Correlation analysis between imaging classification of varus knee osteoarthritis and axis angle of tibiofemoral and patellofemoral joints / 中国骨伤

OBJECTIVE@#To explore correlation between imaging classification of knee osteoarthritis (KOA) and axis angle of tibiofemoral and patellofemoral joints.@*METHODS@#A retrospective analysis of 739 middle-aged and elderly patients with KOA (1 026 knee joints) who underwent vertical X-ray examination of both lower limbs and lateral knee joints from September 2018 to December 2020. Among them, 63 patients with K-L 0 grade (95 knee joints), 100 patients with K-L 1 grade (130 knee joints), 161 patients with K-L 2 grade (226 knee joints), 187 patients with K-L 3 grade (256 knee joints), and 228 patients of K-L 4 grade (319 knee joints). According to relative position of knee joint center and line between hip joint center and ankle joint center, the affected knee was divided into varus group(844 knees joints) and valgus group (182 knees joints). According to Install-Salvati method, the affected knee was divided into three groups, such as high patella (patella height>1.2 mm, 347 knees joints), median patella (patella height ranged from 0.8 to 1.2 mm, 561 knees joints), and low patella (patella height<0.8 mm, 118 knees joints). Lower femur angle, upper tibia angle, femoral neck shaft angle, femoral tibial angle, joint gap angle, hip-knee-ankle angle, patella-femoral angle and patella height among different groups were observed and compared.@*RESULTS@#(1) In varus KOA group, there were statistical differnces in hip-knee-ankle angle, tibiofemoral angle, lower femoral angle, upper tibial angle, joint space angle, and femoral neck shaft angle of patients with different K-L grades (P<0.05). Hip-knee-ankle angle, tibiofemoral angle, lower femoral angle, upper tibial angle, joint space angle and K-L grade were significantly positively correlated at 0.01(P<0.05);femoral neck shaft angle and K-L grade showed negative correlation at 0.01(P<0.05). (2) In valgus KOA group, hip-knee-ankle angle, there were statistical differences in tibiofemoral angle, inferior femoral angle, superior tibial angle, joint space angle, and femoral neck shaft angle of patients with different K-L grades(P<0.05). Hip-knee-ankle angle, tibiofemoral angle, lower femoral angle, upper tibial angle, and femoral neck shaft angle showed negative correlation with K-L grades at level of 0.01 (P<0.05);joint gap angle and K-L grades showed significantly positive correlation at level of 0.01(P<0.05). (3) In high patella group, there were statistically differences in patellar height and patellar femoral angle of different K-L grades(P<0.05);there were no statistical difference in patella height and patellar femoral angle of different K-L grades in median patella group. There was no significant difference in patella heightin low patella group with different K-L grades(P>0.05), and there was statistical difference in patellofemoral angle(P<0.05). Patellar height and patella-femoral angle of high patella group were significantly positively correlated with K-L grades at the level of 0.01 (P<0.05);patella height and patella-femoral angle were not correlated with K-L grades in median patella group(P>0.05). There was no correlation between height of patella and K-L grade in low patella group (P>0.05). There was significant negative correlation between patella-femoral angle and K-L grade at level of 0.05 (P<0.05).@*CONCLUSION@#Inferior femoral angle, tibiofemoral angle, joint gap angle, hip-knee-ankle angle, femoral neck shaft angle and high patella are related to K-L classification of varus KOA, which could be used for early diagnosis and provide objective data for efficacy analysis of conservative treatment.

Comparison of radiographic and tomographic evaluations for measurement of the Canal Flare Index in dogs / [Comparação entre avaliação radiográfica e tomográfica para mensuração do Canal Flare Index em cães]

The outcome of total hip arthroplasty (THA) in dogs is directly related to surgical planning. Templating of radiographs prior to THA should help the surgeon anticipate prosthesis size and femoral shape allowing canal fill of the proximal metaphysis by the implant ensuring primary stable fixation. The canal flare index (CFI) obtained from radiograph has been used as a measure of risk of complications for the technique in human beings and dogs. However, standard radiographs only provide limited data for the selection of cementless prostheses and the assessment of their fit within the femoral canal, due to factors like radiographic magnification and femoral rotation. Therefore, three-dimensional evaluation based on computed tomography (CT) may be a better tool for CFI measurement. The aim of this study was to compare anatomical measurement with CFI values obtained from craniocaudal radiography and CT. Craniocaudal radiographs using a horizontal radiographic beam (CR), CT, and anatomical macroscopic measurements (A) were obtained from 45 femurs from 23 canine cadavers. The differences between the values of CFI obtained from radiograph (CFI-R), computed tomography on transverse (CFI- TT) and longitudinal axis (CFI-TL) compared to the CFI obtained from macroscopic measurements - gold standard - (CFI-A), and 95% limits of agreement (LOA) between the values, were evaluated by the Bland-Altman method. Dimensions obtained from CT techniques had a greatest mean difference from anatomical and CFI values were also different (P=0.032). Under the experimental conditions, the craniocaudal radiograph, provided the most accurate measurement of the CFI (mean difference: 0.087 ± 0.42).(AU)

O resultado da artroplastia total do quadril (ATQ) em cães está diretamente relacionado ao planejamento cirúrgico. O templating radiográfico pré-operatório da ATQ deve ajudar o cirurgião a prever o tamanho da prótese e o formato do fêmur, o que permitirá um preenchimento ideal da metáfise proximal pelo implante, garantindo, assim, fixação primária estável. O índice de alargamento do canal (Canal Flare Index - CFI) obtido em radiografias tem sido utilizado como fator de risco de complicações para a técnica em humanos e cães. No entanto, as radiografias podem fornecer apenas dados limitados para a seleção de próteses não cimentadas e a avaliação do seu encaixe no canal femoral, devido a fatores como ampliação radiográfica e rotação femoral. Portanto, a avaliação tridimensional baseada na tomografia computadorizada (TC) pode ser uma ferramenta vantajosa para a mensuração do CFI. O objetivo deste estudo foi comparar a medida anatômica com os valores de CFI obtidos na radiografia craniocaudal e na TC. Radiografias craniocaudais utilizando feixe radiográfico horizontal (CR), tomografia computadorizada e medidas macroscópicas anatômicas (A) foram obtidas de 45 fêmures de 23 cadáveres caninos. As diferenças entre os valores de CFI obtidos na radiografia (CFI-R), na tomografia computadorizada no eixo transversal (CFI-TT) e no eixo longitudinal (CFI-TL), em comparação com os valores de CFI obtidos nas medições macroscópicas - padrão-ouro - (CFI-A) e os limites de concordância de 95% (LOA) entre os valores, foram avaliadas pelo método de Bland-Altman. As dimensões obtidas pelas técnicas de TC apresentaram maior diferença média dos valores anatômicos, e as do CFI também foram diferentes (P=0,032). Nas condições experimentais, a radiografia craniocaudal forneceu a medida mais precisa do CFI (diferença média: 0,087 ± 0,42) para representar o padrão-ouro deste estudo.(AU)

Tumor de células gigantes del fémur / Tumor of giant cells of the femur

El tumor de células gigantes de hueso es un tumor raro de características benignas con un comportamiento agresivo localmente. Predomina en mujeres y por lo general se presenta en la epífisis y metáfisis de los huesos largos. El propósito de este estudio es presentar el caso de un paciente con una lesión tumoral de rodilla y muslo izquierdos de 2 años de evolución y señalar las características diagnósticas de este tumor al mismo tiempo que se revisan los métodos imagenológicos recientes para su confirmación. Se presenta a un paciente masculino de 19 años de edad, que comenzó con dolor, aumento de volumen de la rodilla y muslo izquierdos, acompañado de impotencia funcional. Se reportaron los hallazgos clínicos, radiográficos e histológicos. Debido a la demora entre el inicio de los síntomas y el diagnóstico se practicó el tratamiento quirúrgico del miembro afectado (amputación). Tras 10 meses de observación no se han presentado recidivas o metástasis. Se envió al Servicio de Oncología para valorar e tratamiento con radioterapia. El tumor de células gigantes del hueso es un tumor raro, de buen pronóstico, pero que puede recidivar y causar metástasis cuando se maligniza. Por la posibilidad de transformación en sarcoma requiere estudio y observación periódica. El tiempo para realizar el diagnóstico es fundamental y debe pensarse en este tumor en caso de lesiones líticas de hueso reportadas por imagenología(AU)

The giant cell tumor of bone is a rare benign tumor with a locally aggressive behavior. It predominates in women and usually occurs in the epiphysis and metaphysis of long bones. To present a patient with a tumor lesion left knee and thigh two years of evolution, also noted the diagnostic characteristics of this tumor while recent imaging methods are reviewed for confirmation. 19-year-old male who began with pain, increased volume of the knee and left thigh, accompanied by functional impotensia. clinical, radiological and histological findings were reported. Because of the delay between the onset of symptoms and diagnosis surgical treatment of the affected limb (amputation) was performed. After ten months of observation there have been no recurrences or metastases. The giant cell tumor of bone is a rare tumor with good prognosis but can recur and metastasize when it becomes malignant. The possibility of transformation in sarcoma requires periodic study and observation. The time for diagnosis is essential and should think of this tumor in case of lytic bone lesions reported by imaging(AU)

Relationship of the Pelvic-Trochanteric Index with greater trochanteric pain syndrome

OBJECTIVES: This study aimed to correlate a higher Pelvic-Trochanteric Index (PTI) with an increased varus of the femoral neck with greater trochanteric pain syndrome (GTPS). The secondary objective was to check whether the pelvic width changes with age. METHODS: A prospective study was conducted to compare female patients diagnosed with GTPS (case group) with asymptomatic female participants (control group) from March 2011 to June 2017. On an anteroposterior pelvic radiograph, lines were drawn by two radiologists, and the PTI (ratio of the distance between the greater trochanters and distance between the iliac crests) was defined and the femoral neck-shaft angle was measured. RESULTS: Data collected based on radiographs of 182 female patients (cases) and 150 female participants (controls) showed that the mean PTI was 1.09 (SD=0.01) in the case group and 1.07 (SD=0.01) in the control group (p<0.05), regardless of age. The distance between iliac crests increased with age (p<0.05) in symptomatic and asymptomatic individuals. It was also found that the mean femoral neck-shaft angle was 130.6° (SD=0.59) and progression of the varus angulation occurred with age in both groups, with a significance level of 5%. CONCLUSIONS: The PTI was higher in patients with GTPS. The femoral neck-shaft angle does not differ between individuals with and without GTPS; however, it does decrease with age. The pelvic width tends to increase with aging in symptomatic or asymptomatic individuals; therefore, the increase in the pelvic width and decrease in the femoral neck-shaft angle can be interpreted as normal in aging women, which could alter the biomechanics of the hips and pelvis.

Aging and low-intensity exercise change oxidative biomarkers in brain regions and radiographic measures of femur of Wistar rats

We investigated changes in oxidative biomarkers in brain regions such as brainstem, cerebellum, and cerebral cortex of 3-, 6-, 18-, 24-, and 30-month-old rats. We also assessed the effects of low-intensity exercise on these biomarkers in these regions of 6-, 18-, and 24-month-old rats that started exercise on a treadmill at 3, 15, and 21 months of age, respectively. Radiographic images of the femur were taken for all rats. A total of 25 rats (age: twelve 6-, ten 18-, ten 24-, and three 30-month-old rats) were used. Lipid hydroperoxide levels increased in cerebellum at 18 months. Total antioxidant activity exhibited lowest values in brainstem at 3 months. Superoxide dismutase activity did not exhibit significant changes during aging. Total thiol content exhibited lowest values in brain regions of 24- and 30-month-old rats. Exercise reduced total thiol content in brainstem at 6 months, but no change occurred in other regions and other ages. Femur increased its length and width and cortical thickness with advancing age. No change occurred in medullary width. Radiolucency increased and sclerosis was found in cortical and medullary bone with advancing age. Exercise reduced radiolucency and medullary sclerosis. Therefore, aging differentially changed oxidative biomarkers in different brain regions and radiographic measures of the femur. Low-intensity exercise only ameliorated some radiographic measurements of femur. Since the present study possessed limitations (small number of rats per group), a beneficial effect of regular low-intensity exercise on oxidative markers in brain cannot be ruled out.

Rabbit growth plate morphology in temporary bilateral blocking / Morfología de la placa de crecimiento de conejos durante bloqueo bilateral temporario

Blocking of the growth plate (GP) using plates with screws (tension band plating) is a modern method used to correct deformities and moderate leg length discrepancy in growing children. Determining the duration of temporary bilateral blocking without the occurrence of irreversible changes of GP is of paramount importance important. Methods: Two-month-old Californian breed male rabbits (n=30) were exposed to bilateral blocking of the distal GP of the right femur locking plates with screws for 3, 5, and 7 weeks. The fixators were removed after 5 and 7 weeks in 18 rabbits and 3 weeks after that, animals were sacri!ced. The contralateral limb was used as a control. Histological, histomorphometric, and X-ray analyses were performed. Results: During GP blocking, its height gradually decreased. This decreased was more pronounced after 7 weeks. Destructive changes progressed with an increase in the blocking duration. Three weeks after discontinuation of the bilateral blocking that lasted 5 weeks, the height of the GP signi!cantly increased 1.2 times on the lateral side and 1.9 times on the medial side (p<0.001) compared to the control. When blocking was discontinued after 7 weeks, the structure of the GP was partially restored after 3 weeks, the height of GP signi!cantly increased 1.2 times on the lateral side, and 1.07 times on the medial side (p<0.01) compared to the control. Conclusion: Restoration of the structuralfunctional features of the GP after the removal of the plates depends on the duration of temporary bilateral blocking, which must be taken into account in the clinical setting. (AU)

El bloqueo de la placa de crecimiento (PC) utilizando placas con tornillos (banda de tensión) es un método moderno utilizado para corregir deformidades y alteraciones moderadas en la longitud de las piernas en niños en crecimiento. Es de suma importancia determinar cuál debe ser la duración del bloqueo bilateral temporal sin que ocurran cambios irreversibles en la PC. Métodos: Conejos machos de raza californiana de dos meses de edad (n = 30) fueron expuestos al bloqueo bilateral de la PC distal colocando placas del fémur derecho con tornillos durante 3, 5 y 7 semanas. Los fijadores fueron retirados después de 5 y 7 semanas en 18 de los conejos, y 3 semanas después los animales fueron sacrificados. La extremidad contralateral se utilizó como control. Se realizaron análisis histológicos, histomorfométricos y de rayos X. Resultados: Durante el bloqueo de la PC, su altura disminuyó gradualmente. Esta disminución fue más pronunciada después de 7 semanas. Los cambios destructivos se incrementaron a medida aumentaba la duración del bloqueo. Tres semanas después de la interrupción del bloqueo bilateral que duró 5 semanas, la altura de la PC aumentó significativamente 1.2 veces en el lado lateral y 1.9 veces en el lado medial (p <0.001) en comparación con el control. Conclusión: La restauración de las características funcionales estructurales de la PC después de la extracción de las placas depende de la duración del bloqueo bilateral temporal, lo que debería tenerse en cuenta en el tratamiento clínico de estas alteraciones. (AU)

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.

Zoledronic acid effect on bone of growing rats / Efecto del ácido zoledrónico en el hueso de ratas en crecimiento

Zoledronic acid (ZA) is an antiresorptive drug used in children with bone diseases like osteogenesis imperfecta, juvenil osteoporosis, fibrous dysplasia and primary bone tumors. The aim of the present study was to evaluate the effects of ZA dose accumulation on growing bone during different periods of treatment in normal rats. Methods: A 4x2 factorial design was used to study the effect of the dose of ZA (D: 0-2.5-12.5-25 µg Z/kg body weight/s.c. weekly) and the length of treatment (T: 15-30 days) in normal female Sprague Dawley rats. Bone morphometric, histomorphometric, densitometric and biomechanical studies were performed. Results: Femoral length and cross-sectional area were affected by both D and T. A significant interaction between D and T was observed in length with a lower value at higher dose and 30 days of treatment. Growth plate of the tibia showed a decrease in total thickness with D and T. Histomorphometric and connectivity parameters of trabecular bone were significantly increased with D and several parameters were also affected by T. Cortical bone strength was increased only with T. Biomechanical parameters of trabecular bone showed significant interaction with greater effect at higher D and T. Conclusion: Even though a mild negative effect of the highest dose of ZA on linear and appositional growth was observed, the other bone parameters evaluated were improved. A careful risk/benefit analysis would lead us to conclude that the mild deleterious effects of ZA during growth are outweighed by the benefit obtained with treatment. (AU)

El ácido zoledrónico (AZ) es un fármaco antirresortivo utilizado en niños con enfermedades óseas como osteogénesis imperfecta, osteoporosis juvenil, displasia fibrosa y tumores óseos primarios. El objetivo del presente estudio fue evaluar los efectos de las dosis acumuladas de AZ en el hueso en crecimiento de ratas hembras normales durante diferentes períodos de tratamiento. Métodos: se utilizó un diseño factorial de 4x2 para estudiar el efecto de la dosis de AZ (D: 0-2,5-12,5-25 µg Z / kg de peso corporal /sc semanalmente) y el período de tratamiento (T: 15-30 días) en ratas Sprague Dawley. Se realizaron estudios óseos morfométricos, histomorfométricos, densitométricos y biomecánicos. Resultados: la longitud y el área de sección transversal del fémur se vieron afectadas tanto por D como por T. Se observó una interacción significativa entre D y T en la longitud obteniéndose un valor más bajo a la dosis más alta y a 30 días de tratamiento. El cartílago de crecimiento de la tibia mostró una disminución en el espesor total con D y T. Los parámetros histomorfométricos y de conectividad del hueso trabecular aumentaron significativamente con D y varios parámetros también se vieron afectados por T. La fortaleza ósea cortical aumentó solo con T. Los parámetros biomecánicos del hueso trabecular mostraron una interacción significativa con un mayor efecto a mayor D y T. Conclusión: a pesar que se observó un leve efecto negativo de la dosis más alta de AZ sobre el crecimiento lineal y aposicional, el resto de los parámetros óseos evaluados mejoraron. Un análisis cuidadoso del riesgo /beneficio permite concluir que los efectos negativos leves del AZ durante el crecimiento son superados por el beneficio obtenido con el tratamiento. (AU)

Lean mass as a determinant of bone mineral density of proximal femur in postmenopausal women

ABSTRACT Objective: To verify which component of body composition (BC) has greater influence on postmenopausal women bone mineral density (BMD). Subjects and methods: Four hundred and thirty women undergoing treatment for osteoporosis and 513 untreated women, except for calcium and vitamin D. Multiple linear regression analysis was performed in order to correlated BMD at lumbar spine (LS), total femur (FT), femoral neck (FN) with body mass (BM), total lean mass (LM) and total fat mass (FM), all determined by DXA. Results: BM significantly correlated with all bone sites in untreated and treated women (r = 0.420 vs 0.277 at LS; r = 0.490 vs 0.418 at FN, r = 0.496 vs 0.414 at FT, respectively). In untreated women, the LM correlated better than FM with all sites, explaining 179% of LS; 32.3% of FN and 30.2% of FT; whereas FM explained 13.2% of LS; 277% of FN, 23.4% of FT In treated women, correlations with BC were less relevant, with the LM explaining 6.7% of BMD at LS; 15.2% of FN, 16% of FT, whereas the FM explained 8.1% of LS; 179% of FN and 176% of FT. Conclusion: LM in untreated women was better predictor of BMD than FM, especialy for distal femur, where it explained more than 30% of the BMD, suggesting that maintaining a healthy muscle mass may contribute to decrease osteoporosis risk. Treatment with anti-osteoporotic drugs seems to mask these relationships. Arch Endocrinol Metab. 2018;62(4):431-7

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)

Ensayo pictórico: descripción del posicionamiento del túnel femoral en distintas técnicas de reconstrucción del ligamento cruzado anterior (lca) / Pictory essay: description of the positioning of the femoral tunnel in different techniques of reconstruction of the anterior cruciate ligament

En la práctica radiológica habitual el radiólogo se encuentra frecuentemente con distintas técnicas de reconstrucción del LCA que debe conocer de manera general para una adecuada descripción e interpretación de los hallazgos. En el presente ensayo pictórico exponemos diferentes tipos de técnica de reconstrucción del LCA, con énfasis en el concepto de reconstrucción anatómica, presentando distintas posiciones del túnel femoral, buscando entregar herramientas al radiólogo para reconocer la normalidad postoperatoria e interpretar posibles complicaciones.

In daily radiological practice, we frequently fid different ACL reconstruction techniques, which we must know in order to achieve adequate interpretation of the fidings. In this pictorial essay, we show different types of LCA reconstruction techniques, highlighting the anatomical reconstruction concept and presenting different positions of the femoral tunnel, seeking to deliver tools to the radiologist in order to recognize the normal postoperative fidings and possible complications.

Lesión por estrés de la fisis distal del fémur: reporte de un caso y revisión del tema / Distal physis femur stress injury

En este reporte presentamos el caso de un niño de 14 años sin antecedentes mórbidos, que consulta por un cuadro de gonalgia, confirmándose el diagnóstico mediante resonancia magnética (RM) de lesión por estrés de la fisis distal del fémur. La literatura muestra que este tipo de lesiones son frecuentes en pacientes jóvenes deportistas y que el mecanismo que lleva al engrosamiento fisiario se produce por un trauma repetido que genera estrés mecánico y distracción del cartílago de crecimiento. El objetivo de esta publicación es aportar un caso a la literatura y dar a conocer la importancia de la radiología en el diagnóstico precoz de esta enfermedad, para que de esta forma el paciente no presente complicaciones futuras.

In this case report we present a 14-year-old patient with no previous medical history, who asked for knee pain. He was diagnosed with stress injury of the femur physis. The literature shows that this type of injuries are frequent in young athletes and the mechanism that leads to physeal widening is produced by a repeated trauma that generates mechanical stress and distraction of the growth cartilage. The aim of this case report is to show the relevance of radiology in the early diagnosis of this disease preventing future complications.

Radiographic anatomy of the proximal femur: femoral neck fracture vs transtrochanteric fracture / Anatomia radiográfica do fêmur proximal: fratura de colo vs. fratura transtrocantérica

ABSTRACT OBJECTIVE: To evaluate the correlation between radiographic parameters of the proximal femur with femoral neck fractures or transtrochanteric fractures. METHODS: Cervicodiaphyseal angle (CDA), femoral neck width (FNW), hip axis length (HAL), and acetabular tear drop distance (ATD) were analyzed in 30 pelvis anteroposterior view X-rays of patients with femoral neck fractures (n = 15) and transtrochanteric fractures (n = 15). The analysis was performed by comparing the results of the X-rays with femoral neck fractures and with transtrochanteric fractures. RESULTS: No statistically significant differences between samples were observed. CONCLUSION: There was no correlation between radiographic parameters evaluated and specific occurrence of femoral neck fractures or transtrochanteric fractures.

RESUMO OBJETIVO: Correlacionar parâmetros radiográficos do fêmur proximal com a ocorrência de fraturas do colo do fêmur ou fraturas transtrocantéricas do fêmur. MÉTODOS: Foram avaliados o ângulo cevicodiafisário (ACD), a largura do colo femoral (LCF), o comprimento do eixo do quadril (CEQ) e a distância entre as lágrimas acetabulares (DL) de radiografias de bacia em incidência anteroposterior de 30 pacientes com fratura de colo de fêmur (n = 15) e fratura transtrocantérica de fêmur (n = 15). A avaliação foi feita com a comparação dos pacientes com fratura de colo de fêmur com os pacientes com fratura transtrocantérica. RESULTADOS: Não foram observadas diferenças estatisticamente significantes entre as amostras obtidas entre os dois grupos comparados. CONCLUSÃO: Não houve correlação entre os parâmetros radiográficos avaliados e ocorrência específica de fraturas de colo de fêmur ou fraturas transtrocantéricas de fêmur.

Evaluación de score de hueso trabecular (TBS) en pacientes menopáusicas con fracturas y sin ellas / Trabecular bone score evaluation in postmenopausal women with or without fractures

El score de hueso trabecular (TBS, Trabecular Bone Score) es una medición de la textura de los grises derivada de la evaluación del raquis por DXA y proporciona un índice de la microarquitectura ósea. Se ha demostrado que los valores bajos presentan capacidad para predecir fracturas. Nuestro objetivo fue evaluar si existían diferencias entre los valores de TBS de pacientes con fracturas frente a no fracturadas. Materiales y métodos: se revisaron 159 historias clínicas de mujeres menopáusicas que consultaron para evaluación de su salud ósea. Se consideraron los antecedentes autorreferidos de fracturas (Fx), la DMO de raquis, cuello femoral y fémur total y TBS. Resultados: treinta pacientes (18,9%) presentaron fracturas y en ellas se observó menor TBS (con Fx: 1,295±83 vs. sin Fx: 1,366±84, p<0,0001), menor índice de masa corporal (IMC) (con Fx: 23,7±1,9 vs. sin Fx: 25,7±4,2, p=0,02), sin diferencias en la edad (p=0,39), ni en valores de DMO (L1-L4 p=0,11, cuello femoral p=0,20 y fémur total p= 0,12). Muchas de las fracturas ocurrieron en pacientes sin osteoporosis por DXA. Conclusiones: el TBS aumentaría la capacidad de DXA para identificar a mujeres argentinas en riesgo de padecer fracturas sin tener osteoporosis densitométrica. Este es el primer trabajo realizado en la Argentina con medición de TBS. (AU)

Trabecular Bone Score (TBS) is a measure of the grey scale derived from DXA lumbar image and provides information about microarchitecture. It has been shown that low TBS values can predict fractures. Our objective was to evaluate if there are any differences between the TBS values in patients with fractures vs. non-fractures. Materials and methods: We reviewed 159 medical records of menopausal women who consulted for evaluation of their bone health. Self-reported fractures (Fx), spine BMD, femoral neck and total femur and TBS were evaluated. Results: thirty patients (18.9%) presented fractures and they showed lower TBS (with Fx: 1,295±0,083 vs. without Fx: 1,366±0,084, p<0.0001), lower body mass index (BMI) (with Fx: 23.7±1.9 vs. without Fx 25.7±4.2, p=0.02), without differences in ages (p=0.39) or in BMD values (L1-L4 p=0.11, femoral neck p=0.20 and total femur p=0.12). Some fractures occurred in patients without osteoporosis, as determined by DXA. Conclusions: TBS would increase the ability of DXA to identify Argentine women at risk for fractures without densitometric osteoporosis. This is the first work done in Argentina with TBS measurement. (AU)

Three dimensional morphometry of proximal femur to design best-fit Femoral stem for Indonesian population / Morfometría tridimensional del fémur proximal para diseñar prótesis a medida en la población de indonesa

To design custom-made prosthesis in a certain population, the morphometry needs to be measured. The results of this study were expected to provide basic data to design the ideal size of the total hip arthoplasty prosthesis for Indonesian population. This was an anthropometric study conducted on sex matched 100 healthy Indonesian mongoloid race subjects based on Computer Tomographic (CT) imaging on the proximal femur. The parameters being used in this study were Femoral Head Offset (FHO), Femoral Head Position (FHP), Femoral Head Diameter (FHD), Neck-Shaft Angle (NSA), Anteroposterior Width (APW) and Mediolateral Width at 3 different locations, and Canal Flare Index (CFI). This study showed that Indonesian has smaller proximal femur morphometry as compared to Western population. The mean value of all parameters in male were larger than female. Moreover, FHO and FHP showed significant difference among male and female indicating the location of male femoral head center lies superiorly as compared to female. The dimension of femoral canal was found to be mediolaterally oval, 1.43, 1.28, and 1,34, respectively, in 3 different cutting (20 mm above and 40 mm below lesser trochanter, and isthmus). CFI of Indonesian was classified to be stovepipe femoral canal (2.99) that is the suggestion to use cemented femoral stem. This study showed that Indonesian proximal femur dimension has smaller build compared with Western counterpart. The proposed dimensions can be used as the basic data to design the ideal size of the femoral stem for Indonesian population.

Para diseñar prótesis a medida en una población determinada, la morfometría necesita ser conocida. El objetivo de este estudio fue obtener resultados que sean útiles en la investigación para diseñar el tamaño ideal de una prótesis total de artroplastía de cadera para la población de Indonesia. Fue realizado un estudio antropométrico en 100 sujetos sanos de raza mongoloide de Indonesia, en los que se estudió la parte proximal del fémur por tomografía computadorizada (TC). Se consideraron como parámetros la cabeza del fémur (CF), posición de la cabeza del fémur (PCF), diámetro de la cabeza del fémur (DCF), ángulo cérvicodiafisario (ACD), ancho anteroposterior (AAP) y ancho-lateral en 3 lugares diferentes. La población Indonesia tiene una morfometría menor del fémur proximal en comparación con la población occidental. El valor medio de todos los parámetros en hombres fueron mayores a las mujeres. Por otra parte, CF y PCF mostraron diferencia significativa entre hombres y mujeres e indicó una ubicación superior del centro de la cabeza del fémur en hombres, en comparación con las mujeres. Se encontró que la dimensión del canal femoral fue mediolateral oval, 1,43, 1,28, y 1,34, en 3 cortes diferentes, respectivamente (20 mm superior y 40 mm inferior del trocánter menor e istmo). La dimensión del fémur proximal en la población de Indonesia es de menor tamaño en comparación con la contraparte occidental. Las dimensiones propuestas se pueden utilizar como datos básicos para el diseño de un tamaño ideal de vástago femoral para la población Indonesia.

Osteosarcoma con presentación atípica en tercio medio de diáfisis de fémur. Reporte de un caso clínico y revisión de la literatura / Atipic osteosarcoma in the femoral shaft case report and review of the literature

Resumen: El osteosarcoma es el tumor maligno primario más frecuente del hueso. Se caracteriza por la formación de osteoide por las células tumorales. Su localización más frecuente es en las metáfisis de los huesos largos; sin embargo, la presentación puramente diafisaria se reporta en 10% de los casos. Se expone el caso de paciente del género femenino de 25 años que inició padecimiento cuatro meses previos a nuestra valoración al presentar dolor y aumento de volumen en tercio medio de muslo derecho, sin causa aparente. Las radiografías del fémur revelaron un tumor en la diáfisis del mismo. La resonancia magnética mostró extensión a partes blandas, sin compromiso del paquete neurovascular. Se tomó biopsia incisional con reporte histopatológico de osteosarcoma osteoblástico y condroblástico. Se clasificó como Enneking IIB, AJCC IIB. Inició tratamiento con tres ciclos de quimioterapia neoadyuvante y posteriormente se le realizó resección intercalar de fémur más reconstrucción con clavo centromedular y espaciador diafisario. El reporte histopatológico evidenció necrosis de 95% (Huvos grado III). Se continuó con tres ciclos de quimioterapia adyuvante. A 18 meses de concluida la quimioterapia adyuvante la paciente se encuentra sin datos de actividad tumoral local o a distancia, tolerando la deambulación sin auxiliares de la marcha. A pesar de que el osteosarcoma no se presenta de forma habitual en el tercio medio de la diáfisis de los huesos largos, debe siempre tomarse en cuenta como un diagnóstico diferencial con otras patologías de localización más frecuente en dicha región. Esta localización nos permite una amplia gama de alternativas quirúrgicas con la preservación de las articulaciones adyacentes.

Abstract: Osteosarcoma is the most frequent primary malignant bone tumor. It is characterized by osteoid production by tumor cells. Its most frequent location is in the metaphyses of long bones, but a purely diaphyseal presentation is reported in 10% of cases. We report the case of a female 25 year-old patient whose symptoms of pain and swelling of the right mid thigh started four months before, without an apparent cause. Femur X-rays showed a tumor in the femoral shaft. The MRI showed extension to soft tissues with no compromise of the neurovascular bundle. The histopathologic report of the incisional biopsy was osteoblastic and chondroblastic osteosarcoma, classified as Enneking IIB, AJCC IIB. Treatment consisted of three cycles of neoadjuvant chemotherapy. Then intercalary femur resection plus reconstruction with centromedullary nailing and a diaphyseal spacer were performed. The histopathologic report was 95% necrosis (Huvos grade III). Three cycles of adjuvant chemotherapy were given and now, 18 months after completing the latter, the patient has no signs of local or distant tumor activity, and she can walk unassisted. Despite the fact that osteosarcoma does not occur usually in the mid shaft of long bones, we should always bear it in mind as part of the differential diagnosis for other conditions that occur more frequently in that region. Such location allows for a broad gamut of surgical approaches that spare the adjacent joints.

Validación posoperatoria en la selección asistida por computadora de aloinjertos de fémur distal / Postoperative assessment in computer assisted selection of femur osteoarticular allograft

El objetivo de nuestro trabajo fue comparar dos grupos de pacientes tratados con trasplantes osteoarticulares del fémur distal en términos de evaluar: 1) el volumen del fémur distal del receptor y del trasplante, 2) la superficie articular de contacto del fémur distal del receptor y del trasplante, 3) el ángulo del valgo anatómico femoral del fémur distal del receptor y del trasplante. Materiales y métodos: se realizó una búsqueda retrospectiva entre 2002 y 2012 analizando a pacientes tratados con un trasplante osteoarticular de fémur distal. Se incluyó un total de 32 pacientes. Estos fueron divididos en dos grupos de acuerdo con el método de selección del trasplante: Grupo 1, conformado por 16 pacientes con trasplantes seleccionados mediante tomografía 2D y Grupo 2, 16 pacientes con trasplantes seleccionados a través de un método 3D. La evaluación fue realizada por un observador independiente y ciego para los dos grupos. Resultados: las diferencias en las pruebas de estimación de volumen y superficie articulares entre el donante y el receptor no fueron estadísticamente significativas (p>0,05). Sin embargo, la diferencia entre los ángulos de valgo del fémur receptor y el fémur donante, seleccionados por el método 2D fue significativa (p<0,05), mientras que la diferencia de estos ángulos en el método 3D no lo fue (p>0,05). Conclusión: el método de selección de un aloinjerto, mediante la utilización de un banco de huesos virtual 3D para la reconstrucción con un trasplante osteoarticular de femur distal, permite obtener una mejor alineación del miembro comparado con aquellos seleccionados solo con un método bidimensional. (AU)

The aim of our study was to compare two groups of patients treated with distal femur osteoarticular allograft in terms of: 1) the volume of the distal femur of the allograft and patient, 2) the articular surface contact, 3) the anatomical femoral valgus angle. Material and methods: a retrospective review was performed between 2002 and 2012 and all patients with an osteo-articular allograft of the distal femur were analysed. A total of 32 patients were included in the study. Patients were divided into two groups according to the selection method of the allograft: Group 1, 16 patients with allograft selected by 2D (CT) and Group 2, 16 patients selected through a 3D method. The evaluation was done by an independent and blind observer. Results: the differences in terms of volume estimation and joint surface contact between the donor allograft and patient distal femur were not statistically significant (p>0.05). However, the difference between the valgus angle showed significant differences between donor and patient femurs selected by the 2D method (p<0.05) but no difference in the group of patients selected by 3D method (p>0.05). Conclusion: the 3D method for allograft selection of the distal femur showed better results in limb alignment compared to 2D selection method. (AU)

Bursectomy, Curettage, and Chemotherapy in Tuberculous Trochanteric Bursitis

We presented three patients with trochanteric tuberculosis and described the clinical and imaging findings of the infection. Histology revealed a necrotizing granulomatous bursitis and microbiology confirmed tuberculosis. All cases were successfully treated with bursectomy and curettage of the trochanteric lesion and antituberculous chemotherapy including isoniazid, pyrazinamide, rifampicin, and ethambutol.