Signos y síntomas en niños y adolescentes con hipermovilidad articular: un estudio transversal cuantitativo observacional / Signs and symptoms in children and adolescents with joint hypermobility: an observational, quantitative cross-sectional study

Contexto y Objetivo: La hipermovilidad articular (HA) puede representar el ex-tremo del rango normal de movimiento o condición para un grupo de trastornos hereditarios del tejido conectivo, con una variación de 2-64.6% en diferentes poblaciones. El objetivo fue caracterizar la asociación entre HA con las manifestaciones en forma de signos y síntomas.Tipo de Estudio y Ajuste: Estudio transversal cuantitativo observacional en un hospital universitario público.Métodos: Estudio con niños y adolescentes entre 5 y 16 años, de ambos sexos, en asistencia multiprofesional en la clínica ambulatoria de HA y SED en el Hospital Base de São José do Rio Preto y en la Unidad del Proyecto "Gato de Botas", en colaboración con FAMERP. Se utilizó un cuestionario para registrar datos y análisis realizados en base a cálculos de medidas de tendencia central, dispersión y conteos de frecuencia.Resultados: El puntaje 4 obtuvo la frecuencia más alta (45,61%), seguido del puntaje 6 (21,05%). Las manifestaciones musculoesqueléticas y extraesqueléticas fueron frecuentes. La variable de hiperextensión del quinto dedo >90º fue la variable con mayor incidencia, seguida de la aposición del pulgar al tocar la región flexora del antebrazo.Conclusiones: Entre los niños y adolescentes con HA, la mitad o más presentaron manifestaciones musculoesqueléticas o extraesqueléticas.

Background and Aim: Joint hypermobility (JH) may be the extreme of the normal range of motion or a condition for a group of hereditary connective tissue disorders, with a prevalence rate of 2 to 64.6% in different populations. The aim of the present study was to characterize the association between JH and manifestations in the form of signs and symptoms. Study Type and Setting: An observational, quantitative, cross-sectional study was conducted at a public hospital. Methods: This study involved the participation of male and female children and adolescents aged five to 16 years under multidisciplinary care at the JH and Ehlers-Danlos syndrome clinic of the São José do Rio Preto Base Hospital and the "Gato de Botas" Project Unit in partnership with the São José do Rio Preto School of Medicine. A questionnaire was administered for the recording of the data, which were analyzed descriptively, with the calculation of central tendency and dispersion measures as well as the determination of frequencies.Results: Beighton score 4 was the most frequent (45.61%), followed by score 6 (21.05%). Musculoskeletal and extraskeletal manifestations were frequent. Hyperextension of the 5th finger > 90º had a higher occurrence, followed by the thumb touching the flexor region of the forearm. Conclusions: Among children and adolescents with hypermobility, half or more had musculoskeletal or extraskeletal manifestations.

Mensuração da força de preensão palmar em indivíduos com hipermobilidade articular / Handgrip strength measurement in individuals with joint hypermobility

Objetivos: Avaliar a força de preensão palmar de mulheres com hipermobilidade articular, comparando-as com as sem hipermobilidade articular, relacionando idade, dominância manual e comportamento da força de preensão palmar ao longo das mensurações. Métodos: Trata-se de estudo transversal de caráter analítico. A amostra foi composta por 68 mulheres, das quais 42 formaram o Grupo Hipermobilidade Articular e 26 o Grupo Controle. Como instrumento de coleta, foi utilizado o dinamômetro Jamar®, tendo sido seguido o protocolo recomendado pela American Sociecity of Hand Therapists (ASHT). A análise estatística foi realizada utilizando o software BioEstat 5.0 e a análise de variância, para avaliar a significância das médias, seguido dos testes de Tukey e t de Student independente para as variáveis antropométricas, idade e força manual bilateral, considerando índice de significância de 95%. Resultados: Houve predomínio da força de preensão palmar da mão direita em relação à esquerda em ambos os grupos. Indivíduos portadores de hipermobilidade articular possuíam menor força em ambas as mãos quando comparados ao Grupo Controle. A força manual bilateral do Grupo Controle foi maior naqueles com idade igual e superior a 21 anos em relação aos indivíduos com idade igual e menor a 20 anos. Ainda, indivíduos hipermóveis com idade igual e menor a 20 anos possuíam menor força quando comparados ao Grupo Controle com idade igual e maior a 21 anos em ambas as mãos. Conclusão: Considerando os resultados concebidos por este estudo, sugere-se que há correlação entre força de preensão manual e hipermobilidade articular.

Objective: To evaluate handgrip strength in women with joint hypermobility, comparing them with those who do not have joint hypermobility, relating age, hand dominance and behavior of the hand grip strength throughout the measurements. Methods: This is an analytical cross-sectional study. The sample consisted of 68 women, of which 42 formed the group Joint Hypermobility, and 26 the Control Group. As a collection instrument, the Jamar® dynamometer was used, and the protocol recommended by American Sociecity of Hand Therapists ­ ASHT was followed. Statistical analysis was performed using the software BioEstat 5.0, and the analysis of variance, to evaluate the significance of the means, followed by the Tukey e t-student tests, independent for the anthropometric variables, age and bilateral hand strength, considering a significance index of 95%. Results: There was a predominance of hand grip strength of the right hand in relation to the left in both groups. Individuals with joint hypermobility have less strength in both hands when compared to the control group. Bilateral hand grip strength of the Control Group is greater in those aged 21 years and over, compared to individuals aged less than 20 years. Moreover, hypermobile individuals aged less than 20 years had lower strength when compared to the Control Group with age equal to and greater than 21 years in both hands. Conclusion: considering the results conceived by this study, a correlation between hand grip strength and joint hypermobility is suggested

Menisco lateral hipermóvil: diagnóstico y tratamiento de lesiones de fascículos poplíteo meniscales / Hypermobile lateral meniscus: diagnosis and treatment of popliteomeniscal fasciculi injuries

El Síndrome de Menisco Hipermóvil, caracterizado por bloqueos mecánicos dolorosos de la rodilla, tiene un sustento anatómico basado en los fascículos poplíteo meniscales anteroinferior y posterosuperior, responsables de la estabilidad primaria de la esquina posterolateral meniscal. Con un cuadro clínico característico, usualmente con Resonancia Magnética sin hallazgos sugerentes de patología, la artroscopía juega un rol esencial en casos de alta sospecha, comprobando el diagnóstico al presentar hipermobilidad del cuerno posterior del menisco lateral. MÉTODO: Se presentan 9 casos resueltos, con hiperlaxitud posterolateral meniscal, y presentación clínica caracterizada por bloqueo articular de rodilla sin causa aparente. En todos los casos se realizó reparación de los fascículos poplíteo meniscales con suturas meniscales, con resolución completa de la sintomatología y sin complicaciones post quirúrgicas. CONCLUSIÓN: El manejo del cuadro de menisco hipermóvil está basado por la sospecha clínica y el descarte de otras patologías como causa subyacente de la sintomatología. El manejo quirúrgico con suturas meniscales ha demostrado restaurar la biomecánica normal del compartimento posterolateral de la rodilla, logrando la resolución completa de los síntomas. NIVEL DE EVIDENCIA: IV.

Hypermobile Meniscus Syndrome, characterized by painful mechanical blockages of the knee, has an anatomical support based on the anteroinferior and posterosuperior poplíteomeniscal fascicles, responsible for the primary stability of the posterolateral meniscal corner. With a characteristic clinical presentation, usually with Magnetic Resonance without suggestive findings of pathology, arthroscopy plays an essential role in cases of high suspicion, checking the diagnosis by presenting hypermobility of the posterior horn of the lateral meniscus. METHOD: We present 9 resolved cases, with posterolateral meniscal hypermobility, and clinical presentation characterized by knee articular block without apparent cause. In all cases, poplíteomeniscal fascicles were repaired with meniscal sutures, with complete resolution of the symptoms and without post-surgical complications. CONCLUSION: The management of the hypermobile meniscus syndrome is based on clinical suspicion and the discarding of other pathologies as the underlying cause of the symptomatology. Surgical management with meniscal sutures has been shown to restore the normal biomechanics of the posterolateral compartment of the knee, achieving complete resolution of symptoms. LEVEL OF EVIDENCE: Case series IV.

Síndrome de Ehlers-Danlos hipermóvel: um relato de caso / Hypermobile Ehlers-Danlos syndrome: a case report

A síndrome de Ehlers-Danlos é estabelecida por distúrbios hereditários do tecido conjuntivo que tem como manifestações principais a hipermobilidade articular, a hiperextensibilidade da pele e a fragilidade de tecidos, como articulações, ligamentos, pele, vasos sanguíneos e órgãos internos. São reconhecidos 13 subtipos, de acordo com Classificação Internacional de 2017. Dentre estes, abordamos o hipermóvel, cujo diagnóstico é eminentemente clínico, com manifestações sistêmicas distintas. Esse artigo refere-se ao caso de uma paciente diagnosticada com síndrome de Ehlers-Danlos hipermóvel, tendo como intuito a atualização acerca dos novos critérios diagnósticos, assim como o diagnóstico precoce de tal raropatia.

Ehlers-Danlos syndrome is established through hereditary disorders of connective tissue, and has as its manifestations: joint hypermobility, skin hyperextensibility, and fragility of tissues such as joints, ligaments, skin, blood vessels, and internal organs. Thirteen subtypes have been recognized according to the 2017 International Classification. Among these, the hypermobile type, the diagnosis of which is eminently clinical, with distinct systemic manifestations, will be addressed. This article refers to the case of a patient diagnosed with hypermobile Ehlers-Danlos syndrome, with the objective of updating the new diagnostic criteria, as well as the early diagnosis of such a rare disease.

Translation, cross-cultural adaptation and validation of the Norwich Patellar Instability score for use in Brazilian Portuguese

ABSTRACT BACKGROUND: The Norwich Patellar Instability (NPI) score is a tool for evaluating the impact of patellofemoral instability on joint function. It has not been translated or culturally adapted for the Brazilian population before. OBJECTIVE: This study had the aims of translating and culturally adapting the NPI score for use in Brazilian Portuguese and subsequently assessing its validity for this population. DESIGN AND SETTING: Translation, cross-cultural adaptation and validation study conducted at the State Public Servants' Institute of São Paulo, Brazil. METHODS: Sixty patients of both sexes (aged 16-40 years) with diagnoses of patellar dislocation were recruited. The translation and cultural adaptation were undertaken through translation into Brazilian Portuguese and back-translation to English by an independent translator. Face validity was assessed by a committee of experts and by 20 patients. Concurrent validity was assessed through comparing the Brazilian Portuguese NPI score with the Brazilian Portuguese versions of the Lysholm knee score and the Kujala patellofemoral disorder score among the other 40 patients. Correlation analysis between the three scores was performed using Pearson correlation coefficients with significance levels of P < 0.05. RESULTS: The Brazilian Portuguese version of the NPI score showed moderate correlation with the Brazilian Portuguese versions of the Lysholm score (r = -0.56; 95% confidence interval, CI: -0.74 to -0.30; P < 0.01) and Kujala score (r = -0.57; 95% CI: -0.75 to -0.31; P < 0.01). CONCLUSION: The Brazilian Portuguese version of the NPI score is a validated tool for assessing patient-reported patellar instability for the Brazilian population.

Avaliação ortopédica e ultrassonográfica da estabilidade dos quadris de recém-nascidos encaminhados por pediatras, com suspeita de Displasia Típica do Desenvolvimento / Orthopedic and ultrasound assessment of hip stability of newborns referred by pediatricians with suspected Developmental Dysplasia

RESUMO Objetivo: avaliar recém-nascidos com suspeita de instabilidade do quadril, encaminhados por pediatras a um serviço ortopédico terciário. Métodos: recém-nascidos de uma maternidade pública universitária, com suspeita de instabilidade ou fatores de risco para displasia do quadril, eram encaminhados ao Departamento de Ortopedia e Anestesiologia, Ribeirão Preto/SP, onde eram avaliados clinicamente e através de exames ultrassonográficos dos quadris. Constatada a displasia, iniciava-se o tratamento, e em casos em que havia apenas imaturidade do quadril e exame clínico normal, procedia-se à observação e re-exame clinico e ultrassonográfico com dois ou três meses de vida. Resultados: foram examinados 448 recém-nascidos, com predominância feminina e média de idade na primeira avaliação de 27 dias. A principal causa do encaminhamento foi apresentação pélvica. Em 8% havia sinal de Ortolani positivo e em 12,5% estalido no quadril. No exame ortopédico, 405 (90,5%) pacientes eram normais, 8,5% apresentavam estalido no quadril e 1,1% apresentavam teste de Ortolani positivo. À ultrassonografia, 368 (89,5%) apresentavam imaturidade, 26 (6,3%) tinham displasia moderada e em 17 (4,1%) pacientes os quadris eram francamente displásicos. Todos os casos com sinal de Ortolani positivo apresentavam quadro ultrassonográfico de displasia. Conclusão: houve excesso de diagnóstico de instabilidade do quadril na avaliação do pediatra, o que, no entanto, permitiu ao paciente uma segunda avaliação, em ambiente mais especializado e com mais recursos tecnológicos.

ABSTRACT Objective: to evaluate newborns with suspected hip instability, referred by pediatricians to a tertiary orthopedic service. Methods: newborns from a public university maternity hospital, with suspected instability or risk factors for hip dysplasia, were referred to the Department of Orthopedics and Anesthesiology, Ribeirão Preto/SP, where we evaluated them clinically and through ultrasound examinations of the hips. Once we found dysplasia, we initiated treatment, and in cases in which there was only hip immaturity and normal clinical examination, we performed clinical and ultrasound observation and review at two or three months of age. Results: we examined 448 newborns, with female predominance and average age at first evaluation of 27 days. The main cause of referral was pelvic presentation at delivery. In 8% there was a positive Ortolani sign and in 12.5%,. At orthopedic examination, 405 (90.5%) patients were normal, 8.5% had hip click and 1.1% had positive Ortolani test. At ultrasound, 368 (89.5%) had immaturity, 26 (6.3%) had moderate dysplasia and in 17 (4.1%) patients the hips were frankly dysplastic. All cases with positive Ortolani sign showed dysplasia at ultrasound. Conclusion: there was an excess diagnosis of hip instability in the pediatrician evaluation, which, however, allowed the patient a second assessment, in a more specialized environment and with more technological resources.

Luxación glenohumeral inferior recurrente ( luxatio erecta ) tratamiento artroscópico, revisión de la literatura y reporte de caso / Lower glenohumeral recurrent luxation ( luxatio erecta ) arthroscopic treatment, literature review and case report

Resumen: Es de suma importancia tener en cuenta las complicaciones de la luxación glenohumeral inferior que, aunque poco frecuentes, pueden llegar a ser incapacitantes a mediano y largo plazo, incluso en algunos casos reportados ponen en riesgo la vida del paciente. Material y métodos: Se presenta el caso clínico de un joven paciente adulto con diagnóstico de luxación glenohumeral inferior (luxatio erecta) recurrente derecha, con lesión de Bankart y lesión de Hill Sachs, tratado mediante artroscopía con reparación de la lesión de Bankart, plicatura del receso capsular inferior y remplissage. Resultados: Evaluamos la funcionalidad del paciente al cabo de 18 meses con la escala de UCLA obteniendo una puntuación final de 30 puntos con buenos resultados funcionales.

Abstract: It is extremely important to take into account the complications of inferior gelnohumeral dislocation, which, although infrequent, may become incapacitating in the medium and long term, even in some cases reported, endangering the life of the same. Material and methods: We present the case of a young adult patient diagnosed with inferior rectal glenohumeral dislocation (luxatio erecta), with Bankart lesion and Hill Sachs lesion, treated by arthroscopy with repair of the Bankart lesion, plication of the lower capsular recess and remplissage. Results: We evaluated the functionality of the patient at 18 months with the UCLA scale, obtaining a final score of 30 points with good functional results.

3D point cloud in the evaluation of processes that generate instability of the lumbar spine / Nuvem de pontos tridimensional na avaliação de processos que geram instabilidade da coluna lombar / Nube de puntos tridimensional en la evaluación de procesos que generan inestabilidad de la columna lumbar

OBJECTIVE: To integrate patients with lumbar instability in a multisensor platform in the process of assessment and diagnosis, assigning quantitative parameters for the sagittal balance (SB) and muscle function. METHODS: Experimental study involving adult patients diagnosed with diseases that cause alterations in the SB, that were or were not submitted to surgery with posterior instrumentation and fusion. Each patient underwent anthropometric measurements in body composition scale; a kinesiological analysis using a multisensor platform consisting of depth camera to static/dynamic analysis for the quantitative measurement of SB, and surface electromyography to capture the level of abdominal and lumbar muscles activation and through flexion and extension. RESULTS: Seven adult patients: five females (62.5%)and two men (37.5%) with a mean age 48 years. Images with depth cameras resulted in a SB of from -6.4 to +5.3cm (average -5.7cm). In individuals with positive sagittal balance the percentage of activation (PA) of the abdominal muscles was 58.5% and the lower back lumbar was 75.25%; patients with negative SB integrated the PA of the abdominal muscles of 70.25% and lumbar of 65%; the patient with neutral SB exhibited activation of the abdominal muscles of 87.75% and lumbar muscles of 78.25%. CONCLUSIONS: We observed a trend towards positive SB in patients with overweight and obesity by BMI, as well as increased activation of the abdominal muscles. The multi sensor platform is a useful tool for the diagnosis and prognosis of diseases involving sagittal imbalance. .

OBJETIVO: Integrar os pacientes com instabilidade lombar em uma plataforma multissensor no processo de avaliação e diagnóstico, atribuindo parâmetros quantitativos para o equilíbrio sagital (ES) e função muscular. MÉTODOS: Estudo experimental com pacientes adultos diagnosticados com doenças que causam alterações no ES, submetidos ou não à cirurgia com instrumentação e fusão por via posterior. Em cada paciente realizaram-se medidas antropométricas em balança de composição corporal, análise cinesiológica utilizando uma plataforma multissensor constituída por câmera profundidade para análise estática/dinâmica para medição quantitativa do ES e eletromiografia de superfície para capturar o nível de ativação da musculatura abdominal e lombar por meio de flexão e extensão. RESULTADOS: Sete pacientes adultos: cinco mulheres (62,5%) e dois homens (37,5%) com média de idade de 48 anos. As imagens com câmeras de profundidade resultaram em ES de -6,4+5,3cm (média -5,7cm). Nos indivíduos com equilíbrio sagital positivo, o percentual de ativação (PA) dos músculos abdominais foi 58,5% e dos músculos lombares foi 75,25%; nos pacientes com ES negativo integrado, a PA dos músculos abdominais foi de 70,25% e lombar 65%; o paciente com ES neutro apresentou ativação dos músculos abdominais de 87,75% e dos músculos lombares, de 78,25%. CONCLUSÃO: Observamos uma tendência ao ES positivo em pacientes com sobrepeso e obesidade pelo IMC, bem como ao aumento da ativação dos músculos abdominais. A plataforma multissensor constitui uma ferramenta útil para o diagnóstico e prognóstico de doenças com desequilíbrio sagital. .

OBJETIVO: Integrar a pacientes con inestabilidad lumbar a una plataforma multisensor en su proceso de evaluación y diagnóstico, dando parámetros cuantitativos para el balance sagital (BS) y la función muscular. MÉTODOS: Estudio de tipo experimental con pacientes adultos diagnosticados con patologías que causan alteraciones en el BS, unos no operados, y otros operados con instrumentación y fusión posteriores. Cada paciente fue sometido a mediciones antropométricas en báscula de composición corporal; un análisis kinesiólogo utilizando una plataforma multisensor constituida por cámara de profundidad para el análisis estático/dinámico para la medición cuantitativa del BS, y un electromiógrafo de superficie captó el grado de activación muscular en región abdominal y lumbar, mediante movimientos de flexión y extensión. RESULTADOS: Siete pacientes adultos: cinco mujeres (62.5%), dos hombres (37.5%); media de edad de 48 años. Las imágenes con cámaras de profundidad resultaron en un BS de -6.4 a+5.3cm (promedio-5.7cm). Aquellos con BS positivo el porcentaje de activación (PA) de los músculos abdominales fue de 58.5% y la de los lumbares fue de 75.25%; pacientes con BS negativo integraron un PA de los músculos abdominales de 70.25% y de lumbares de 65%; el paciente con balance sagital neutro tuvo activación de la musculatura abdominal de 87.75% y lumbar de 78.25%. CONCLUSIONES: Observamos tendencia al BS positivo en pacientes con sobrepeso y obesidad por IMC, así como mayor activación de músculos abdominales. La plataforma multisensor constituida es una herramienta útil para el diagnóstico y pronóstico de enfermedades con desbalance sagital. .

Relación entre laxitud articular e inestabilidad glenohumeral. Un meta-análisis de la literatura / Relationship between articular laxity and shoulder instability. A meta-analysis

El objetivo de esta revisión sistemática fue establecer si existe alguna relación entre la inestabilidad glenohumeral y cualquier forma de laxitud articular. Se realizó un algoritmo de búsqueda de acuerdo a las guías de PRISMA en las bases de datos de PubMed, OVID, Sport Discus, Scopus y Web of Science usando las palabras clave “(Ligament Laxity OR ligamentous Laxity OR generalized joint laxity) AND (shoulder dislocation OR shoulder subluxation OR shoulder luxation OR Shoulder instability) hasta Diciembre de 2013. Se incluyeron los artículos en lengua inglesa que describan algún tipo de relación objetiva, entre inestabilidad glenohumeral y laxitud articular focal o generalizada. Fueron excluidos estudios en cadáveres, o in vitro, o que contengan pacientes con enfermedades del tejido conectivo, reportes de casos, reportes biomecánicos, revisiones, cartas de editores y notas técnicas. La búsqueda arrojó un total de 603 artículos de los cuales 15 cumplían los criterios de inclusión. Según la evidencia encontrada la laxitud articular podría influir en la inestabilidad glenohumeral, pero debido a la gran diversidad de formas en que ambas se relacionan y las diferentes maneras de diagnosticarlas es imposible obtener un análisis estadístico que provea información confiable. Los cirujanos ortopedistas debemos unificar criterios en relación a la definición y a los test para evaluar laxitud articular e inestabilidad glenohumeral y, así de esta manera, poder obtener información más confiable y objetiva. Nivel de Evidencia: IV. Tipo de Estudio: Revisión Sistemática...

The aim of this meta-analisis was to establish whether there is a relationship between any kind of articular laxity and shoulder instability. The search algorithm according to the PRISMA guidelines of PubMed, OVID, Sport Discus, Scopus and Web of Science databases using the keywords “(Ligament laxity OR ligamentous laxity OR generalized joint laxity) AND (shoulder dislocation OR shoulder subluxation OR shoulder luxation OR shoulder instability) until December of 2013 was done. Inclusion Criteria: articles in English showing relationship between any types of glenohumeral instability with focal or generalized joint laxity. Studies on cadavers, or in vitro, involving patients with connective tissue diseases, case reports, biomechanical reports, revisions, letters to editors and technical notes were excluded. Fifteen articles of 603 reference of the search were included. Joint laxity may influence shoulder instability. We found diversity not only in how to relate joint laxity and glenohumeral instability buy also different ways of diagnosing. This makes it difficult to obtain statistical analysis that can provide reliable data. Additional efforts aiming to provide consensus are required to clarify this subject. Orthopedics surgeons must unify criteria regarding lax shoulder as well as glenohumeral instability and thus can get more objective and reliable data. Level of Evidence: IV. Study design: Systematic Review...

Inetabilidad patelofemoral / Patellofemoral instability

La inestabilidad rotuliana es una disfunción multifactorial. La estabilidad de la articulación patelofemoral depende de factores estáticos y dinámicos. Dentro de los estáticos está la anatomía ósea (rótula y tróclea), tejidos blandos (fundamentalmente LPFM) y el eje del miembro; y dentro de los dinámicos al cuádriceps. El diagnóstico es fundamental para indicar el tratamiento adecuado. Lo realizamos con la clínica, Rx y TAC. El tratamiento conservador puede ser indicado, aunque la incidencia de reluxación es alta. Se basa en rehabilitación. Con respecto al tratamiento quirúrgico en agudo en el primer episodio solo lo indicamos cuando hay una fractura osteocondral, avulsión ósea del LPFM, luxaciones incoercibles, rotura bien evidenciable del LPFM en fémur o alta demanda deportiva con factores de riesgo. En las inestabilidades crónicas las dos técnicas que se indican más frecuentemente son: la reconstrucción del LPFM cuando no hay alteraciones óseas de importancia, y la transposición de TAT cuando no hay un gran deseje o trastorno rotacional en cadera o tibia. El completo estudio de cada paciente en particular y el entendimiento de cómo y cuánto afecta cada uno de los factores causales de inestabilidad en forma individual, nos permite decidir un tratamiento. Este tratamiento estará dirigido a corregir funcional o quirúrgicamente las anomalías causales de la disfunción. Nivel de evidencia: V

Patellar instability is a multifactorial dysfunction. The stability of the patellofemoral joint depends on static and dynamic factors. Within the static ones are: the bony anatomy (patella and trochlea), the soft tissue one (mainly MPFL) and the axis of the member, and within the dynamic factors: the quadriceps. Diagnosis is essential to indicate the appropriate treatment which is done with the clinic, x-rays and CTs. The conservative treatment can be indicated but the incidence of redislocation is high. It is based on rehabilitation. With regard to the acute surgical treatment in the first episode, we indicate it when there is: an osteochondral fracture, an MPFL bony avulsion, uncontrollable dislocations, a well evidenciable MPFL femur tear, or in high Sports demand with risk factors. In chronic instability the two techniques that are frequently indicated are: MPFL reconstruction when there are no significant bone changes and/or TAT transposition when there is no important malalignment in femur or tibia. The thorough study of each patient and the understanding of how and to what extent each one of the causal factors of instability affects the patient in an individual way, allows us to decide on a treatment. This treatment will be aimed at correcting the causal anomalies of the dysfunction, functionally or surgically. Level of evidence: V

Del rostro al texto: tras las huellas de la hiperlaxitud y la disautonomía en escritores / From the face to the text: after the fingerprints of the hyperlaxity and the dysautonomia in writers

At present there is a renew interest in delineating diagnostic criteria for the Ehlers-Danlos Syndrome type III (EDS-III), condition than even though is not serious, can produce poor quality of life, due to alteration of various organs and the presence of dysautonomia. The fragility of tissues, that causes the symptomatology, can frequently be reflected in some external signs. In this study, some authors have been selected that present facial signs that are characteristic of this syndrome and gives us the opportunity to look in their texts some tracts of this disease, by looking in their autobiographic texts or in their fiction works. This exercise of free association helps us to have a more complete view of their rich and complex personalities and helps us also to appreciate the importance in detecting and preventing the consequences of this disease, that with an adequate management can produce a notable improvement in the quality of life...

Hoy se está produciendo un renovado interés por afinar los criterios diagnósticos del síndrome de hipermovilidad articular (similar al SED-III), condición que, aunque no suele ser grave, puede traducirse en una mala calidad de vida, por trastornos en diversos órganos y la presencia de disautonomía. La debilidad de los tejidos conectivos, causante de la sintomatología, suele reflejarse también en algunos signos externos. En este estudio se seleccionan algunos escritores que presentan signos en el rostro característicos de este síndrome y que nos dan la oportunidad de buscar entre sus textos algunas pistas de esta enfermedad, ya sea en textos autobiográficos o en sus obras de ficción. Este ejercicio de libre asociación nos ayuda a tener una mirada más completa de sus ricas y complejas personalidades, y nos ayuda también a tomar conciencia de la importancia de detectar y prevenir las consecuencias de esta enfermedad, que con manejo adecuado puede traducirse en una mejoría notable de la calidad de vida...

Síndrome de hipermovilidad articular benigna: manifestaciones musculoesqueléticas en pie y tobillo / Benign joint hypermobility syndrome: musculoskeletal manifestations in foot and ankle

The hypermobility syndrome benign joint (SHAB) is an inherited disorder that refers to the presence of a greater range of joint mobility associated with musculoskeletal symptoms, such as joint pain, muscle pain, soft tissue injury and non-inflammatory limb pain without coexistence of other systemic rheumatic disease. For the identification of joint hypermobility 1973 Beighton criteria used and the criteria for Brighton SHAB 1998. The joints most commonly affected are knees (87 percent), hip (77 percent), ankle (74 percent) and feet (72 percent). The latter two regions have received little attention. The foot problems include pain in the Achilles tendon, plantar fasciitis, tenosynovitis of the posterior tibial or peroneal, flexor and extensor tendinopathy, bursitis and hallux valgus. For diagnosis, the physical exam and ancillary studies such as ultrasound and MRI to detect changes that are not evident in the observation is used...

El síndrome de hipermovilidad articular benigna (SHAB) es un trastorno hereditario que se refiere a la presencia de un mayor rango de movilidad articular asociado a síntomas musculoesqueléticos, como son artralgias, dolor muscular, lesión de tejidos blandos y dolor no inflamatorio de extremidades, sin coexistencia de otra enfermedad reumática sistémica. Para la identificación de hipermovilidad articular se utilizan los criterios de Beighton 1973, y para SHAB, los criterios de Brighton 1998. Las articulaciones con mayor afección son rodillas (87 por ciento), cadera (77 por ciento), tobillo (74 por ciento) y pies (72 por ciento). Los problemas en el pie incluyen dolor en el tendón de Aquiles, fascitis plantar, tenosinovitis del tibial posterior o peroneos, tendinopatía de flexores y extensores, bursitis y hallux valgus. Para su diagnóstico se emplean el examen físico y estudios complementarios como ultrasonido y resonancia magnética que permitan detectar cambios que no son evidentes en la observación...

¿Qué tan frecuente es la hiperlaxitud articular en pediatría? experiencia del hospital San Juan de Dios / How frequent is joint hypermobility in pediatrics? the San Juan de Dios hospital experience

Hypermobility (HM) and Hypermobility Syndrome (HMS) are frequent condition in pediatrics, usually subdiagnosticated and there are no studies published in pediatric Chilean population. Our objective was to determine the prevalence of both conditions in the consult of pediatric rheumatologist at San Juan de Dios`s Hospital and in a school population. Describe also the most frequent clinical manifestations and evaluate the importance of HMS in arthralgia. Metods: The Beighton Score and Brighton Criteria were applied to 172 children from pediatric rheumatology consult, San Juan de Dios`s Hospital which consult with any diagnostic and 25 children of a apparently healthy school population. We analyzed the most frequent characteristic and presence of light blue sclera and easy bruise. Results: The prevalence of HM was 26,4 percent and HMS 25,7 percent from a total of 163 patients. The 46 percent of patients, who consult for arthralgia, had finally hypermobility syndrome. The presence of light blue sclera was found in 34,3 percent of healthy children and 70 percent of unhealthy children, and easy bruise in 37,2 percent and 53 percent respectively. Conclusions: Hypermobility and hypermobility syndrome were found in a considerable number of patients in both groups (hospital and school). Hypermobility syndrome is present in a quite number of hypermobile patients, not necessarily having quite hypermobility, it means, they do not reach 5/9 points in Beighton Score. The results of this investigation confirm that hypermobility syndrome is an important cause of arthralgia (46 percent). Light blue sclera and easy bruise could be considered like a guide for this condition. This publication is the first prevalence study in Chilean pediatric population.

La hiperlaxitud articular (HA), que se caracteriza por rangos articulares aumentados en una persona asintomática, y el Síndrome de Hiperlaxitud Articular (SHA), que es la hiperlaxitud asociada a síntomas, son condiciones frecuentes en Pediatría. Estas condiciones son generalmente subdiagnosticadas y no encontramos estudios publicados en población pediátrica chilena. El objetivo de este trabajo fue determinar la prevalencia de la HA y SHA en la consulta de Reumatología Pediátrica del Hospital San Juan de Dios y en una población escolar. Describir las manifestaciones clínicas más frecuentes y evaluar la importancia de SHA como causa de artralgias. Material y método: Se aplicaron el Score de Beighton (ScB) y Criterio de Brighton (CrB) a un total de 172 niños de la consulta reumatológica pediátrica del Hospital San Juan de Dios, que se controlan por cualquier diagnóstico, y a 25 niños de una población escolar aparentemente sana. Se estudiaron las características más frecuentes y la presencia de escleras celestes y moretones fáciles. Resultados: De los 163 pacientes evaluables (hospital), la prevalencia de HA fue de 26,4 por ciento y de SHA, 25,7 por ciento. De los pacientes que consultaron por artralgias el 46 por ciento fue secundario a SHA. La presencia de escleras celestes se encontró en 34,3 por ciento de los pacientes sanos y 70 por ciento de los pacientes no sanos, y los moretones fáciles, en 37,2 por ciento y 53 por ciento, respectivamente. Conclusiones: Se encontró un considerable número de pacientes con Hiperlaxitud Articular y Síndrome de Hiperlaxitud Articular en ambos grupos (hospital y colegio). Existe un porcentaje alto de pacientes que presentan el Síndrome de Hiperlaxitud Articular sin tener, necesariamente, hiperlaxitud articular importante, es decir, no alcanzan a cumplir 5/9 puntos en el ScB. Se comprueba que el Síndrome de Hiperlaxitud Articular es una causa frecuente de artralgias (46 por ciento). Las escleras celestes y moretones fáciles se...

Capsuloplastia derivativa en T para el tratamiento de la inestabilidad anteroinferior del hombro / Capsuloplastie dérivative en T pour le traitement de l'instabilité antéro-inférieure de l'épaule / Derivative T-capsuloplasty for the treatment of anterior-inferior shoulder instability

Introducción: el tratamiento abierto de la inestabilidad anteroinferior de hombro se ha llevado a cabo con diferentes técnicas, entre ellas, la capsuloplastia derivativa en T modificada. Objetivo: evaluar los resultados de la capsuloplastia citada en relación con la estabilidad, rango de movimiento y retorno a la actividad habitual de los pacientes. Métodos: estudio retrospectivo en una serie de 22 pacientes con diagnóstico de inestabilidad anterior y anteroinferior a quienes se les realizó capsuloplastia anterior derivativa modificada, desde enero de 2000-2012. Resultados: a los tres meses, la evaluación en 15 pacientes fue excelente y buena en siete; a los seis meses fue excelente en 20/22 pacientes, al año todas fueron excelente. Entre los dos y ocho meses posteriores a la operación, todos regresaron a su actividad previa, entre ellos, cuatro atletas, que se incorporaron al mismo nivel de competencia anterior. Hubo complicaciones en tres pacientes, solucionadas con tratamiento médico, entre ellas, una subluxación. La pérdida media de la rotación externa fue de 0 a 10º grados con una media de 5º a los tres meses, rangos que pueden estar en relación con el grado de tensión durante la capsuloplastia. Conclusiones: la capsuloplastia derivativa en T modificada, es una buena técnica para la inestabilidad anteroinferior de hombro sin lesión de Bankart, garantiza alto índice de estabilidad, conserva el rango de movimiento completo o casi completo con un bajo índice de complicaciones(AU)

Introduction: open treatment of anterior-inferior shoulder instability has been conducted with various techniques, including modified derivative T-capsuloplasty. Objective: evaluate the results of the aforementioned capsuloplasty in terms of stability, range of movement and patients' return to their routine activities. Methods: retrospective study of a series of 22 patients diagnosed with anterior and anterior-inferior instability undergoing modified derivative anterior capsuloplasty from January 2000 to 2012. Results: at three months, evaluation was excellent in 15 patients and good in 7. At six months it was excellent in 20 / 22 patients. At a year, all evaluations were excellent. All patients returned to their routine activities between two and eight months after surgery. Among them were four athletes, who reintegrated to their previous competition level. There were complications in three patients, which were solved with medical treatment. One of them was a subluxation. Average loss of external rotation ranged from 0º to 10º, with a mean 5º at three months. This could be associated with the degree of tension during the capsuloplasty. Conclusions: modified derivative T-capsuloplasty is a good technique for anterior-inferior shoulder instability without Bankart lesion. It ensures a high rate of stability, and preserves a full or almost full range of movement with a low rate of complications(AU)

Introduction : le traitement ouvert de l'instabilité antéro-inférieure de l'épaule est réalisé par différentes techniques telles que la capsuloplastie dérivative en T modifiée. Objectif: le but de cette étude est d'évaluer les résultats de la capsuloplastie compte tenu de l'instabilité, le rang de mouvement, et la réintégration à la vie quotidienne des patients. Méthodes: une étude rétrospective d'une série de 22 patients diagnostiqués d'instabilité antérieure et antéro-inférieure de l'épaule, et traités par capsuloplastie antérieure dérivative modifiée, est effectuée entre janvier 2000 et janvier 2012. Résultats: au bout de trois mois, quinze patients ont eu des résultats excellents, tandis que sept ont eu des résultats bons ; les résultats ont eu excellents dans le plupart de patients (20/22) en six mois, et un an après les résultats ont été excellents dans la totalité des cas. Après 2-8 mois de l'opération, leur réintégration à la vie quotidienne est complète, y compris quatre athlètes, avec le même niveau compétitif d'auparavant. Il y a eu des complications (3 cas), telles qu'une sous-luxation, corrigées par traitement médical. La perte moyenne de la rotation externe a été 0° à 10°, avec une moyenne de 5° en trois mois, ce qui peut être associé au degré de tension au cours de la capsuloplastie. Conclusions: la capsuloplastie dérivative en T modifiée est une bonne technique pour la correction de l'instabilité antéro-inférieure de l'épaule sans lésion de Bankart, assurant un haut niveau de stabilité et conservant le rang de mouvement complet ou quasi complet avec un taux faible de complications(AU)

Angulo Q extendido: un nuevo signo clínico para decidir técnica de realineación distal de aparato extensor / Extended Q angle: a new sign for the physical exam for deciding distal realignement

Los trastornos patelofemorales son una de las causas más frecuentes de consulta en ortopedia, y múltiples son los factores etiológicos descriptos en la fisiopatogenia. Un examen físico completo es imprescindible para detectar él o los factores influyentes en cada paciente para realizar un tratamiento “a la carta”. En la bibliografía se suele considerar a la realineación distal del aparato extensor como sinónimo de transposición de la TAT, sin embargo este concepto no contempla el factor rotacional generador de grandes fuerzas desestabilizantes en esta articulación. En este trabajo se describe un signo semiológico muy útil para decidir la realineación distal del aparato extensor, donde se agrega un vector más al ángulo Q clásico, desde el polo inferior de la rótula y paralelo a la diáfisis tibial y su relación con la posición del pie. Este signo se mide con rodilla en 30° de flexión, rótulas al cenit. Se describen 2 tipos de ángulo Q aumentado, contemplando la posición del pie que es fundamental para detectar trastorno rotacional con intrarotación de rodilla durante la marcha. También se describe y fundamenta la necesidad de diferenciar los 2 tipos de ángulo Q extendido para un tratamiento de realineación distal que respeta la biomecánica patelofemoral.

Patellofemoral problems are one of the most common cause of consult in orthopaedic practice. Multiple etiologic factors have been described in the genesis of the pathology. A complete physical exam is very important for the detection of factors that affect each patient, so that we can make a “a la carte” treatment. In the literature the distal realignement is consider as sinonym of transfer of the tibial tuberosity, but this concept not consider the rotational influence that generate grate forces at the articulation. Here we describe a new sign for the physical exam, useful for deciding distal realignement, where we add and other vector from the distal pole of the patella and paralel to the tibial diafisis and the relantionship with the foot. The sign must be taken in 30° of knee flexion, patellas facing straight to the cenit . We find that there is two types of extended Q angles considering the position of the foot and the presence of a rotational problem wich produce an inward knee. We describe the importance of different type of treatment for each extended Q angles in distal realignement procedures considering more physiological and anatomic treatment for patellofemoral problems.

Análisis de variabilidad inter e intra-observador en el diagnóstico artroscópico de lesión de SLAP / Evaluation of the intra and inter-observer variability for arthroscopic diagnosis of SLAP lesion

Introducción: La lesión de SLAP se encuentra en permanente estudio en todos sus aspectos. La tendencia actual en su diagnóstico es considerar fundamentalmente la evaluación artroscópica. Nuestro objetivo es evaluar la variabilidad intra e inter-observador en el diagnóstico artroscópico de la lesión de SLAP utilizando la clasificación de Snyder. Material y Método: 27 videos pertenecientes a pacientes con patología de SLAP fueron editados, mostrando la fase diagnóstica de la artroscopía de hombro, y enviados a 4 cirujanos ortopedistas especializados en artroscopía, a quienes se les solicitó determinar un diagnóstico respecto al labrum superior de acuerdo a la clasificación de Snyder. Finalmente, se obtuvo la variabilidad diagnóstica intra e inter-observador utilizando para ello el porcentaje de concordancia así como el coeficiente Kappa. Resultado: se analizaron 216 respuestas, entre los cirujanos con más de 5 años de experiencia obtuvimos una concordancia diagnóstica inter-observador (k) casi perfecto, mientras que respecto a los datos obtenidos de los fellowship resultó en una variabilidad moderada. En ambos grupos la mayor discordancia se encontró en las Lesiones SLAP Tipo I, con marcada diferencia respecto al resto, siendo en su mayoría sobre-diagnosticadas como lesiones Tipo II. Conclusión: Podemos decir que la variabilidad en el diagnóstico artroscópico tanto inter como intra-observador de la lesión SLAP disminuye considerablemente cuanto mayor experiencia posea el observador

Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator

OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties. METHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient. RESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases. CONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.

Correlação tomográfica da técnica de Magerl para artrodese C1-C2 em crianças / Tomographic correlation for Magerl's technique in C1-C2 arthrodesis in children

OBJETIVO: Analisar a morfologia e as dimensões, por meios tomográficos, das vértebras C1 e C2, nos pacientes pediátricos, avaliar a possibilidade de utilização da técnica de Magerl nesses pacientes, bem como fornecer dados para realização dessa técnica com maior segurança.MÉTODOS: Foram analisadas retrospectivamente 40 tomografias cervicais de pacientes entre 24 e 120 meses de idade de ambos os sexos e sem deformidades cervicais. Os dados foram analisados estatisticamente para obtenção dos valores médios e da variação de cada medida: do comprimento do pedículo de C2 até a massa lateral de C1, da espessura do pedículo de C2, do ângulo de ataque do parafuso no istmo de C2 com a horizontal e da distância do odontoide ao arco anterior de C1.RESULTADOS: Os valores médios encontrados foram respectivamente: lado direito 30,68 mm e esquerdo 31,47 mm; direito 5,28 mm e esquerdo 5,26 mm; direito 46,250, esquerdo 44,500 e 2,17mm.CONCLUSÃO: A técnica de Magerl, segundo análise tomográfica, parece ser utilizável nos pacientes pediátricos. Nível de Evidência IV, Série de Casos.

OBJECTIVE: To analyze through tomographic studies, the morphology and dimensions of the C1-C2 vertebrae in pediatric patients, to evaluate the possibility of application of Magerl's technique in these patients, and to contribute with data for the usage of the technique in safety.METHOD: Forty normal cervical tomographies, from patients at an age range of 24-120 months of age and from both genders, were retrospectively analyzed. Data was statistically analyzed to obtain mean value and variations of each measurement: length from the C2's pedicle to C1's lateral mass, thickness of the pedicle of C2, the attack angle of the screw at the C2 isthmus with the horizontal axis and the distance from the odontoid to the anterior arch of C1.RESULTS: The mean values obtained were: length right 30.86 mm, left 31.47 mm; thickness right 5.28 mm, left 5.26 mm; attack angle right 46.250 , left 44.500 ; distance from odontoid to anterior arch of C1 2,17 mm.CONCLUSION: The Magerl technique, after tomographic study, seems to be a viable option to be used in pediatric patients. Level of Evidence IV, Case Series.