Vasculitis reumatoidea: una manifestación poco habitual. Presentación de tres casos clínicos y revisión de la literatura

La vasculitis reumatoidea es una complicación sistémica y poco frecuente de la Artritis Reumatoidea. Si bien su incidencia ha descendido en los últimos años con el advenimiento de las nuevas terapias inmunosupresoras y biológicas, continua teniendo una alta morbimortalidad. Predomina en el sexo masculino, en pacientes seropositivos y con un largo período de la enfermedad establecida. Requiere de alta presunción diagnostica, siendo el compromiso cutáneo y nervioso periférico el más frecuente. La biopsia de nervio o piel es requerida habitualmente para su diagnóstico. El tratamiento se basa en corticoides e inmunosupresores. Presentamos tres casos clínicos y realizamos una revisión de la literatura.

Rheumatoid vasculitis is a rare systemic complication of rheumatoid arthritis. Although its incidence has decreased in recent years with the advent of new immunosuppressive and biological therapies, it continues to have a high morbidity and mortality. It predominates in males, in seropositive patients and with a long period of established disease. It requires high diagnostic presumption, with skin and peripheral nervous involvement being the most affected. Nerve or skin biopsy is usually required for diagnosis. Treatment is based on corticosteroids and immunosuppressants. We present three clinical cases and carry out a review of the literature.

A vasculite reumatóide é uma complicação sistêmica rara da artrite reumatóide. Embora sua incidência tenha diminuído nos últimos anos com o advento de novas terapias imunossupressoras e biológicas, continua apresentando elevada morbidade e mortalidade. Predomina no sexo masculino, em pacientes soropositivos e com longo período de doença estabelecida. Exige alta presunção diagnóstica, sendo o envolvimento cutâneo e nervoso periférico os mais afetados. A biópsia de nervo ou pele geralmente é necessária para o diagnóstico. O tratamento é baseado em corticosteroides e imunossupressores. Apresentamos três casos clínicos e realizamos uma revisão da literatura.

Manifestaciones digestivas en el curso de enfermedades reumáticas, estudio de 5 años / Digestive manifestations in the course of rheumatic diseases, 5-year study

RESUMEN Introducción: Las enfermedades reumáticas son un grupo de alrededor de 250 afecciones que afectan fundamentalmente el sistema osteomioarticular, aunque la mayoría tiene un carácter sistémico. En el caso del sistema digestivo el compromiso puede estar causado por el propio proceso inflamatorio de la enfermedad o secundario a la afectación que causa los distintos grupos farmacológicos usados contra las enfermedades reumáticas. Objetivo: Caracterizar el compromiso digestivo de una cohorte de paciente con enfermedades reumáticas durante un periodo de estudio de 5 años. Métodos: Investigación básica, no experimental, descriptiva y longitudinal que incluyó como población de estudio una cohorte de 109 pacientes con diagnóstico de enfermedades reumáticas según criterios del Colegio Americano de Reumatología. Se identificaron las características generales de los pacientes, de las enfermedades reumáticas incluidas en la investigación y las principales manifestaciones digestivas identificadas. Resultado: Promedio de edad de 57,83 años, predominio de pacientes femeninas (71,56 %), procedencia urbana (55,05 %) y con diagnóstico de artritis reumatoide (50,46 %). El 90,82 % de los pacientes refirió haber utilizado glucocorticoides. El 94,49 % de los pacientes presentó algún tipo de manifestación extraarticular digestiva. La gastritis (36,89 %), úlcera péptica (25,24 %), reflujo gastroesofágico (18,45 %) y sequedad bucal (15,53 %) fueron las de mayor frecuencia de presentación. Conclusiones: Las manifestaciones digestivas constituyen una expresión extraarticular frecuente en el curso de las enfermedades reumáticas. Su origen pude estar supeditado a la patogenia de la enfermedad o a los eventos adversos de los grupos farmacológicos utilizados en los esquemas terapéuticos de las enfermedades reumáticas. Los glucocorticoides fueron el grupo farmacológico más usado. Algunas manifestaciones digestivas puede llegar a poner en peligro la vida de los pacientes.

ABSTRACT Introduction: Rheumatic diseases are a group of around 250 conditions that mainly affect the osteomyoarticular system, but most of them have a systemic nature, which is why they affect different organs and organ systems. In the case of the digestive system, the compromise may be caused by the inflammatory process of the disease itself or secondary to the affectation generated by the different pharmacological groups that are used to control rheumatic diseases. Objective: To characterize the digestive compromise of a cohort of patients with rheumatic diseases during a study period of 5 years. Methods: Basic, non-experimental, descriptive, correlational and longitudinal research that included as a study population a cohort of 109 patients diagnosed with rheumatic diseases according to the criteria of the American College of Rheumatology. The general characteristics of the patients, the rheumatic diseases included in the research, the main digestive manifestations identified were identified. Result: Average age of 57.83 years, predominance of female patients (71.56%), urban origin (55.05%) and with a diagnosis of rheumatoid arthritis (50.46%). 90.82% of the patients reported having used glucocorticoids. 94.49% of the patients presented some type of extra-articular digestive manifestation. Gastritis (36.89%), peptic ulcer (25.24%), gastroesophageal reflux (18.45%) and dry mouth (15.53%) were the ones with the highest frequency of presentation. Conclusions: Digestive manifestations are a frequent extra-articular expression in the course of rheumatic diseases. Its origin may be subject to the etiopathogenic mechanisms of the disease or to the adverse events of the pharmacological groups used in the therapeutic regimens for rheumatic diseases. Glucocorticoids were the most frequently used pharmacological group in the therapeutic regimens for rheumatic diseases. The presence of some digestive manifestations endanger the lives of patients.

Manifestaciones extrarticulares y anticuerpos contra péptidos cíclicos citrulinados en artritis reumatoide / Extrarticular manifestations and antibodies against citrullinated cyclic peptides in rheumatoid arthritis

Introducción: La artritis reumatoide se manifiesta como enfermedad inflamatoria sistémica presenta manifestaciones extrarticulares. Objetivos: Determinar la frecuencia de manifestaciones extrarticulares en pacientes con artritis reumatoide, identificar las más frecuentes y su asociación con anticuerpos contra péptidos cíclicos citrulinados. Métodos: Se realizó un estudio descriptivo y transversal, en 101 pacientes con diagnóstico de artritis reumatoide, atendidos en La Consulta Protocolizada del Servicio de Reumatología del Hospital Clínico Quirúrgico Hermanos Ameijeiras, entre agosto y diciembre del año 2019. Se identificaron características sociodemográficas como edad, sexo, tiempo de evolución de la artritis reumatoide y tabaquismo. Se buscaron presencia de manifestaciones extrarticulares por el interrogatorio, examen físico y con ayuda de exámenes complementarios y se determinaron los títulos de anticuerpos contra péptidos cíclicos citrulinados en el plasma de los pacientes. Resultados: Las manifestaciones extrarticulares estuvieron presentes en 38 pacientes para 37,6 por ciento de los casos, las más frecuentes fueron los nódulos subcutáneos 37 pacientes, y la anemia en 35 que constituyen 36,6 por ciento y 34,7 por ciento de los casos, respectivamente. Fueron positivos a antipéptidos cíclicos citrulinados 78 enfermos, 77,2 por ciento de la muestra, no existió asociación entre presencia de los antipéptidos cíclicos citrulinados y la actividad de la enfermedad. No existió asociación significativa entre estos anticuerpos y las manifestaciones extrarticulares p<0,0001. Fue significativa la asociación entre los niveles de antipéptidos cíclicos citrulinados y el número de manifestaciones extrarticulares en un paciente p=0,0018. Conclusiones: Las manifestaciones articulares existentes en los pacientes estudiados se asociaron, significativamente, con la presencia de los antipéptidos cíclicos citrulinados(AU)

Introduction: Rheumatoid arthritis within its expression as a systemic inflammatory disease presents extra-articular manifestations. Objectives: To determine the frequency of extra-articular manifestations in patients with rheumatoid arthritis, to identify the most frequent and their association with antibodies against citrullinated cyclic peptides. Methods: A descriptive and cross-sectional study was carried out in 101 patients with a diagnosis of rheumatoid arthritis, assisted in the protocolized consultation of Rheumatology service at Hermanos Ameijeiras Clinical Surgical Hospital, from August to December 2019. Sociodemographic characteristics were identified, such as age, sex, time of evolution of rheumatoid arthritis, smoking habits. The presence of extra-articular manifestations was searched for by questioning, physical examination and with the help of complementary tests, and the titers of antibodies against citrullinated cyclic peptides were determined in the plasma of the patients. Results: Extra-articular manifestations were present in 38 patients, 37.6percent of the cases, the most frequent were subcutaneous nodules in 37 patients, and anemia in 35, which constituted 36.6percent and 34.7percent of the cases, respectively. Seventy eight patients were positive for citrullinated cyclic antipeptides, 77.2percent of the sample, there was no association between the presence of citrullinated cyclic antipeptides and the activity of the disease. There was no significant association between the presence of these antibodies and the presence of extra-articular manifestations p <0.0001, the association between the levels of citrullinated cyclic antipeptides and the number of extra-articular manifestations in a patient was significant p=0.0018. Conclusions: The existing joint manifestations in the studied patients were significantly associated with the presence of citrullinated cyclic antipeptides(AU)

Osteosíntesis mínima invasiva percutánea con placa en fractura de tibia distal / Percutaneous Minimally Invasive Plate Osteosynthesis in Distal Tibial Fracture

Introducción: Las fracturas diafisarias de la tibia tienen una alta incidencia por año, incluidas las del tercio distal. Son las más frecuentes de los huesos largos y se observan sobre todo en adultos jóvenes. Se producen, generalmente, por traumatismos de alta energía como accidentes del tránsito y caídas de alturas. Objetivo: Presentar los resultados del tratamiento realizado a un paciente con fractura extrarticular del tercio distal de la tibia, mediante una técnica de osteosíntesis percutánea mínimamente invasiva. Presentación del caso: Paciente de 45 años, masculino, de piel blanca que sufrió accidente del tránsito, y fue atendido en el servicio de Ortopedia y Traumatología del Hospital General Docente Dr. Antonio Luaces Iraola, con trauma en pierna izquierda. Presentó dolor, inflamación e imposibilidad para caminar. A la exploración física se constató dolor, deformidad, crepitación, movilidad anormal, aumento de volumen e impotencia funcional absoluta. Se realizó radiografía, se corroboró diagnóstico y se decidió tratamiento quirúrgico con técnica mínima invasiva percutánea. Se siguieron los principios de la osteosíntesis biológica y se utilizó placa de segunda generación del sistema AO. Conclusiones: El tiempo quirúrgico fue de 45 minutos, la estadía hospitalaria fue de 48 horas. Se comenzó apoyo parcial a las ocho semanas, y total a las 15 semanas. Se logró la consolidación total de la fractura a las 16 semanas de operado, evaluado de excelente a través de la American Orthopaedic Foot and Ankle Society (AOFAS) score(AU)

Introduction: Diaphyseal fractures of the tibia have high incidence per year, including those of the distal third. They are the most common of the long bones and are seen mostly in young adults. They are generally caused by high-energy trauma such as traffic accidents and falls from heights. Objective: To present the results of the treatment on a patient with extra-articular fracture of the distal third of the tibia, using minimally invasive percutaneous osteosynthesis technique. Case report: A white 45-year-old male patient was injured in a traffic accident, and he was treated in the Orthopedics and Traumatology service at Dr. Antonio Luaces Iraola General Teaching Hospital, because of a trauma to his left leg. He had pain, swelling and inability to walk. Physical examination revealed pain, deformity, crepitus, abnormal mobility, increased volume, and absolute functional impotence. X-rays were performed. The diagnosis was confirmed, and surgical treatment was decided with a minimally invasive percutaneous technique. The principles of biological osteosynthesis were followed and a second generation plate of AO system was used. Conclusions: The surgical time was 45 minutes. The hospital stay was 48 hours. Partial support of the leg was started at eight weeks, and full support at 15 weeks. Full fracture healing was achieved 16 weeks after surgery, the procedure was evaluated as excellent according to the American Orthopedic Foot and Ankle Society (AOFAS) score(AU)

Extra-articular Extra-synovial Solitary Osteochondromatosis of the Ankle

ABSTRACT Synovial chondromatosis or osteochondromatosis is a benign neoplastic condition arising from synovial tissue of joints, tendon sheath and bursa. The commonly involved joints are the knee, hip, shoulder, elbow and ankle. According to the author's knowledge, only four cases have been reported in the English literature, describing the extra-articular synovial chondro-matosis around the ankle joint. The peculiarity of the index case lies in its subtle clinical and radiological presentations which can create a diagnostic dilemma.

Sequential Approach to Differential Diagnosis of TMJ Disorder from Other Oro Facial Muscles Pain – A Systematic Review

This systematic review (SR) synthesises recent evidence and assesses the methodological quality of published SRs in the Differential diagnosis of temporomandibular disorders (TMD). A systematic literature search was conducted in the PubMed, Cochrane Library, and Bandolier databases for 1987 to September 2019. Three investigators evaluated the methodological quality of each identified SR using two measurement tools: The assessment of multiple systematic reviews (AMSTAR) and level of research design scoring. Thirty-one SRs met inclusion criteria and 28 were analysed: 20 qualitative SRs and eight meta-analysis.The main aim of this article is to Differential diagnose the pain which is not related to any dental disease. Most of dental clinician have problem to diagnose TMD (Temporomandibular Disorders) and Orofacial Muscle pain. The approach of this article is to simplify the differential diagnosis for better and fast treatment of the respective disease by classifying various TMJ related and muscle related problems

Outcome analysis of extraarticular distal humerus locking plate for fresh fractures of humerus shaft

Background: The complex anatomy of distal humerus with proximity of radial nerve make the exposure and fixation of these fractures difficult. The standard technique of plate osteosynthesis consider at least eight cortices hold in both distal and proximal ends. Obeying these principles becomes difficult in distal humerus fractures. These difficulties have been overcome with the use of anatomical extra-articular distal humerus plate which has more hole density in the distal part with 3.5 mm screws for greater hold in distal part.Methods: A prospective study was carried out at Institute of Medical Sciences BHU Trauma Centre for 19 cases of distal third fracture excluding open fractures of patients between 18-68 years who attended our OPD or Emergency from June 2017 to July 2019. All patients were operated with the triceps-reflecting modified posterior approach. Regular follow-up was done to evaluate elbow functionality, fracture union, secondary displacement, non-union, implant failure and any complications; Mayo Elbow Performance score (MEPS) was used for the final functional assessment.Results: Fourteen 73.6% male and 5 (26.3%) female patients with mean age 41 years constituted the study group, who had an average follow-up of 17.1 months. Preoperatively one patient had radial nerve palsy (neuropraxia) who recovered completely 3 months after surgery. Overall, 18 (94.7%) patients were adjudged to have complete radiological union within 14 weeks; Mean flexion achieved was 134±11.5 (range 90–140). Average MEPS at the latest follow-up was 94.7±7.5.Conclusions: Extra-articular fractures of distal humerus can be satisfactorily treated with the use of single anatomically pre-contoured locking compression plate with excellent elbow functional range of motion and union rates.

Assessment of the Rheumatoid Factor Titers in Extra-Articular Manifestation of Rheumatoid Arthritis

Introduction: Rheumatoid arthritis (RA) is a chronicmultisystem disease of unknown cause. The characteristicfeature of RA is persistent inflammatory synovitis usuallyinvolving the peripheral joints in a symmetric fashion.Hence;the present study was undertaken for assessing rheumatoidfactor titers in extra-articular manifestation of rheumatoidarthritis.Material and methods: A total number of 50 patientswho met the inclusion criteria were included in this study.Rheumatoid arthritis diagnosed as per 2010 revised criteriafor the classification of RA were enrolled. The RA patientsthus selected were screened for various common clinicalfeatures, articular and extra-articular manifestations usinga structured Proforma designed for this study. At the end ofthe study the titers of RF factor in articular and extra articularmanifestations in 50 rheumatoid arthritis patients screenedwere calculated and expressed as percentage. All the resultswere recorded in Microsoft excel sheet and were analysed bySPSS software.Results: The clinical examination in the study revealedpallor in 34(68%) patients. Rheumatoid factor titres of 1:16were observed in 4(13%) of patients, 1:32 in 7(24%), 1:64 in8(28%) and 1;128 in 10(35%) of patients. Hemoglobin <8g/dl in 10 patients i.e.;(20%), 8-10g/dl in 14 patients i.e;40%,10-12g/dl in 10 patients i.e.; 28%. (Normal Hb 12-14g/dlin females, 14-16g/dl in males). Peripheral smear showed24 patients i.e 70% of them had normocytic normochromicanemia. Extra-articular manifestations were seen in about72%, Anemia in 34(68%), Lymphadenopathy in 8(16%),Purpuric –rash in 4(8%), Rheumatoid nodules in 4(8%) andSplenomegaly in 2(4%).Conclusion: Extra-articular manifestations contributesignificantly to the morbidity and mortality in rheumatoidarthritis. Careful screening of all patients for extra-articularmanifestations may help reduce the same, with the propermanagement of such patients

Desenlaces funcionales asociados a las diferentes técnicas de reemplazo total de rodilla en pacientes adultos con deformidades extra-articulares: Revisión sistemática de la literatura / Functional outcomes associated with the different total knee replacement techniques in adult patients with extra-articular deformities: A systematic review of the literature

Introducción El reemplazo total de rodilla (RTR) en pacientes con deformidades extraarticulares es un desafío. Se han descrito diferentes intervenciones como la corrección con cortes intraarticulares y la realización de osteotomías concomitantes. El objetivo del estudio es evaluar los desenlaces funcionales asociados a las diferentes técnicas de RTR en pacientes con deformidades extra-articulares. Materiales y Métodos Revisión sistemática de la literatura. Se incluyeron estudios que evaluaran desenlaces funcionales del RTR primario en pacientes adultos con osteoartritis y deformidades extra-articulares. Se describen el tipo de deformidad e intervención, escalas de funcionalidad y rango de movilidad. Resultados Se incluyeron 29 estudios para un total de 401 rodillas. La deformidad del eje mecánico más frecuente fue varo, con un promedio menor a 20° en la mayoría de estudios. El "Knee score" (KS) promedio postoperatorio en el grupo de RTR con cortes intra-articulares y guías convencionales osciló entre 85 y 96,5; con cortes guiados por navegación entre 82 y 95; y en el grupo con osteotomía concomitante entre 60,7 y 97. El "Function Score" (FS) postoperatorio promedio estuvo entre 69,5 y 91,4, 80 y 95,4, y 72,3 y 90 respectivamente. Se reportaron más complicaciones en el grupo de RTR más osteotomía concomitante. Discusión El RTR con cortes intra-articulares y balance de tejidos blandos, con guías convencionales o por navegación, es una opción viable especialmente en casos de deformidades extra-articulares leves. En casos con deformidades mayores se puede considerar la realización concomitante de osteotomía correctora.

Background Total knee replacement (TKR) in patients with extra-articular deformities is a challenging procedure for the surgeon. Different types of surgical techniques have been described, such as correction with intra-articular cuts, and concomitant osteotomies. The objective of this study is to evaluate the functional outcomes associated with the different TKR techniques in patients with extra-articular deformities. Methods A systematic review of the literature was performed. Studies evaluating functional outcomes of primary TKR in adult patients with osteoarthritis and extra-articular deformities were included. The type of deformity and intervention, functional scales records, and range of motion were evaluated. Results A total of 29 studies were included with a total of 401 knees. The most frequent mechanical axis deformity was varus, with a mean range below 20° in most studies. The mean after surgery knee score (KS) in the TKR group with intra-articular cuts and conventional guides ranged between 85 and 96.5. Those with cuts guided by navigation had a score between 82 and 95, and between 60.7 and 97 in the group with concomitant osteotomy. The mean post-operative Function Score (FS) was between 69.5 and 91.4, 80 and 95.4, and 72.3 and 90, respectively. More complications were reported in the TKR plus concomitant osteotomy group. Discussion TKR with intra-articular cuts and soft tissue balance, with conventional guides or by navigation, is a viable option and should be preferred in cases of mild extra-articular deformities. In cases with major deformities, a concomitant corrective osteotomy should be considered.

Evaluación de fugas extrarticulares del Fosfato crómico marcado con Fósforo-32 de producción nacional en pacientes hemofílicos / Evaluation of joint leakage of national Chromic Phosphate labeled with Phosphorus-32 in hemophilic patients

La radiosinoviortesis como tratamiento de la artropatía hemofílica, frecuentemente, ofrece excelentes resultados, al reducir grandemente el número de episodios de sangramiento y evitar daños ulteriores a las articulaciones. El Centro de Isótopos desarrolló el fosfato crómico coloidal marcado con Fósforo-32, producto listo para su empleo en pacientes hemofílicos. El objetivo de este trabajo fue evaluar la fuga extrarticular de este radiofármaco utilizado en la radiosinoviortesis en pacientes hemofílicos. Se determinó el porcentaje de fuga extrarticular del radiofármaco en 9 pacientes hemofílicos con sinovitis crónica, a los que se les realizó la radiosinoviortesis en la articulación de la rodilla. La radiactividad se midió, con un contador Geiger-Muller, sobre la rodilla tratada, en sus aspectos lateral, encima y medial; la rodilla contralateral; las cadenas linfáticas inguinales, de ambos lados, y el hígado. Los valores de fuga encontrados posteriormente a la inyección fueron 0,0046 por ciento a los 10 min; 0,0023 por ciento a las 24 horas; 0,1332 por ciento el día 7 y 4,0213 por ciento el día 30. Estos resultados coinciden con los valores comunicados por otros autores y con lo esperado de acuerdo a las características del producto, indican que se ejecutó el proceder adecuadamente y que los pacientes fueron seleccionados correctamente(AU)

Radiosynoviorthesis as a treatment for hemophilic arthropathy often offers excellent results, greatly reducing the number of bleeding episodes and avoiding further damage to the joints. The Isotope Center developed a product, Colloidal Chromic Phosphate labeled with Phosphorus-32, ready for use in hemophiliac patients. Our objective was to evaluate the joint leakage of this radiopharmaceutical use in radiosynoviorthesis in hemophilic patients. The percentage of radiopharmaceutical joint leakage was evaluated in 9 hemophilic patients with chronic synovitis, who underwent radiosynoviorthesis in the knee joint. The radioactivity was measured on the treated knee, in its lateral, above and medial aspects, the contralateral knee, the inguinal lymphatic chains of both sides and the liver, with a Geiger-Muller detector. The leakage values 8203;​found after the injection were 0.0046 percent at 10 minutes, 0.0023 percent at 24 hours, 0.1332 percent on day 7 and 4.0213 percent on day 30. These results are agreed with the values reported by other authors and with was expected according to the characteristics of the product, indicatate that the procedure was executed properly and that the patients were correctly selected(AU)

Study of Prognostic Significance of Anti Cyclic Citrullinated Peptide Antibodies in Patients with Rheumatoid Arthritis

Background: Rheumatoid arthritis is a chronic autoimmune inflammatory disease with articular and extra-articular manifestation that affects 0.5 to 1 % of total population. Aim and Objectives: To correlate Rheumatoid factor (RF) and Anti-CCP antibody in RA, to evaluate prognostic value of RF and Anti-CCP antibody in RA. Materials and methods: Retrospective study of total 50 patients admitted to our hospital from January 2018 to December 2018 was done. All patients were diagnosed as rheumatoid arthritis as per diagnostic criteria of American College of Rheumatology. All patients had symptom duration of at least one Year. Anti-CCP and lgM-RF were evaluated in all patients. Disease activity score 28 was calculated in all patients. Radiological Damage was assessed by Larsen Score. Results: Anti-CCP and RF were significantly correlated with each other and both were seen as significant independent predictors of radiological outcomes (p value 0.01 and <0.05 respectively). Combination of these two had highest risk for erosive joint damage. Conclusion: RA is more common in female. Anti-CCP antibody and RF both in combination were associated with higher probabilities of erosive disease.

Advances in internal fixation for the treatment of extra-articular distal tibial fracture / 中华外科杂志

Extra-articular distal tibial fractures as a result of high-energy damage are often comminuted or displaced, frequently accompanied by severe soft tissue injuries.Poor blood supply and various complications make the treatment more difficult,affecting life quality of the patients.The main goals of the treatment are to abtain a healed,well-aligned fracture,functional range of motion of the ankle joint and minimizing complications.It is generally recommended that surgical treatment be performed in the proper context of local conditions to facilitate early functional exercise.Plate fixation and intramedullary nail fixation are the common options for closed fractures.This article focuses on the two treatment methods and some important auxiliary technologies in both domestic and foreign, hoping to provide some references for clinical treatment.

Extra-articular distal tibial fractures, is interlocking nailing an option? A prospective study of 147 cases / 中华创伤杂志(英文版)

PURPOSE@#Distal tibia fractures comprise about 7%-10% of lower extremity trauma. Because of the peculiarity of the soft tissue and subcutaneous location of the bone there are many controversies in the ideal treatment of distal tibia fractures especially extra articular pilon fractures. Plating is fraught with complications of wound dehiscence and infection. There are limited studies which document outcomes in such cases using intramedullary interlocking nail. We intend to study the outcome and complications of extra articular distal tibial fractures treated with interlocking nailing.@*METHODS@#This is a prospective study conducted in a tertiary care orthopaedic hospital in southern India. There are 147 patients of distal tibia extra-articular fractures managed by IM nailing with follow up of more than one year were included in this study. Only cases with fresh injury (less than 1 week), fracture below the isthmus, closed and open Gustilo Anderson type 1 and 2 fractures were included in the study. Patients were reviewed at 3, 6, 12 and 24 weeks after surgery and thereafter at one year and were assessed for clinical and radiological signs of healing, any complications, time to union and functional outcome.@*RESULTS@#There were 102 males and 45 females (male/female ratio is 2.3:1) with a mean age of 38.96 (range 23-65) years. According to AO classification, there were 78 cases (53.06%) of 43-A1, 39 cases (26.53%) of 43-A2 and 30 cases of 43-A3 constituting 20.40%. The fracture united in all the patients at an average of 18 weeks (range 16-22 weeks), none of the patient in our series had a delayed or non-union. Two patients (1.47%) had the fracture united in mild valgus but it was well within the acceptable limits (<5°). The functional outcome was assessed in all the patients at final follow up using Olerud and Molander score all the patients fared an excellent to good score, there were no cases with poor score.@*CONCLUSION@#Intramedullary nailing is a viable option to treat distal tibial fractures with excellent outcome. Wound complications related to plating can be avoided but meticulous surgical technique is key to avoid malunion.

Vasculitis reumatoide: a propósito de dos casos / Rheumatoid vasculitis: about two cases

Resumen La vasculitis reumatoide constituye una complicación inusual, pero severa, de la artritis reumatoide, caracterizada por un proceso inflamatorio que compromete vasos sanguíneos de pequeño y mediano calibre, asociada o no a manifestaciones extraarticulares. Algunos factores predisponentes descritos incluyen ciertos haplotipos de antígenos leucocitarios humanos, fumado y enfermedad de larga data. Una disminución en la incidencia ha sido notada desde los años 90 y confirmada en estudios recientes, asociada en particular a un diagnóstico precoz de artritis reumatoide y estrategias terapéuticas que incluyen un aumento en la prescripción de metotrexate. La vasculitis reumatoide se asocia a tasas de mortalidad hasta del 40% a los 5 años y morbilidad importante. Se presentan dos pacientes con diagnóstico previo de artritis reumatoide, con un cuadro crónico de úlceras y disestesias en miembros inferiores, asociado a síndrome anémico. Los estudios histológicos revelaron vasculitis de mediano vaso compatible con vasculitis reumatoide. Se inició manejo con inmunosupresores más esteroides, con resolución del cuadro clínico inicial.

Abstract Rheumatoid vasculitis remains a rare but serious complication of rheumatoid arthritis characterized by an inflammatory process that primarily affects small to medium-sized blood vessels, it can be associated with other extra-articular manifestations. A number of predictor or predisposing factors including certain human leukocyte antigen haplotypes, smoking and long-standing disease. A declining trend in the incidence of rheumatoid vasculitis has been noted since the 1990s and reconfirmed in recent studies, related to early diagnosis of rheumatoid arthritis, and widespread use of methotrexate. Rheumatoid vasculitis is associated with high rates of premature mortality with up to 40% of patients dying by 5 years, as well as a significant morbidity. We present two patients with diagnosis of rheumatoid arthritis with a chronic condition of ulcers and dysesthesias on legs associated with anemic syndrome; the histological study revealed medium size vasculitis. Treatment with inmunosuppresants and steroids was given with resolution of symptoms.

Retropharyngeal Tenosynovial Giant Cell Tumor Misdiagnosed as Oropharyngeal Cancer: a Case Report

Extra-articular tenosynovial giant cell tumor (TS-GCT) in retropharyngeal space is a rare case. We found only two case reports in the literature, in which one was located in retropharynx or prevertebral space of the cervical spine. We describe a rare case of TS-GCT in the retropharynx, which was initially misdiagnosed as oropharyngeal cancer. Furthermore, we want to assure that extraarticular diffuse type TS-GCT should be considered in the differential diagnosis of lesions showing low signal intensity in MRI scan.

Effects of Leukocyte-and Platelet-rich Fibrin on Tendon-bone Healing of Rabbits' Extra-articular Bone Tunnel in the Early Period / 中国运动医学杂志

Objective To evaluate the early effect of leukocyte-and platelet-rich fibrin (L-PRF)on tendon-bone healing in rabbits' extra-articular bone tunnel.Methods Thirty healthy New Zealand rabbits were randomly divided into an experimental group and a control group,each of 15.The semitendinosus tendon harvested from the hind leg of each rabbit was prepared as free autografts.Each autograft was implanted into the bone tunnel created at ipsilateral proximal tibial metaphysis.The experimental group was added with autologous peripheral blood-derived L-PRF,while the control group did not add anything.Speciments from each group were harvested at 4,8 and 12 weeks after operation.The morphological changes were observed and evaluated at each time point.The fibroblasts on the tendon-bone interface were counted and analyzed under the high magnification microscope.Results The number of fibroblasts between the tendon and bone in the experimental group was significantly higher than that of the control group at each time point (P＜0.05).And the connection between tendon and bone was closer and the collagen fibers were more regular in the experimental group than the control group at each time point.Sharpey's-like fibers which marked the early healing of the tendon to bone,were observed at 4th week in the experimental group,while they were observed at 8th week in the control group.As the healing time extended,Sharpey's like fibers continue to increase in both groups and significant differences were observed in the histological morphology (Buark grades)between the two groups (P＜0.05).Conclusion Autologous peripheral blood-derived L-PRF can promote early healing of autologous tendon to bone in the extra-articular bone tunnel of model rabbit.

Effectiveness of total knee arthroplasty using three-dimensional printing technology for knee osteoarthritis accompanied with extra-articular deformity / 中国修复重建外科杂志

Objective: To evaluate the effectiveness of total knee arthroplasty (TKA) using three-dimensional (3D) printing technology for knee osteoarthritis (KOA) accompanied with extra-articular deformity.

Distal Femur Fractures and its Treatment with Distal Femur Locking Plate.

In this prospective study, 50 patients with distal femur fracture were treated using distal femur locking plate. Extra-articular fractures were fixed with minimal invasive technique without exposing the fracture site and intra-articular fractures were treated by open technique. Schatzker and Lambert (1979) criteria is used for functional assessment. In our series majority of the patients were males (70%), predominantly with AO type C fracture. RTA was the major mode of trauma (80%). Average union time was 14.2 weeks and average range of motion was 109.50. According to Schatzker and Lambert's criteria 22 patients had excellent results, 16 patients had good results, 8 patients had fair results and 4 patients had failure. We conclude that this implant should be used in distal femur fractures especially in, fractures with articular extension and comminution. Locking compression plate allows early weight bearing which is an additional advantage for good vocational, mental, social and physical health.

Staged management of missed lisfranc injuries：A report of short-term results / 国际外科学杂志

Objective To analyze the clinical and radiographic outcomes of staged reduction and fixation in a consecutive series of patients with the old Lisfranc injuries. Methods Fifty patients (16 feet) with Lisfranc injuries were treated with staged reduction. Mean duration between injury and surgery was 4. 8month ( 3 to 8 month) . In first stage an external fixator was applied across the Lisfranc joint and distraction was done at 1 milliliter per day to 2 milliliter per day. In the second staged the ORIF ( open reduction and internal fixation) was doneand we were able to reduce all the fractures and dislocations. Extra-Articular screws and staple fixation were used for fixation. We compared categorical variables using Fisher’ s exact test and continuous variables using paired t-test or Wilcoxon signed-rank test. Results All patients were followed up 1 to 3 years ( mean 2. 2 years) in the clinic. The visual analogue scale score averaged 3. 1 points at the final follow-up, the average AOFAS scores for these patients were 55. 8 points ( range, 43 to 98 points), with a significant increase than before surgery ( P=0. 001). The mean duration between two surgeries was 3. 2 weeks (range 2. 5-4. 5 weeks). Anatomic reduction was obtained in all 15 patients. At the last follow-up, 2 patients had lost reduction. Posttraumatic osteoarthritis was observed in 5 patients, and all of them were scheduled for arthrodesis because of persistent pain. Conclusions The study have displayed that staged reduction and Extra-Articular fixation should be considered for old Lisfranc injuries with a good reduction, the firm stability, low risk of intraoperative fracture. The short-term effectiveness is good, but the long-term effectiveness needs further follow-up.

Clinical analysis of 10 cases with traumatic extra-articular ankylosis of temporomandibular joint / 实用口腔医学杂志

The data of 10 cases of traumatic extra-articular ankylosis of temporomandibular joint(TMJ),including the type of trauma and the type of ankylosis,pathology,treatment method,prognosis,and so on were collected and analyzed.A reference of diagnosis and treatment is provided.