Técnica de Krogius-Lecène en el tratamiento de la luxación habitual de rótula. Resultados a largo plazo / Krogius-Lecène technique in the treatment of recurrent patellar dislocation. Long-term results

Objetivo. La luxación habitual de rótula se trata de una patología en la que se produce una luxación de la misma cada vez que el paciente realiza una flexión de la rodilla, volviendo a su posición correcta en el surco intercondíleo con la rodilla en extensión. El tratamiento debe ir encaminado al recentraje rotuliano, y es importante realizarlo de forma precoz, para evitar daños irreparables producidos por las constantes luxaciones y choques de los cóndilos con el cartílago rotuliano. Cuando esta patología se produce en pacientes en los que el cartílago de crecimiento se encuentra todavía activo, la cirugía ósea no se puede llevar a cabo. El objeto del trabajo es valorar en este grupo de pacientes la cirugía de realineamiento rotuliano actuando exclusivamente sobre partes blandas. Material y método. Estudiamos la evolución de las rodillas de 11 pacientes (14 rodillas) afectos de luxación habitual de rótula antes de la madurez esquelética en los que se realizó realineamiento rotuliano mediante la técnica Krogius-Lecène. Resultados. El seguimiento medio de estos pacientes fue de 21,9 años, período tras el cual los resultados clínicos obtenidos fueron excelentes en 10 rodillas, buenos en tres y regulares en una. En ningún caso la rodilla volvió a sufrir episodios de luxación. Conclusión. La técnica de Krogius-Lecène para el tratamiento de la luxación habitual de rótula es un método que consigue buenos resultados a largo plazo en pacientes con el cartílago de crecimiento activo (AU)

Frozen cancellous bone allografts: positive cultures of implanted grafts in posterior fusions of the spine.

We have carried out a study on the behaviour pattern of implanted allografts initially stored in perfect conditions (aseptically processed, culture-negative and stored at -80 degrees C) but which presented positive cultures at the implantation stage. There is no information available on how to deal with this type of situation, so our aim was to set guidelines on the course of action which would be required in such a case. This was a retrospective study of 112 patients who underwent a spinal arthrodesis and in whom a total of 189 allograft pieces were used. All previous bone and blood cultures and tests for hepatitis B and C, syphilis and HIV (via PCR techniques) were negative. The allografts were stored by freezing them at -80 degrees C. A sample of the allograft was taken for culture in the operating theatre just before its implantation in all cases. The results of the cultures were obtained 3-5 days after the operation. There were 22 allografts with positive culture results (12%) after implantation. These allografts were implanted in 16 patients (14%). Cultures were positive for staphylococci coagulase negative (ECN) in 10 grafts (46%), Pseudomonas stutzeri in two grafts (9%), Corynebacterium jeikeium in two grafts (9%), staphylococci coagulase positive in two grafts (9%) and for each of the following organisms in one case each (4%): Corynebacterium spp., Actinomyces odontolyticus, Streptococcus mitis, Peptostreptococcus spp., Rhodococcus equi and Bacillus spp. No clinical infection was seen in any of these patients. Positive cultures could be caused by non-detected contamination at harvesting, storing or during manipulation before implantation. The lack of clinical signs of infection during the follow-up of our patients may indicate that no specific treatment different from our antibiotic protocol is required in the case of positive culture results of a graft piece after implantation.

Tratamiento de la espondilolistesis en niños y adolescentes / Treatment of spondylolisthesis in children and adolescents

La espondilolistesis es una de las causas identificables de dolor lumbar más frecuentes en la infancia, llegando a afectar al 6 por ciento de los niños mayores de 6 años. Cómo tratar esta patología ha sido motivo de controversia dado que no se pueden dar reglas generales. El tratamiento debe ser individualizado para cada paciente. Asimismo es importante recalcar el hecho de que aunque un paciente no necesite tratamiento, mientras tenga capacidad de crecer, podrá tener un avance en la deformidad, especialmente en las espondilolistesis displásicas, por lo que el seguimiento periódico de estos pacientes es obligatorio. Con este trabajo pretendemos mostrar nuestra experiencia en el tratamiento de esta patología presentando una serie de 139 pacientes con una media de edad en el diagnóstico de 11,8 años (9 meses-19años) controlados en nuestro centro con una evolución superior a los dos años (AU)

[Radiologic evaluation of idiopathic congenital clubfoot and its clinical correlation in Codivilla's surgical technique]. / Valoración radiológica del pie zambo congénito idiopático y su correlación clínica en la operación de Codivilla.

Thirty-seven patients (52 idiopathic clubfeet) were treated with Codivilla's technique between 1971 and 1985. Radiological measurements and clinical evaluation before and after surgery were performed; a correlation was carried out between these evaluations and personal satisfaction. The results were rated as follows: poor in 4 feet (7.7%), fair in 18 feet (34.6%), good in 24 feet (46.2%) and excellent in 6 feet (11.5%) with a total percentage of satisfactory results amounting to 57.7%. Our conclusion is that when the indications are properly established, Codivilla's technique is a good procedure to correct clubfoot.

[Congenital synostoses of the tarsus. Concept, classification, diagnosis and therapeutic approach]. / Sinostosis congénitas del tarso. Concepto, clasificación, diagnóstico y planteamiento terapéutico.

The incidence of congenital tarsal coalition is about 1%. It is recognized as the main etiology of painful, rigid flatfoot in the pediatric population. Talonavicular (50%) and talocalcaneal (40%) coalition are the most common presentation. We must suspect a tarsal coalition in a child with mechanical pain and shoes deformity. Rigid and painful planovalgus deformity are found in physical exam which led to describe in the pass this entity as peroneal spastic flatfoot. Lateral and oblique (35 degrees-45 degrees) radiographs must be practice to observe the coalition. The presence of a beak in the head of the talus or a half moon condensation image as the result of the superposition of the talus over the calcaneus are commonly described. CT-scan is also useful to delineate the size of the coalition and its location. Resection of the bar is the surgical treatment of choice. Excision of the coalition and interposition of fat or a graft must be tried in young patients in order to preserve foot biomechanical properties and to avoid long term problems associated with arthrodesis. Triple arthrodesis or subtalar arthrodesis must be used in older patients with degenerative signs in radiographs or in those cases of multiple coalition or if resection has failed.

Femoral anteversion osteotomy for the treatment of hip dislocation in Down syndrome: long-term evolution.

We propose a femoral desrotational osteotomy to antevert the femoral head associated with plication of the anterior and superior capsule for treatment in the early stages of hip dislocation in Down syndrome. Eight patients (10 hips) with Down syndrome and hip dislocation were reviewed. Five children (seven hips) were operated. We used the proposed surgical technique in three patients (four hips). The average follow-up was 11 years (range, 5-16 years). No infections or complications were observed. In our short experience, this is the recommended procedure in the early stages of hip dislocation in Down syndrome.

Sinostosis congénitas del tarso Concepto, clasificación, diagnóstico y planteamiento terapéutico / Congenital tarsal coalition. Concept, classification, diagnostic and therapy

La incidencia de las sinostosis congénitas del tarso se estima en torno al 1 por ciento de la población, siendo una de las causas más comunes de pie plano rígido doloroso en la población pediátrica. La barra calcáneoescafoidea (50 por ciento) y el puente astragalocalcáneo (40 por ciento) son las formas de presentación más frecuentes. La restricción de la movilidad, el dolor mecánico en el lugar de la fusión y la deformidad del calzado referida en la anamnesis deben hacernos sospechar esta entidad. En la exploración física destaca la rigidez del retropió con limitación dolorosa característica de la pronosupinación que ha motivado clásicamente la errónea denominación de pie plano peroneo espástico. El diagnóstico radiológico se hace normalmente con radiografías simples (proyecciones laterales y oblicuas entre 35 y 45°), en las que observamos el osteofito anterior de la cabeza del astrágalo o la imagen de condensación en "media luna" del astrágalo superpuesto con el calcáneo, siendo necesario en ocasiones recurrir al TAC. Entre las posibilidades terapéuticas, el tratamiento quirúrgico es el único resolutivo del problema de base. La resección-artroplastia de interposición debe intentarse en pacientes jóvenes en los que se quiera preservar la biomecánica normal del pie, evitándose los problemas a largo plazo de la artrodesis. La triple artrodesis o la artrodesis subastragalina, se reservan para pacientes mayores con signos degenerativos, en casos de fusiones tarsianas múltiples y tras fracaso de la resección-artroplastia (AU)

[Surgical treatment of vertebral metastasis]. / Tratamiento quirúrgico de las metástasis vertebrales.

Spinal metastases may cause pain and neurologic dysfunction secondary to bone destruction and spinal cord compression. The new oncology therapy have prolonged life expectancy of many patients with different primary tumors. The treatment of metastases is frequently necessary to enhance quality of life. We reviewed 121 patients with spinal metastases of different primary tumors operated between 1982 and 1995. We employed different approach and instrumentation depending on particular case, metastases location and life expectancy. We analysed primary tumor location, spinal pain, neurologic function, pre and post surgical treatment, complications and development. Spinal stabilization and cord decompression gives excellent results for pain relief, neurological improvement and quality of life, always helping to medical treatment of a patient with metastatic disease.

Lumbosacral arthrodesis using pedicular screws and ringed rods.

Sixty-one patients who had lumbar instability and chronic low back pain or deformity from nontraumatic lumbar pathologies were studied. In all of them a posterior lumbosacral fusion with CUN (Clinic of the University of Navarre) pedicle rod fixation was used. The mean follow-up period was 36 months (range 26-46 months). The consolidation rate was evaluated according to plain and functional radiographs, and a clinical evaluation was made using an analogue pain scale. The rate of fusion was 93.5%. Neurological complications occurred in 3.3%. The incidence of screw failure was 2.3% of all the screws. No other implant failure occurred. The patients rated their clinical results as 'excellent' in 33.8% of the cases, 'good' in 42.2%, 'fair' in 16.9% and 'poor' in 6.7%. CUN instrumentation is a versatile internal fixation system that has been shown to provide satisfactory stability. Furthermore, the clinical results are comparable to those reported in studies in which the most common hardwares were used.

[Allografts in extensive spinal arthrodesis]. / Aloinjertos en artrodesis vertebrales extensas.

Surgery of spinal deformities and vertebral tumors often requires extensive arthrodesis, with the difficulty of obtaining sufficient autogenous bone graft (particularly in children and cases of paralytic deformities) and the necessity of a second incision, thus lengthening the operation and eventual increase of the morbidity. We present 52 patients who suffered from vertebral tumours, fractures or spinal deformities and underwent spinal arthrodesis surgery. Femoral head allografts were used as cancellous bone graft to add to the amount obtained from the arthrodesis bed itself (posterior structures). In three occasions, femoral head grafts shaped as a strut were also used as intersomatic bone graft, being implanted via a costotansversectomy. The only complication was the appearance of seromas of spontaneous resorption in the first 15 cases (thereafter repeated cleaning of the bone graft avoided this problem). In our experience, bone grafts facilitate the carrying out of shorter surgical operations but can also avoid having to recourse the further incisions without reducing the possibility of obtaining a successful arthrodesis.

Lumbosacral instrumentation in patients with scoliosis in cerebral palsy.

We review our experience in surgical treatment of scoliosis in cerebral palsy (CP) patients to improve the functional status of such patients. The results with two types of instrumentation are reported. The best results with fusion to the sacrum were obtained with ringed rods with sublaminar and basispinous wiring, adding distraction and compression, and pedicular screws.

Lumbar spine anomalies in a pycnodysostosis case.

We report a case of pycnodysostosis in which several clefts in the laminas, interarticular parts, and pedicles of the whole lumbar spine were revealed for the first time on CT. We review similar findings in the literature, and discuss their pathogenesis.

Lumbosacral arthrodesis with louis technique. Review of 186 cases.

A retrospective study was carried out of 186 patients surgically treated by lumbosacral arthrodesis using Louis plates from 1981 to 1989 with an average follow-up of 7.2 years (range 3-11). The average age of the patients was 42.2 years (range 11-71). The indication for surgery was a herniated disc and segmentary instability in 29% (54 patients), spondylolysis or spondylolisthesis in 26.3% (49 patients), arthrosis in 11.3% (21 patients), instability (narrowing of the disc space and zygapophyseal hypertrophy) and stenosis in 5.9% (11 patients), tumour in 5.4% (10 patients), fractures in 0.5% (1 patient) and combinations of the above in 21.5% (40 patients who mainly had a herniated disc and associated spinal stenosis). Iliac crest autograft was used in 33 cases (17.7%), bank allograft in 5 (2.6%), and in the other 148 patients the graft was obtained from the arthrodesis bed. After follow-up we observed loosening of the screws in 20 patients and screw rupture in 10. We only documented 2 cases of pseudarthrosis using dynamic X-radiography. We conclude that the Louis plate is a simple method that leads to lumbosacral arthrodesis with a low rate of pseudoarthrosis.

Eosinophilic granuloma of the spine with and without vertebra plana: long-term follow-up of six cases.

Vertebral eosinophilic granuloma is a rare condition frequently associated with vertebra plana. In this paper we present six patients with eosinophilic granuloma of the spine; three were without vertebra plana, which represents a diagnostic problem. The mean follow-up was 9 years, (range 2 to 23) and the mean age was 10.8 years at diagnosis. All complained of pain with no neurological deficit. The lesions were located on the vertebral bodies of C4, T9, T10, L1, L2, and L5, respectively. Histologic confirmation of diagnosis was obtained in all patients, two by puncture and four by open biopsy. The patients with vertebra plana (T10, L1, and L5, respectively) were treated conservatively. Long-term follow-up demonstrated total healing of the vertebral body in two and partial rebuilding 8 years after diagnosis in one. Patients without vertebra plana (C4, T9, and L2, respectively) underwent curettage and bone grafting. In the patient with T9 location, a T8-10 anterior arthrodesis with autogenous rib graft was performed. The outcome was satisfactory in all.

[Histiocytosis X]. / Histiocitosis X.

We make a clinical and bibliographical review in diagnosis and treatment of Histiocytosis X, who includes three components: Eosinophylic granuloma, Hand-Schüller-Christian disease and Letterer-Siwe syndrome. We had 28 cases, with an average age of 11.8 years. Eighteen (64%) were males and 10 (36%) females. Seventeen were solitary lesions and 8 had multiple skeletal lesions. Three patients had generalized disease: 2 with Hand-Schüller-Christian disease and 1 with Letterer-Siwe syndrome. The femur lesion was frequently observed among the solitary lesions and the cranium involvement in the multiple skeletal lesions. The total number of lesions was 47. The treatment depended on the location, the clinical manifestations and the number of lesions. The patients with solitary lesions (17) were treated with curettage and bone grafting in 6 cases, segmental resection in 3 cases, only curettage in 3, radiotherapy in one and 4 patients didn't receive treatment. The patients with multiple lesions (8), were treated surgically (4 cases), only radiation therapy (2 patients), with surgery and radiotherapy (1) and one patient had no treatment. The generalized disease was treated with surgery of the main lesion depending in the clinical manifestations and chemotherapy and radiotherapy. The prognosis was good in almost all the patients and we observed regression of the disease even without specific treatment. The case of acute generalized disease died due to systemic complications.

Neurologic complications after sublaminar wiring. An experimental study in lambs.

To study possible neurologic complications, five lambs were operated on by sublaminar wiring at the thoracolumbar spine. Monitoring of the central motor pathway was carried out by percutaneous electrostimulation. A comparative anatomic study was designed to compare the magnitude of the spinal canal and the area occupied by the spinal cord at the low thoracic and lumbar level in 15 lamb, 8 pig, and 8 human spines. The following parameters were measured by slide caliper: the anteroposterior diameter of the spinal canal and the spinal cord, the length and thickness of the laminas, and the distance between each consecutive lamina. All five operated lambs showed major neurologic deficits after surgery. The results of the anatomic study suggest that there exists in humans a sufficiently ample "safety zone" that permits wire insertion without risking injury to neurologic structures. Such a "safety zone" is nonexistent in lambs and pigs unless an extensive laminectomy is performed to decrease the depth of wire penetration.

The neurocentral vertebral cartilage: anatomy, physiology and physiopathology.

The neurocentral cartilage (NCC) described by Schmorl was an intermediate cartilage has aroused discussion among numerous authors as to its role, its age of closure and its possible involvment in the genesis of scoliosis. The authors have attempted to define these problems on the basis of a histologic study of 20 vertebral specimens of different ages and a scanographic study of 25 children. The NCC remains open until adolescence and even beyond, but its maximal activity is probably around 5-6 years. Part of its function is to ensure growth of the posterior arch. Finally, the scanograms of scoliosis show the NCC to be more widely open on the concave side, as if this remained active for a longer period.