Reconstrucción de aparato extensor en sarcoma fibromixoide de bajo grado en rodilla: reporte de caso

Introducción: El sarcoma fibromixoide de bajo grado es una tumoración maligna con alto riesgo de desarrollar recurrencia y metástasis, siendo la resección quirúrgica con márgenes amplios el tratamiento principal, la preservación de la extremidad y su reconstrucción es de alta demanda para los cirujanos. Reporte de caso: Presentamos el caso de una mujer de 67 años con recurrencia de tumoración en rodilla desde hace 12 meses, operado dos años antes. Se realizo resección oncológica de tumoración con reconstrucción de articulación de rodilla con prótesis Endo Model y reconstrucción de aparato extensor con injerto sintético de malla de polipropileno más autoinjerto de semitendinoso y gracilis. La patela se reconstruyó con autoinjerto de cóndilo femoral posterior. A los 16 meses de seguimiento la paciente se encuentra libre de enfermedad, con puntaje de 27 en la escala para miembro inferior de la MSTS (Musculoskeletal Tumour Society). Conclusión: La combinación de injerto sintético con autoinjerto de isquiotibiales puede disminuir la tasa de falla de la reconstrucción del aparato extensor por resecciones oncológicas.

Introduction: Low-grade fibromyxoid sarcoma is a malignant tumor with a high risk of developing recurrence and metastasis, surgical resection with wide margins is the main treatment, limb preservation and reconstruction is in high demand for surgeons. Case of report: We present the case of a 67-year-old woman with a recurrence of a knee tumor that had been operated on two year earlier. Oncological resection of the tumor was performed with reconstruction of the knee joint with an Endo Model prosthesis and extensor mechanism reconstruction with a synthetic polypropylene mesh graft plus a semitendinosus and gracilis autograft. The patella was reconstructed with posterior femoral condyle autograft. At 16 months of patient follow-up, she is free of disease, with a score of 27 on the lower limb scale of the MSTS (Musculoskeletal Tumor Society). Conclusion: The combination of synthetic graft with hamstring autograft can reduce the failure rate of extensor mechanism reconstruction due to oncological resections.

Realineamiento Proximal del Mecanismo Extensor en la Luxación Congénita de la Rótula en Niños y Adolescentes / Proximal Realignment of the Extensor Mechanism in Congenital Dislocation of the Knee in Children And Adolescents

Introducción La luxación congénita de la rótula (LCR) es una entidad poco frecuente. El diagnóstico precoz suele ser difícil porque la rótula en el recién nacido es pequeña y de difícil palpación. El tratamiento no quirúrgico ha demostrado ser ineficaz. El enfoque terapéutico de esta patología requiere de la liberación externa y extensa del cuádriceps, el avance del vasto interno oblicuo y de la transferencia o hemitransferencia del aparato extensor. Materiales y métodos se busca evaluar la funcionalidad de los pacientes tratados quirúrgicamente mediante realineamiento proximal del mecanismo extensor por la técnica descrita por Green y modificada por los autores. Desde el año 2000 hasta el año 2015 se recolectaron 15 pacientes (20 rodillas) con diagnóstico de LCR tratados quirúrgicamente mediante la técnica descrita. Resultados Los resultados postoperatorios fueron evaluados mediante el cuestionario Kujala: 93.8/100 en promedio. Discusión El tratamiento de la LCR es un desafío y más aún si se encuentra asociada a retracción idiopática del recto anterior. Los resultados clínicos y funcionales obtenidos sugieren que la recolocación anatómica y estable de la rótula dentro de la tróclea femoral permite una satisfactoria alineación extensora del cuádriceps, desapareciendo su acción flexora inicial, lo que permite la elongación progresiva del mecanismo extensor durante las fases postoperatorias de rehabilitación. La técnica quirúrgica descrita ofrece una buena alternativa para el tratamiento de esta infrecuente patología congénita de la rodilla.

Background Congenital dislocation of the patella (CDP) is a rare condition. The early diagnosis is difficult, as the patella in the newborns is small and also difficult to recognise. The therapeutic approach of this disorder requires the extended and external release of the quadriceps, the forward movement of the internal oblique vastus, and the transfer or hemi-transfer of the extensor compartment. Methods To review the functionality of those patients who have received surgical treatment with proximal realignment of the extensor mechanism using Green's surgical technique and the one modified by the author. Between the years 2000 and 2015, a total of 15 patients with 20 knees found to have had congenital dislocation of the patella, and had received the abovementioned surgical treatment. Results The post-operative results were evaluated using the Kujala questionnaire, which gave a mean result of 93.8 / 100. Discussion The CDP treatment is a challenge, and even more so if it is associated with an idiopathic retraction of the anterior rectus. The clinical and functional results obtained suggest that an anatomic and stable realignment of the patella in the femoral trochlea allows a satisfactory extensor alignment of the quadriceps. This leads to the disappearance its initial flexor action, which allows the gradual elongation of the extensor mechanism during the postoperative phases of rehabilitation. The surgical technique described offers a good alternative for the treatment of this rare congenital disorder of the knee.

Paratricepital Approach for Fixation of Distal Humerus Fractures in Adult – A Review of Thirty Cases

Background: Distal humerus fractures are most commonly managed by surgical approaches that disrupt the extensor mechanismof the elbow. Paratricepital approach for distal humerus fracture fixation has been done by orthogonal or parallel plate constructthat allows excellent healing of fracture, motion arc of elbow more than 100°, and maintains of extensor mechanism strength.Materials and Methods: Atotal of 30 cases of distal humerus fractures are fixed by paratricepital posterior approach. Bicolumnerfixation done by elevating and retracting the triceps of the distal humerus keeping triceps insertion undisturbed by orthogonalor parallel plate construct. Early active-assisted range of motion initiated within limits of pain. The age group was 15–60 years.Among them 21% was Type A fracture, 17% Type B fracture, 33% Type C1 fracture, and 29% Type C2 fracture. More than60% of cases have 1 year of follow-up. Radiograph and functional evaluation were done by mayo elbow performance score(MEPS), disability of arm, shoulder, and hand questionnaire.Results: All 30 fractures healed primarily. The median arc of elbow motion was 105° (range 70°–140°). Average MEPS was91 points (range 65–100) indicating excellent scores.Conclusion: Treatment of distal humerus fracture in adults by paratricepital posterior approach results in excellent healing, amean flexion extensor arc more than 100°, maintains of almost normal elbow extensor strength compared with the contralateralnormal elbow.

Total knee arthroplasty:Comparison between quadriceps sparing approach and medial parapatellar approach / 中国组织工程研究

BACKGROUND:Now, domestic total knee arthroplasty surgeries mainly use medial parapatel ar approach, with the disadvantages of large trauma and slower recovery. The quadriceps sparing approach is more accorded with normal anatomy, which can keep the knee extension system intact. The clinical comparison between quadriceps sparing approach and medial parapatel ar approach is rare. OBJECTIVE:To compare the early effect of total knee arthroplasty through quadriceps sparing approach and medial parapatel ar approach. METHODS:From January 2009 to January 2010, 55 patients (70 knees) were randomly divided into quadriceps sparing approach group (n=26, 35 knees) and medial parapatel ar approach group (n=29, 35 knees). Patients in two groups received total knee arthroplasty through quadriceps sparing approach and medial parapatel ar approach respectively. The incision length, operative time, postoperative drainage volume, additional amount of etoricoxib tablets, pain degree, straight leg raising time, start walking time, hospitalization time, range of motion of knee joint, Hospital for Special Surgery Knee Score, radiographic alignment of al components and complications were compared between two groups. Al the prostheses used in this study were the Sigma type prostheses provided by the rotation platform of Johnson&Johnson Company. RESULTS AND CONCLUSION:Al the patients were fol owed-up for 12-24 months without infections, deep vein thrombosis, neurovascular injury, prosthesis instability, prosthesis loosening or displacement. Position of al the prostheses was normal in patients. The operative time in the quadriceps sparing approach group was longer than that in the medial parapatel ar approach group (P=0.00), while the incision length, postoperative drainage volume, additional amount of etoricoxib tablets, visual analog scale, straight leg raising time, start walking time, hospitalization time, range of motion of knee joint at 3 days after replacement and Hospital for Special Surgery Knee Score in the quadriceps sparing approach group were better than those in the medial parapatel ar approach group (Psignificant differences in range of motion of knee joint at 3 days after replacement and Hospital for Special Surgery Knee Score between two groups. The early effect of total knee arthroplasty through quadriceps sparing approach is better than the medial parapatel ar approach, and there is no significant difference in prosthesis alignment between two methods.

Total Knee Arthroplasty in Hemophiliacs: Gains in Range of Motion Realized beyond Twelve Months Postoperatively

BACKGROUND: Hemophiliacs have extrinsic tightness from quadriceps and flexion contractures. We sought to examine the effect of a focused physical therapy regimen geared to hemophilic total knee arthroplasty. METHODS: Twenty-four knees undergoing intensive hemophiliac-specific physical therapy after total knee arthroplasty, at an average age of 46 years, were followed to an average 50 months. RESULTS: For all patients, flexion contracture improved from -10.5 degrees preoperatively to -5.1 degrees at final follow-up (p = 0.02). Knees with preoperative flexion less than 90 degrees were compared to knees with preoperative flexion greater than 90 degrees. Patients with preoperative flexion less than 90 degrees experienced improved flexion (p = 0.02), along with improved arc range of motion (ROM) and decreased flexion contracture. For those patients with specific twelve-month and final follow-up data points, there was a significant gain in flexion between twelve months and final follow-up (p = 0.02). CONCLUSIONS: Hemophiliacs with the poorest flexion benefited most from focused quadriceps stretching to a more functional length, with gains not usually seen in the osteoarthritic population. This data may challenge traditional views that ROM gains are not expected beyond 12-18 months.

Ortesis para el tratamiento del dedo en martillo traumático: experiencia en la parroquia Guasdualito (Venezuela) / Orthesis for the treatment of traumatic hammer finger: experience in Guasdualito jurisdiction (Venezuela) / Orthèse pour le traitement du doigt en marteau, un cas à la paroisse Guasdualito (Venezuela)

INTRODUCCIÓN. El dedo en martillo constituye una discontinuidad del mecanismo extensor de la articulación interfalángica distal y es una de las lesiones más comunes en los extremos de los dedos. El presente trabajo tuvo como objetivo mostrar los resultados preliminares obtenidos con una ortesis de alambre de Kirschner (ideada por A. F. Fernández Abreu), confeccionada y colocada de urgencia en el cuerpo de guardia a pacientes con dedo en martillo traumático. MÉTODOS. Se realizó un estudio de 18 pacientes, con edades entre 14 y 56 años, que fueron atendidos durante 10 meses en el Centro de Atención Integral de la Parroquia Guasdualito, en la República Bolivariana de Venezuela. Los pacientes tenían diagnóstico de dedo en martillo traumático y para su tratamiento se utilizó la ortesis presentada por Fernández Abreu y cols. Ésta se confeccionó con alambre de calibre de 1 mm, en el cuerpo de guardia por el propio traumatólogo, pues acelera el proceso de curación e implica un bajo costo para el paciente y la institución. El período de inmovilización promedio fue de 6 semanas. RESULTADOS. Predominó el sexo masculino (12 pacientes; 66,7 por ciento) y el dedo anular fue el más afectado (66,7 por ciento). Los accidentes deportivos fueron la causa más frecuente (10 pacientes; 55,6 por ciento). Según la clasificación de Bunnel, 10 pacientes presentaron lesiones de grado II (55,6 por ciento) y 8 de grado III (44,4 por ciento). Los resultados fueron buenos en 14 pacientes (77,8 por ciento), regular y malo, con 2 pacientes cada uno. Solo un paciente presentó rigidez articular al término del tratamiento y se encuentra en rehabilitación. CONCLUSIONES. Proponemos generalizar el tratamiento inmediato para el dedo en martillo traumático con esta ortesis que, además de ser de bajo costo, es muy cómoda para los pacientes. Constituye una opción de tratamiento ideal para los pacientes de esta parroquia.

INTRODUCTION. The hammer finger is a lack of continuity of extensor mechanism of distal interphalangeal joint (DIJ) and also is a commonest lesions of finger's terminal phalanx. The aim of present paper was to show the preliminary results obtained with a Kirschner's wire Orthesis (designed by A.F. Fernández Abreu), drawed up and placed in Emergency Room to patients with hammer fingers that urgently needed these device. METHODS. Authors made an study in eighteen patients aged between 14 and 56 seen during 10 months in Integral Care Center of Guasdualito jurisdiction in Venezuela. Patients were diagnosed with traumatic hammer fingers using for treatment the Orthesis of Fernández Abreu et al. It was a1mm diameter wire designed in Emergency Room by the traumatologist himself, thus it accelerates the cure process and has a low cost for patient and for institution. The mean immobilization period was of 6 weeks. RESULTS. There was a sex male predominance (12 patients, 66,7 percent) and the annular finger was the more affected (66,7 percent). Sports accidents were the more frequent cause (10 patients, 55,6 percent). According to Bunnel classification, 10 patients had II degree lesions (55,6 percent) and 8 had III degree lesions (44,4 percent). Results were good in 14 patients (77,8 percent), regular and poor in two patients each. Only one patient had articular stiffness at the end of treatment and is under rehabilitation. CONCLUSIONS. Our proposal is to generalize the immediate treatment for traumatic hammer finger using this Orthesis because of its low cost and it is very comfortable for patients and is an ideal treatment choice for patients of this jurisdiction.

INTRODUCTION. Le doigt en marteau constitue une perte de l'extension active de l'articulation interphalangienne distale, et c'est l'une des lésions les plus fréquentes des doigts. Ce travail a pour but de montrer les résultats préliminaires obtenus par la orthèse à fil (Kirschner) (sous l'idée de A. F. Fernández Abreu), fabriquée et mise en place au service des urgences chez des patients atteints de doigt en marteau. MÉTHODES. Une étude de 18 patients âgés de 14 à 56 ans, ayant été sous traitement pendant 10 mois au Centre des soins intégraux de la paroisse Guasdualito, à Venezuela, a été réalisée. Les patients ont été diagnostiqués de doigt en marteau, et traités par une orthèse présentée par Fernández Abreu et col. Cette orthèse a été fabriquée au service des urgences par le même traumatologiste, avec un fil de 1 mm de diamètre, afin d'accélérer la guérison et de baisser les coûts pour le patient et le service. La période d'immobilisation a été de 6 semaines en moyenne. RÉSULTATS. Le sexe masculin a été en prédominance (12 patients = 66,7 percent); et c'est le doigt annulaire le plus fréquemment affecté (66,7 percent). La cause la plus fréquente a été l'accident des sports (10 patients: 55,6 percent). D'après la classification de Bunnel, dix patients ont subi des lésions grade II (55,6 percent), et 8 des lésions grade III (44,4 percent). Les résultats ont été bons chez 14 patients (77,8 percent), passables chez 2 patients, et mauvais chez 2 patients aussi. Un seul patient a été atteint de rigidité articulaire à la fin du traitement, et il est en rééducation. CONCLUSIONS. On a conseillé de généraliser le traitement immédiat du doigt en marteau par cette orthèse, étant en plus bon marché et très confortable pour les patients. Cette technique constitue une traitement alternatif idéal pour les patients de cette paroisse.

Treatment of Hoffa facture associated with extensor mechanism injury / 中国矫形外科杂志

[Objective]To investigate the injury characteristics and treatment of the Hoffa facture associated with extensor mechanism injury.[Method]Four patients with Hoffa facture associated with extensor mechanism injury treated in author's hospital in recent 6 years were enrolled in this study.All the patients were multiple-injured,and associated with the ipsilateral limb fracture and retinacular and capsule laceration.The site of the extensor mechanism injury included 1 distal patellar tendon disruption,2 proximal patellar tendon disruption,and 1 distal quadriceps tendon disruption.No cruciate ligament injury was found in 3 ipsilateral bicondylar fractures.One unicondylar fracture was associated with anterior and posterior cruciate ligament and medial collateral ligament injury simultaneously.Emergency operation was performed along with the debridement in the three open fractures.In another patient with closed fracture,operation was performed one week after injury.Fractures were reduced and fixed with lag screws.Extensor apparatus were repaired and strengthened with a tension band wire through both patella and tibia.Ipsilateral limb fractures were reduced and internal fixed with hardware simultaneously. The knees were immobilized in extension with cast after operation,and flexion exercise was commenced four to six weeks later.[Result]Four patients wounds reached the first rate healing.There was no infection and necrosis of skin.All patients were followed-up for six months to three years.All 7 condyles of the 4 patients reached bone union.Healing time was about six to twelve weeks.According to Letenneur’s functional assessment system,excellent and good results were in 1 cases,fine in 3 cases.[Conclusion]Hoffa facture associated with extensor mechanism injury are usually accompanied with injuries in other part of the body.In open fracture,emergency operation is mandatory,and fracture reduction and internal fixation and extensor apparatus repair should be performed along with debridement.Tension band wire may strengthen the stability of the extensor mechanism and facilitated early mobilization.

Extensor Mechanism Injuries of the Finger / 대한정형외과학회잡지

Injuries to the extensor mechanism include a wide range of injuries from minor one to massive defect. And the methods of treatment must be individualized according to the anatomical site, extent and chronicity of injuries. The extensor mechanism is a triangular thin sheet like structure, the function of which cannot be explained completely by the Tubiana's church-steeple like diagram. Authors think that the extensor mechanism should be repaired or reconstructed as a triangular sheet. The tension of the repaired or reconstructed tendon was estimated as good when the neutral extensions were obtained in all the MP, PIP and DIP joints after the completion of sutures. Also authors think that stable sutures are mandatory for the early rehabilitation postopoeratively. Seventy-five patients have been treated by the authors from 1982 to 1994. According to zonal classification, forty-two patients were injured in Zone I. 5 in Zone II, 21 in Zone III, 5 in Zone IV and 2 patients were unclassified due to massive defects of the extensor mechanism. Mostly bony mallet injuries were treated by open reduction and K-wire fixation. Acute tendinous mallet injuries were treated by conservative splinting and old injuries were treated by anatomical plication of the terminal extensor tendon. Old buttonhole deformities were generally treated by the central tendon plication. Massive defects were managed by skin coverage and reconstruction of the extensor mechanism by using a tendon graft which was tailored like a triangular thin sheet. With author's treatment principles, excellent or good results were obtained in about 87%. Consequently, authors emphasize that an anatomical repair or reconstruction is a keystone in the treatment of injuries to the extensor mechanism.