% from the medial tibial articular margin and 53.19% +/- 3.74% from the anterior margin, 46.00% +/- 2.48% from the medial tibial articular margin, respectively. The tibial tunnel position with the transtibial SB technique was located between the AM and PL tunnel positions formed with the transportal DB technique. CONCLUSIONS: Using the 3D-CT measuring method, the location of the tibia tunnel was between the AM and PL footprints, but the center of the femoral tunnel was at more shallow position from the AM bundle footprint when ACL reconstruction was performed by the transtibial SB technique.