La fijación con tornillo de interferencia tibial cuadrante específico permite un constante desplazamiento de los injertos de tejido dentro de tuneles tibiales mal poscionados: análisis cuantitativo de ligamento cruzado anterior en porcinos / Quadrant specific tibial interference screw fixation allows constant displacement of soft tissue grafts inside misplaced tibial tunnels: a porcine anterior cruciate ligament quantitative assessment study

INTRODUCCIÓN El error técnico más común durante la reconstrucción del ligamento cruzado anterior (LCA) es la ubicación incorrecta del túnel. Es incierto si un túnel tibial mal ubicado puede corregirse en el intraoperatorio. OBJETIVO Medir el desplazamiento del injerto de tejido blando con tornillos de interferencia tibial.MATERIALES Y MÉTODOS Estudio experimental ex vivo en 28 rodillas porcinas. Se cosechó el tendón flexor de la extremidad posterior, que fue duplicado y dimensionado para que pasara a través de un túnel tibial mal posicionado. Las muestras se dividieron en 4 grupos según el cuadrante de entrada (anterior [A], posterior [P], medial [M], o lateral [L]) de un tornillo de interferencia tibial de 9 mm con relación al injerto. Se ubicó una regla milimétrica en la meseta tibial, la cual fue fotografiada con una cámara EOS T6 (Canon Inc., Ota, Tokio, Japón), y la imagen fue digitalizada, y puesta en escala a tamaño. La distancia y dirección de los desplazamientos del injerto se midieron con Adobe Photoshop CC 2019 (San José, CA, EEUU). Se analizaron las diferencias medias entre los grupos por análisis de la varianza (analysis of variance, ANOVA, en inglés) unidireccional. El análisis estadístico se realizó con el programa Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, EEUU), versión 25.0 (p ≤ 0,05)).RESULTADOS La distancias medias de los desplazamientos del injerto fueron similares en todos los grupos: A ­ 4,4 mm; P ­ 4,6 mm; M ­ 4,5 mm; y L ­ 4,3 mm, sin diferencias estadísticamente significativas (p = 0,894). Las direcciones medias de los desplazamientos del injerto también fueron similares entre los 4 grupos: A ­ 176° (desviación estándar [DE]: ± 15,4°); P ­ 165° (DE: ± 16,6°); M ­ 166° (DE: ± 12,1°); y L ­ 169° (DE: ± 10,6°). No se encontraron diferencias estadísticamente significativas (p = 0.42).CONCLUSIONES Independientemente del cuadrante de entrada, se observó un desplazamiento constante del injerto hacia el lado opuesto cuando el tornillo tibial alcanzaba la superficie articular. Relevancia clínica: el tornillo tibial mal posicionado puede corregirse en el intraoperatorio con fijación proximal en cuadrante específico, y debe alcanzar la superficie articular para generar un desplazamiento efectivo del injerto. Sin embargo, no podemos predecir la magnitud de error en todos los túneles mal brocados, que debe ser evaluada caso a caso.

BACKGROUND The most common technical error during anterior cruciate ligament (ACL) reconstruction is incorrect tunnel placement. It remains unclear if a misplaced tibial tunnel may be corrected intraoperatively. AIM To measure the displacement of soft-tissue grafts with tibial interference screws. MATERIALS AND METHODS Ex-vivo experimental study in 28 porcine knees. The flexor tendon of the posterior limb was harvested, doubled and sized to fit through a 9-mm misplaced tibial tunnel. The specimens were divided into 4 groups according to the quadrant of entry (anterior [A], posterior [P], medial [M], or lateral [L]) of a 9-mm tibial interference screw in relation to the graft. A millimetric ruler was placed at the tibial plateau, which was photographed with a an EOS T6 (Canon Inc., Ota, Tokio, Japan) camera, and the image was digitalized and scaled to size. The length and direction of the graft displacements were measured with Adobe Photoshop CC 2019 (San José, CA, US). The mean differences among the groups were analyzed through one-way analysis of variance (ANOVA). The statistical analysis was performed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, US) software, version 25.0 (p 0.05) RESULTS The mean lengths of the graft displacements were similar among the groups: A ­ 4.4 mm; P ­4.6 mm; M ­ 4.5 mm; and L ­ 4.3 mm, without statistically significant differences (p » 0.894). The mean directions of the graft displacements were also similar among the groups: A ­ 176° (standard deviation [SD]: 15.4°); P ­ 165° (SD: 16.6°); M ­ 166° (SD: 12.1°); and L ­ 169° (SD: 10.6°). No statistically significant differences were found (p » 0.42). CONCLUSIONS Regardless of the entry quadrant, constant graft displacement to the opposite side was observed when the tibial screw reached the articular surface. Clinical relevance: a misplaced tibial tunnel may be corrected intraoperatively with a quadrantspecific screw, which must reach the articular surface to produce an effective graft displacement. Nevertheless, we cannot predict the magnitude of this error in every poorly-drilled tibial tunnel; it should be assessed case by case.

¿Es segura la cirugía ambulatoria de reconstrucción de ligamento cruzado anterior? experiencia a dos años de seguimiento clínico / Is outpatient reconstruction of the anterior cruciate ligament a safe procedure? experience with two years of follow up

INTRODUCIÓN: La cirugía ambulatoria permite una reducción importante del costo en procedimientos de alta prevalencia; no obstante, siempre debe resguardarse la seguridad del paciente. OBJETIVO: Evaluar las complicaciones operatorias tempranas y resultados funcionales en pacientes sometidos a reconstrucción de ligamento cruzado anterior (R-LCA) en cirugía ambulatoria. Se analiza además una estimación en la reducción de costos por programa ambulatorio. MATERIAL Y MÉTODOS: Estudio retrospectivo de pacientes sometidos a R-LCA con técnica hueso-tendón-hueso (HTH) en pabellón ambulatorio en un mismo centro, entre 2016 y 2018. Se excluyeron pacientes con menos de un año de seguimiento. Se utilizó el mismo protocolo anestésico: anestesia espinal y bloqueo sensitivo único, asociado a analgesia postoperatoria por vía oral. Se entregó a pacientes instructivo de cuidados postoperatorios, síntomas de alarma, y ejercicios de fisioterapia al alta. Se realizó encuesta telefónica al tercer día para evaluar el estado general y las complicaciones, y, al final del seguimiento, para evaluación funcional mediante las escalas de Tegner y Lysholm pre- y postquirúrgicos. Se identificaronó a pacientes no dados de alta el mismo día, consulta precoz no programada, y reintervenciones. Se realizó un análisis de costo para evaluar el ahorro por procedimiento ambulatorio versus hospitalizado. RESULTADOS: Se operaron 36 pacientes de forma ambulatoria. En 4 (11,1%) se asoció a sutura meniscal con técnica dentro-fuera. La encuesta postoperatoria inicial fue respondida por 23 pacientes (63,8%); todos presentaron buen estado general: 43% sin dolor y 57% con molestias tolerables. No hubo sangrados. La encuesta al final del seguimiento (promedio: 22,5 7,9meses) fue respondida por 20 pacientes (55,5%): la puntación en las escalas de Tegner y Lysholm aumentó significativamente, de 3 (rango: 1 a 6) a 6 (rango: 3 a 8) (p » 0,0001) y de 44 (rango: 12 a 81) a 91 (rango: 61 a 100) (p » 0,0001), respectivamente. Todos fueron dados de alta el mismo día de la operación. Hubo 2 (5,5%) consultas precoces, una por caída en domicilio con dehiscencia de herida operatoria, y otra por hematoma no complicado. Se registraron dos reintervenciones: una dehiscencia de herida operatoria y una fractura de patela. La reducción de costos por realizar el procedimiento de forma ambulatoria fue de 203.205 pesos/paciente. CONCLUSIÓN: La cirugía ambulatoria de R-LCA mediante la técnica HTH fue un procedimiento seguro en esta serie, con un manejo adecuado del dolor y resultados funcionales satisfactorios al mediano plazo. Se asoció además a una reducción en estimación de costos.

INTRODUCTION: Outpatient procedures allow for an important cost reduction in highprevalence procedures; however, patient safety must always be ensured. OBJECTIVE: To evaluate the early complications and functional scores of patients undergoing an anterior cruciate ligament reconstruction (ACLR) as an outpatient procedure. An estimated cost reduction is also analyzed. MATERIALS AND METHODS: A retrospective study of patients undergoing outpatient ACLR with a bone-patellar tendon-bone (BPTB) technique in one center between 2016 and 2018. Patients with less than one year of follow-up were excluded. All patients were submitted to the same anesthetic protocol: spinal anesthesia, a one-shot echo-guided adductor canal nerve block, and outpatient analgesics. Upon discharge, all patients received instructions regarding postoperative care, physical therapy exercises, and red flags. A telephone survey was conducted on the third day to evaluate the general conditions and complications, as well at the final follow-up, to collect pre- and postoperative Tegner and Lysholm functional scores. Patients who were not discharged on the same day, early non-scheduled visits, and re-interventions were recorded. A cost-reduction analysis was performed for the inpatient versus outpatient procedures. RESULTS: In total, 36 patients were submitted to an outpatient procedure, and 4 (11.1%) had an outside-in meniscal suture. The survey was filled out by 23 patients (63.8%); all were in good general condition: 43% reported no pain and 57%, tolerable pain. No bleeding was observed. The survey at the end of the follow-up (average: 22.5 7.9 months) was filled out by 20 patients (55.5%); the scores on the Tegner and Lysholm scales improved significantly, from 3 (range: 1 to 6) to 6 (range: 3 to 8) (p » 0.0001), and from 44 (range: 12 to 81) to 91 (61 to 100) (p » 0.0001) respectively. All patients were discharged on the same day of surgery. There were 2 (5.5%) early visits, one due to a fall at home withdehiscence of the surgical wound, and one due to a non-complicated hematoma. Two re-interventions at the end of the follow-up were recorded: traumatic surgical-wound dehiscence and a patellar fracture. The cost reduction for the outpatient procedure was of 203, 205 pesos per patient CONCLUSION: The outpatient ACLR with the BPTB technique was a safe procedure in the present series, with adequate pain management and satisfactory functional scores at the medium-term follow-up. It was also associated with a reduction in cost estimates.

The transcriptional activator of the bfp operon in EPEC (PerA) interacts with the RNA polymerase alpha subunit.

Enteropathogenic E. coli virulence genes are under the control of various regulators, one of which is PerA, an AraC/XylS-like regulator. PerA directly promotes its own expression and that of the bfp operon encoding the genes involved in the biogenesis of the bundle-forming pilus (BFP); it also activates PerC expression, which in turn stimulates locus of enterocyte effacement (LEE) activation through the LEE-encoded regulator Ler. Monomeric PerA directly binds to the per and bfp regulatory regions; however, it is not known whether interactions between PerA and the RNA polymerase (RNAP) are needed to activate gene transcription as has been observed for other AraC-like regulators. Results showed that PerA interacts with the alpha subunit of the RNAP polymerase and that it is necessary for the genetic and phenotypic expression of bfpA. Furthermore, an in silico analysis shows that PerA might be interacting with specific alpha subunit amino acids residues highlighting the direction of future experiments.

Is the Clinician's Eye a Valid and Reproducible Tool for Diagnosing Patella Alta on a Lateral Knee Radiography?

INTRODUCTION: Validity and reproducibility of the clinician's eye (CE) to diagnose patella alta (PA) on a lateral knee radiography (radiograph) is unknown. METHODS: Cross-sectional study of 46 lateral knee x-rays. Three blind observers used CE, Insall-Salvati (IS), modified Insall-Salvati (mIS), and Caton-Deschamps (C-D) to determine patellar height. Sensitivity and specificity of each observer was compared with the musculoskeletal radiologist's C-D measurements. Intraobserver and interobserver agreement were assessed with intraclass correlation coefficient and Fleiss κ, respectively. Time needed to estimate patellar height for every method was recorded in seconds. Statistical differences between observers were calculated with a generalized estimating equation. Analysis of variance and post hoc Bonferroni test compared duration of each method (P < 0.05). Data were analyzed using Stata 15 (StataCorp). RESULTS: CE, IS, mIS, and C-D's sensitivity and specificity values are as follows: 77%, 92%; 94%, 52%; 67%, 58%; and 53%, 89%, respectively. Intraclass correlation coefficient and Fleiss κ of CE, IS, mIS, and C-D values are as follows: 0.66 and 0.43, 0.88 and 0.68, 0.54 and 0.09, and 0.68 and 0.59, respectively. CE was the second most sensitive and most specific method for diagnosis of PA, with moderate intraobserver and interobserver agreement. IS was the most sensitive method with good intraobserver and interobserver agreement. CE was significantly faster (P < 0.05) than all other conventional radiographic ratios. CONCLUSION: CE's sensitivity increases with observer's experience and is highly specific. If normal patellar height is diagnosed, no other ratios are necessary, even in the less experienced clinician. Intraobserver and interobserver reproducibilities were moderate and only inferior to the IS ratio. In case patellar height is uncertain with the CE, the IS ratio is the most sensitive and reproducible method to confirm the diagnosis of PA.

Arthroscopic Intercondylar Notch Bone Marrow Aspiration During Anterior Cruciate Ligament Reconstruction.

The anterior cruciate ligament is the most commonly injured ligament, with up to 10% of surgery failure. Atraumatic instability in the early postoperative period (<6 months) occurs as the result of poor surgical technique, failure of graft integration, or early mechanical overload during rehabilitation. Engineered cell therapy is a developing resource designed to increase the rate of tendon-to-bone interface healing. We describe a simple and safe technique to harvest mesenchymal stem cells by arthroscopic bone marrow aspiration from the intercondylar notch.

Estudio comparativo de reconstrucción de ligamento cruzado anterior con y sin lesiones condrales; resultados funcionales a largo plazo / Anterior cruciate ligament reconstruction with and without chondral lesions; long term functional results

INTRODUCCIÓN: La lesión del ligamento cruzado anterior (LCA), es una patología frecuente, y el éxito de la reconstrucción depende de diversos factores, tales como la técnica quirúrgica empleada, la edad del paciente, índice masa corporal, nivel de actividad y lesiones asociadas. El objetivo de este estudio es comparar los resultados funcionales a largo plazo de pacientes con lesiones condrales tratadas y sin lesiones condrales sometidos a la reconstrucción de LCA (RLCA), con autoinjerto semitendinoso-gracilis (ST-G). MATERIALES Y MÉTODOS: Estudio analítico retrospectivo. Cuarenta y nueve pacientes (34 hombres y 15 mujeres), fueron sometidos a la RLCA con autoinjerto ST-G. Se compararon dos grupos. Grupo RLCA + LC: 24 pacientes con lesiones condrales ICRS grado III y IV tratadas en el mismo acto quirúrgico y grupo RLCA: 25 pacientes sin lesiones condrales concomitantes. Las edades promedio fueron de 32 y 28 años en cada grupo respectivamente. La funcionalidad de los pacientes a largo plazo fue evaluada con el test de Lysholm, IKDC y retorno deportivo. Se compararon los promedios de los scores funcionales según cada grupo con Test de Mann-Whitney. La asociación entre ambos grupos y el retorno deportivo se analizó con Test de Chi2. Los análisis estadísticos se realizaron con Stata IC 13. RESULTADOS: El seguimiento promedio fue de 106,8 meses (rango: 86­125). Los resultados funcionales obtenidos al comparar el grupo RLCA + LC vs grupo RLCA fueron significativamente peores en el primero, con un promedio del score de Lysholm de 84,87 vs 94,52 (p = 0.0001) e IKDC de 84,43 vs 92,08 (p = 0,004), respectivamente. El retorno deportivo de cada grupo fue de 70,8% y 88% (p = 0,136). CONCLUSIÓN: La funcionalidad a largo plazo de los pacientes con una RLCA y que tengan alguna LC profunda tratada concomitante, es significativamente inferior que aquellos pacientes con RLCA aislada. No existen diferencias significativas en el porcentaje de retorno deportivo entre ambos grupos.

INTRODUCTION: Anterior cruciate ligament injury is a frequent sports injury, and successful reconstruction depends on diverse factors, such as surgical technique, age, body mass index, level of activity and other concomitant cartilage and meniscal lesions. The objective of this study is to retrospectively compare the long term clinical outcomes of ACL hamstring tendon autograft reconstruction with and without concomitant cartilage injuries. MATERIALS AND METHODS: Forty nine patients (34 men and 15 women) underwent single bundle transtibial ACL reconstruction and were divided in two groups (Group 1: 24 patients with chondral lesions grade III and IV of the ICRS, and Group 2: 25 patients without chondral lesions). Mean age of both groups was 32 and 28 years, respectively. Clinical outcome was evaluated with Lysholm test, IKDC and return to previous level of sport activities. Mean values of of funcional outcome scores between both groups were compared with Mann-Whitney test. Return to previous level of activity in both groups was analyzed with Chi-2 test. The statistical analysis was performed with Stata IC 13. RESULTS: The mean follow-up period was 106.8 months (range: 86­125). Mean Lysholm test for group 1 vs group 2 was 84.87 and 94.52 (p < 0.001), mean IKDC was 84.43 and 92.08 (p < 0.001), and return to previous sports was 70.8% vs 88% (p = 0.136) for each group. CONCLUSION: Long term clinical outcomes in patients with chondral lesions that underwent ACL reconstruction were significantly lower than patient with isolated ACL injuries. No statistical differences were found in the return to previous sport activities.

Is There Any Correlation Between Short-Term MRI And Mid-Term Clinical Resultsin Patients Undergoing An Osteochondral Autograft In The Knee?

Thirthy three patients (mean age 32 years) undergoing OA were retrospectively evaluated. All patients had MRI at mean 6.6 months. Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores. The aim is to evaluate Magnetic Resonance Imaging (MRI) in patients who underwent an Osteochondal Autograft (OA) and correlate them with their clinical results-evaluated at mean followup of 28 months (12-88). Tegner Pre-operatively: 6.6, Post-operative: 7.4 (p<0.001). Mean Lysholm: 87, mean IKDC: 86. MRI: complete filling of the lesion in 25 (75.7%) patients, complete integration of the graft in 5 (15.1%) and intact repair tissue in 22 (66.6%. Positive correlation between the degree of repair and filling of the defect and higher Lysholm and IKDC (p<0.05). There is a minor association between short-term MRI and mid-term clinical results after an OA being the degree of repair and filling of the chondral defect the only parameters correlated with patient´s evolution.

Reconstrucción mínimamente invasiva del ligamento anterolateral / Minimally invasive anterolateral ligament reconstruction following anterior cruciate ligament revision surgery: technical note

INTRODUCCIÓN: La inestabilidad anteroposterior y la laxitud rotatoria demostrada mediante test de pivot-shift severo podría estar causada por la combinación de lesión de ligamento cruzado anterior (LCA) y de estructuras laterales de la rodilla, particularmente del ligamento anterolateral (LAL). Este último actúa como estabilizador secundario, restringiendo la rotación interna y complementando el rol primario de estabilización del LCA. MATERIAL Y MÉTODOS: Describir la técnica de reconstrucción mínimamente invasiva del LAL tras realizar una cirugía de revisión del LCA. Además, se ofrece una breve descripción de las indicaciones quirúrgicas, resultados y complicaciones. DISCUSIÓN: La inestabilidad rotatoria persistente tras la reconstrucción de LCA indica que la reconstrucción intraarticular podría no ser suficiente para restaurar la estabilidad rotacional en un subgrupo específico de pacientes. Se han descrito numerosas técnicas de reconstrucción extraarticulares (mencionadas previamente), algunas de ellas con incisiones de gran tamaño, con los consiguientes problemas estéticos. Esta nota describe una técnica simple y mínimamente invasiva de reconstrucción de LAL, realizada tras una revisión del LCA con técnica anatómica, todo en el mismo procedimiento quirúrgico. Esta técnica está indicada en roturas agudas o exploraciones/revisiones del LCA que presenten pivot-shift severo, así como también en pacientes con roturas crónicas del LCA o en pacientes que sean hiperlaxos. A pesar de que esta técnica no ha demostrado ser superior a otras reconstrucciones extraarticulares del LAL, se presenta como una cirugía simple, confiable y rápida, con buenos resultados estéticos.

INTRODUCTION: Anteroposterior instability and rotatory laxity demonstrated by severe pivot-shift test may be caused by combined lesions of the anterior cruciate ligament (ACL) and lateral structures of the knee, particularly the anterolateral ligament (ALL). This ligament acts as a secondary stabiliser that restrains internal rotation and supplements the primary stabilising role of the ACL. MATERIAL AND METHODS: To describe a minimally invasive ALL reconstruction technique following anterior cruciate ligament revision surgery. Brief description of surgical indications, outcomes, and complications. DISCUSSION: Persistent rotatory instability after ACL reconstruction suggests that intra-articular reconstruction may not be sufficient to restore rotational stability in a subgroup of patients. Numerous extra-articular reconstruction techniques have been described with long incisions and cosmetic issues. A description is presented of a simple, minimally invasive ALL reconstruction technique performed after anatomical ACL revision in a single procedure. This technique is indicated in patients with acute ACL injuries and revision ACL associated with a severe pivot-shift, chronic ACL injuries, and joint hyper-laxity. Although this technique has not proven to be superior to any other extra-articular anterolateral ligament reconstructions, it uses simple, reliable and cosmetic surgery, with good early results in a small series of patients.

Expectativas y aprensiones de los pacientes sometidos a cirugía de reconstrucción de ligamento cruzado anterior de rodilla / Expectations and concerns of patients undergoing anterior cruciate ligament reconstruction surgery

INTRODUCCIÓN: La lesión del ligamento cruzado anterior (LCA) es una afección frecuente cuyo manejo quirúrgico genera incertidumbre en el paciente sobre su retorno a la actividad. Las expectativas previas al procedimiento influyen en su percepción del éxito del tratamiento, la aparición de complicaciones y en el resultado final, comprometiendo la satisfacción en el postoperatorio. OBJETIVO: Determinar las preocupaciones y expectativas de los pacientes sometidos a cirugía de reconstrucción de LCA. MÉTODO: Estudio prospectivo observacional realizado a través de encuestas a pacientes con lesión del LCA que serían sometidos a una cirugía de reconstrucción. Las variables evaluadas fueron edad, mecanismo de lesión, práctica de actividad deportiva, información previa acerca de la intervención quirúrgica y las preocupaciones y expectativas sobre el procedimiento. RESULTADOS: Cincuenta pacientes fueron encuestados, 38 hombres y 12 mujeres, con edad promedio de 30 años. Los mecanismos de lesión más frecuentes correspondieron a accidentes deportivos de fútbol y esquí. El 96% de los encuestados practicaba algún deporte de forma regular (promedio 5h semanales) previo a la intervención quirúrgica. El 90% de los pacientes investigaron sobre la cirugía de reconstrucción de LCA. Las principales preocupaciones preoperatorias correspondieron al tiempo de recuperación (40%) y a la posibilidad de reintegrarse en la práctica deportiva (38%). Las expectativas se concentraron en lograr un reintegro deportivo precoz (54%) y la presencia de dolor postoperatorio (40%). CONCLUSIÓN: Los pacientes sometidos a reconstrucción de LCA presentan preocupaciones principalmente respecto al tiempo de recuperación postoperatorio y sus expectativas se centran en el logro de un reintegro deportivo precoz.

INTRODUCTION: Anterior cruciate ligament (ACL) injury is a common condition and its surgical treatment causes uncertainty in patients about their return to activity. The expectations prior to the procedure influence their perception of treatment success, development of complications, and final results, and can have an impact on post-surgical patient satisfaction. OBJETIVE: To determine the concerns and expectations of patients undergoing ACL reconstruction surgery. METHOD: Prospective observational study, in which questionnaires were completed by patients with ACL injury that would undergo reconstructive surgery. The evaluated variables were age, mechanism of injury, sports practice, prior information about the surgery and concerns and expectations about the procedure. RESULTS: A total of 50 patients completed the questionnaire, of whom 38 were men and 12 women with a mean age of 30 years. The most common injury mechanisms were when practicing football and skiing. Almost all (96%) of respondents played sports regularly (average 5hours a week) before the surgery. A total of 90% of patients had enquired about ACL reconstruction surgery. The main pre-operative concerns were recovery time (40%) and the possibility of reinstatement of sports (38%). Expectations are focused on achieving an early sports recovery (54%) and the presence of postoperative pain (40%). CONCLUSION: Patients undergoing ACL reconstruction have concerns primarily as regards post-surgical recovery time and expectations are focused on achieving an early reinstatement of sports.

Bloqueo de nervio femoral único vs. continuo en reconstrucción de ligamento cruzado anterior; un estudio clínico aleatorizado / Femoral nerve block in anterior cruciate ligament surgery; a prospective randomised trial

En cirugía de reconstrucción del ligamento cruzado anterior (LCA) es fundamental la rehabilitación precoz y, para ello, la analgesia. El bloqueo de nervio femoral (BNF) es un procedimiento frecuentemente utilizado en cirugía artroscópica y protésica de rodilla, sin embargo, se debate aún cómo debe ser aplicado para mejorar la analgesia sin afectar una rehabilitación precoz. Objetivo: Comparar analgesia mediante BNF con punción única versus infusión continua en las primeras 48h de reconstrucción del LCA. Metodología:Cuarenta y tres pacientes >18 años, ASA 1-2, sometidos a cirugía artroscópica de LCA (autoinjerto) con mismo equipo quirúrgico. Se crearon aleatoriamente 2 grupos: grupo 1 (G1) bloqueo femoral único con bupivacaína más solución fisiológica; grupo 2 (G2) bloqueo femoral+catéter femoral con infusión continua de bupivacaína con adrenalina 1:300.000 por 48h. Se evaluó dolor de reposo y al mover la extremidad, hipoestesia de muslo y necesidad de analgesia adicional a las 6, 12, 24 y 48h. Resultados: El BNF fue exitoso en todos los pacientes, logrando hipoestesia en la totalidad del G2 vs solo 17 por ciento del G1 a las 24h y 74 por ciento vs 0 por ciento a las 48h, respectivamente. El dolor postoperatorio fue bajo y sin diferencias entre los grupos, con requerimiento de analgesia extra de 33 por ciento G1 vs 0 por ciento G2. Conclusión: El BNF es una técnica analgésica eficaz para controlar el dolor postoperatorio en cirugía de LCA. No se observaron diferencias significativas entre las técnicas investigadas. Nivel de evidencia tipo ii...

Early rehabilitation is essential after anterior cruciate ligament (ACL) surgery. Femoral nerve block (FNB) is a frequently used method to control post-operative pain in arthroscopic and reconstructive knee surgery; however, it is still unknown how to apply this procedure to improve analgesia without affecting early rehabilitation. Objective:To compare the effectiveness of pain management after a single dose of FNB vs a continuous FNB infusion during the first 48hours after ACL surgery. Methodology: Forty-three patients older than 18 years, ASA I-II, underwent ACL reconstruction with an autograft. Patients were prospectively randomised into two separate groups: Group 1 (G1) received a single dose of FNB with bupivacaine diluted in 10mL saline solution. Group 2 (G2) received continuous FNB infusion with bupivacaine and epinephrine (1:300.000) for 48hours. Pain was assessed at rest and with controlled passive motion of the knee. Thigh hypo-aesthesia and the need for additional analgesia were evaluated at 6, 12, 24, and 48hours. Statistical analysis was performed with Fisher's exact test (percent) and Mann-Whitney's test (VAS). Statistical significance with P<.05. Results: FNB was successful in all patients, and thigh hypo-aesthesia was present in 100 percent of G2 vs. 17 percent in G1 at 24hours, declining to 74 percent vs. 0 percent at 48hours, respectively. Post-operative pain scores were low, and did not differ between the two groups. Additional analgesia was required in 33 percent of patients in G1 vs. 0 percent in G2. Conclusion: FNB is a successful method for controlling pain after ACL reconstruction. No statistical significance differences were found in pain control between techniques investigated. Level of Evidence type II...

Platelet-rich plasma use in anterior cruciate ligament surgery: systematic review of the literature.

PURPOSE: To systematically review the current literature for evidence that would substantiate the use of platelet-rich plasma (PRP) in the treatment of anterior cruciate ligament (ACL) ruptures. METHODS: We performed a systematic search in PubMed and Embase of studies written in the English and Spanish languages that compared the use of PRP with a control group in patients with ACL injuries assessing graft-to-bone healing, graft maturation, and/or clinical outcomes and were randomized controlled trials or prospective cohort studies. RESULTS: Eleven studies fulfilled the inclusion criteria, comprising 516 patients (266 ACL reconstructions using PRP and 250 ACL reconstructions without PRP). Six studies reported a statistically significant difference (4 studies) or tendency toward faster graft maturation in the platelet group (2 studies). One study found no differences. Regarding tunnel healing/widening, 1 study showed faster healing in the PRP group and 5 studies showed no differences between the 2 groups. Considering clinical outcomes, 1 study showed better clinical outcomes with PRP use and 5 studies showed no benefits with the use of PRP. CONCLUSIONS: Concerning ACL graft maturation, there is promising evidence that the addition of PRP could be a synergic factor in acquiring maturity more quickly than grafts with no PRP, with the clinical implication of this remaining unclear. Regarding tunnel healing, it appears that there is not an improvement with the addition of PRP. There is no proof that clinical outcomes of ACL surgery are enhanced by the use of PRP. LEVEL OF EVIDENCE: Level III, systematic review of Level I through III studies.

Transphyseal anterior cruciate ligament reconstruction in patients with open physes: 10-year follow-up study.

BACKGROUND: The treatment of anterior cruciate ligament (ACL) injuries in skeletally immature patients is controversial. Current evidence supports the view that surgical techniques restore knee stability and prevent progressive articular damage. However, most of the studies on this topic are small case series or they have short- or medium-term follow-up times. PURPOSE: To determine the long-term functional outcomes and secondary complications of transphyseal intra-articular ACL reconstruction with hamstring graft in skeletally immature patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Transphyseal ACL reconstruction with autograft hamstrings was performed in 27 skeletally immature patients. The average age at surgery was 13 years (range, 12-16 years), and the average follow-up time was 10.6 years (range, 10-13 years). Clinical outcomes were assessed with preoperative and final follow-up Tegner, International Knee Documentation Committee (IKDC) subjective, and Lysholm scores. Surgery details, return to sports, and ACL reconstruction failures were collected. The anteroposterior knee laxity was assessed by arthrometry, and the presence of deformities and lower limb length discrepancies were evaluated by radiographs. The presence of degenerative signs on anteroposterior and lateral knee radiographs at final follow-up was also evaluated. RESULTS: Transphyseal ACL reconstruction was performed with vertically oriented tunnels, 7 to 10 mm in diameter, using semitendinosus-gracilis autograft. The average preoperative Tegner, IKDC, and Lysholm scores were 7, 55, and 40, respectively. Significant differences in these scores were observed at the time of the final assessment (Tegner, 6 [P = .026]; IKDC, 94 [P < .001]; Lysholm, 92 [P < .001]). Two patients reported instability during sports activity. Three patients had a rupture of the ACL graft. No leg length discrepancy, axis malalignment, or degenerative changes were observed. CONCLUSION: The transphyseal ACL reconstruction in skeletally immature patients is a safe option, with high functional and satisfaction results, without significant growth plate damage in this series of patients.

A new elevating metatarsal osteotomy: geometrical design and applications.

For metatarsalgia and lesser toe deformities, a commonly performed procedure is the Weil osteotomy, which inevitably depresses the metatarsal head, changing the intrinsic muscle axis and generating phalanx extension. The objective of this study is to present a new metatarsal osteotomy that shortens or lengthens and elevates the metatarsal head, the elevating metatarsal osteotomy (EMO), with its geometrical analysis and possible applications. A geometrical model was designed, planning an oblique subcapital osteotomy with slice resection and distal displacement. A trigonometric analysis was done to calculate how to shorten, elevate, or lengthen the metatarsal head. The EMO elevates the head in one-third of the width of the resected slice. Distal and dorsal displacement of the metatarsal head results in an elevation and lengthening of the metatarsal bone (60% elevation and 65% lengthening). Performing an elevating metatarsal osteotomy will lengthen and elevate the metatarsal head, which sometimes is necessary when treating toe deformities and instability.

Violence related injuries, deaths and disabilities in the capital of Honduras.

BACKGROUND: Honduras has the second highest incidence of violence in the Americas. The aim of this study is to explore the number and mechanism of fatal injuries, non-fatal injuries and the sequelae of these injuries due to violence. This is compared with unintentional injuries, in the capital of Honduras for 2001, with a view to better-targeted prevention. METHODS: Data for non-fatal injuries was retrospectively obtained from medical records of all admissions from the public Emergency Department in Tegucigalpa for 2001. Data on fatal injuries were obtained from the national forensic department. All injuries were reviewed for intention, mechanism and age group. RESULTS: There were 1631 (rate 138/100,000) fatal injuries recorded for 2001 in Tegucigalpa. Of these, 1149 (70.4%) were due to violence, compared to 355 (21.8%) due to unintentional injuries and 127 (7.8%) of unknown intent. Homicides accounted for 1044 (64%), suicides 105 (6.4%) and unintentional deaths 355 (22%). Firearms were the leading cause of death in the homicide group (84.3%). In addition 1592 (rate 235/100,000) non-fatal injuries were documented for people 15 years and above, with 1228 (77.1%) caused by violence, of which 640 (52.1%) were caused by firearms. The age group 15-24 years had the highest rates of fatal and non-fatal injuries due to violence. Twenty percent had permanent sequelae as a result of their injuries. Firearm injuries had the highest proportion of sequelae (28.8%). CONCLUSION: Violence in Tegucigalpa is a major cause of injury resulting in substantial morbidity, mortality and disability, particularly in young individuals. Firearms are the most common form of violence related injury mechanism and carry the highest associated mortality and permanent disability. Prevention programs are urgently needed to address this devastating problem.

Manejo conservador de la enfermedad periodontal crónica en presencia de lesiones vesiculobulosas: reporte de dos casos de pénfigo vulgar / Conservative management of chronic periodontal disease in the presence of vesiculobullous lesions: report of two cases of pemphigus vulgaris

Se reportan dos casos clínicos de pénfigo vulgar, confirmados a través del examen histopatológico, con localización en la región mucogingival de cavidad bucal, en pacientes con presencia de enfermedad periodontal crónica moderada avanzada. El tratamiento periodontal a emplearse en pacientes con lesiones bucales vesiculobullosas como el pénfigo vulgar, puede ser considerado conservador, evitando así la consecuente descamación epitelial de la superficie mucosa y la posterior ulceración de la misma al realizarse tratamientos orientados a las periodontopatías

Identificación de factores de riesgo asociados a enfermedad periodontal y enfermedades sistémicas / Identifying risk factors associated with periodontal diseases and systemic diseases

La identificación de factores de riesgo asociados a la enfermedad periodontal con las enfermedades sistémicas como la diabetes, hipertensión arterial y cardiopatías, son vitales estrategias de medicina preventiva, como una acción de bajo costo y a su vez en consultorios dentales hacer una detección de padecimientos en fase subclínica mejorando las expectativas de la calidad de vida. Se realizó una evaluación de la prevalencia de patologías sistémicas en pacientes con periodontopatías en la consulta odontológica mediante un estudio retrospectivo, observacional, transversal y analítico. La información analizada se recabó del archivo del Posgrado de Periodoncia Tampico de la Universidad Autónoma de Ttamaulipas, en un período de un año, analizándose por grupos de edad, sexo y patología detectada con relación a grado de enfermedad periodontal con base en índices clínicos

Neumonía complicada con empiema en niños, ¿operar o no operar? Factores de riego para cirugía y revisión de la literatura / Pneumonia complicated by empiema in children: To operaate or not to operated? risk factors for surgery and review of the literature

La indicación precisa de cirugía en el manejo del empiema pleural es aún motivo de controversia. Con el propósito de identificar los factores que se asocian a la indicación de cirugía mayor en pacientes pediátricos con neumonía complicada con empiema, se realizó un estudio retrospectivo de casos (18 niños con empiema sometidos a cirugía) y controles (12 niños con empiema resuelto sin cirugía), atendidos de 1992 a 1996. Las variables analizadas fueron las mencionadas en la literatura como factores que se asocian a la indicación de cirugía. Las que se encontraron significativas con una p < de 0.05 fueron: evolución preingreso mayor de 25 días, haber recibido más de tres esquemas de antibióticos, presencia de fiebre; empiema en fase organizada al ingreso; haber colocado dos o más sondas pleurales, duración del tubo de drenaje mayor de nueve días; empiema loculado, pulmón atrapado y engrosamiento pleural. Se concluye que un paciente pediátrico con historia de larga evolución, empiema postneumónico en fase organizada, multitratado, con colecciones purulentas pleurales de difícil acceso y complicaciones que impiden una adecuada expansión pulmonar requerirá muy probablemente cirugía mayor.