Hipoparatiroidismo primario de presentación tardía asociado a patologías autoinmunes / Late onset primary hypoparathyroidism associated with autoimmune disorders

Se presenta una paciente que, en la sexta década de su vida, debuta con episodios de espasmo carpopedal espontáneo. Los valores bajos de calcemia (6,1 mg/dl) y de PTH (8 pg/ml) confirmaron el diagnóstico de hipoparatiroidismo. No había sido sometida a cirugías de cuello ni radioterapia. No existían antecedentes familiares vinculantes. Durante 11 años de seguimiento, la paciente presenta asociación con otras patologías que permiten sospechar la etiología autoinmune del hipoparatiroidismo: candidiasis de piel y uñas, hipotiroidismo por tiroiditis de Hashimoto, penfigoide y psoriasis. Finalmente fallece por una neumonía adquirida en la comunidad, complicada. (AU)

A patient who develops hypoparathyroidism during her sixth decade of life is reported. It was detected due to spontaneous carpopedal spasms. Low calcium (6.1 mg/dl) and PTH (8 pg/ml) levels confirmed the diagnosis. She had not undergone neck surgery or irradiation. There was no relevant family history. Throughout the 11 years follow up she presented association of other pathologies that allow the suspicion of autoimmune etiology of hypoparathyroidism: candidiasis of skin and nails, autoimmune thyroiditis, pemphigoid and psoriasis. She eventually died of complicated community-acquired pneumonia. (AU)

Cyclic load testing and ultimate failure strength of suture anchors in the acetabular rim.

PURPOSE: To determine the resistance to cyclic stress and load-to-failure strength of several suture anchors suitable for hip arthroscopy. METHODS: Ten polyetheretherketone (PEEK) PushLock, PEEK SutureTak, and Bio-SutureTak anchors (Arthrex, Naples, FL); Lupine Loop BR anchors (DePuy Mitek, Norwood, MA); Bio-Mini Revo anchors (ConMed Linvatec, Largo, FL); and BioRaptor 2.9 AB anchors (Smith & Nephew, Andover, MA) were inserted in rotation into different locations on the rim of 4 matched pairs of potted acetabula clamped to the base of a servohydraulic testing machine. The anchors' sutures were cyclically pulled in line with the insertion angle. Displacement at 100 and 500 cycles, yield load, ultimate failure load, and failure mode were recorded. Statistical analysis was performed. RESULTS: Most of the displacement observed during cyclic loading occurred in the first 100 cycles, except for the BioRaptor 2.9 AB, which showed twice as much displacement at 500 cycles as at 100 cycles. The Lupine Loop BR cyclic displacement was greater than that of the PEEK PushLock (at 100 cycles also), Bio-SutureTak, and PEEK SutureTak at 500 cycles (P < .05). The BioRaptor 2.9 AB cyclic displacement was significantly greater at 100 and 500 cycles than that of the PEEK PushLock and Bio-SutureTak (P < .05). The mean ultimate failure loads for these anchors ranged from 154 N (PEEK SutureTak) to 255 N (Bio-Mini Revo) and was statistically equivalent (P = .139). Correlation analysis showed no significant associations between anchor stiffness, cyclic load displacement, or failure load. CONCLUSIONS: Anchors with specific indications for hip arthroscopy showed very little displacement and had consistent failure loads under cyclic conditions in the acetabular rim. All hip anchors except the BioRaptor 2.9 AB showed less than 2.0 mm of displacement after 500 cycles. CLINICAL RELEVANCE: Biomechanical testing of suture anchors designated for hip arthroscopy should be performed in the acetabular rim before their use. Suture anchors used for shoulder arthroscopy may not perform as well in the hip.

Anterior cruciate ligament reconstruction using patellar tendon allograft: an age-dependent outcome evaluation.

PURPOSE: To compare the outcomes of a consecutive series of nonrevision bone-patellar tendon-bone (BPTB) allograft anterior cruciate ligament (ACL) reconstructions in patients aged 40 years or older and patients aged younger than 40 years. METHODS: Prospectively collected data from consecutive BPTB allograft ACL reconstructions fixed with biodegradable interference screws and performed by a single surgeon were analyzed by use of established outcome measures. Preoperative and postoperative outcome assessments included Cincinnati, Lysholm, and Tegner scores and International Knee Documentation Committee (IKDC) activity scores. Lachman test, pivot-shift test, and KT arthrometer (MEDmetric, San Diego, CA) measurements were obtained at a minimum of 24 months after surgery. RESULTS: In total, 32 patients met the inclusion criteria (21 men and 11 women). The mean follow-up was 35 months (range, 24 to 58 months). Of the patients, 21 were aged younger than 40 years (66%) and 11 were aged 40 years or older (34%). The mean age was 35 years (range, 18 to 55 years). In patients aged younger than 40 years, the mean postoperative Cincinnati score was 82.4 (39.1 preoperatively); Tegner score, 6.2 (3.9 preoperatively); Lysholm score, 89.5 (46.8 preoperatively); and IKDC activity score, 2.7 out of 4 (1.7 preoperatively). Five patients had a positive postoperative Lachman test, but none had a positive pivot-shift test. KT examinations showed a manual maximum difference of less than 3 mm in all but 1 patient (mean, 0.7 mm). In patients aged 40 years or older, the mean postoperative Cincinnati score was 83.8 (44.4 preoperatively); Tegner score, 6.6 (3.9 preoperatively); Lysholm score, 88.8 (50.1 preoperatively); and IKDC activity score, 2.7 out of 4 (2.1 preoperatively). One patient had a positive postoperative Lachman test, but none had a positive pivot-shift test. KT examinations showed a manual maximum difference of less than 3 mm in all but 1 patient (mean, 1.3 mm). CONCLUSIONS: The outcomes of BPTB allograft ACL reconstructions were not different both subjectively and objectively for patients aged 40 years or older and patients aged younger than 40 years. BPTB allograft ACL reconstruction provides consistent results for patients of all age groups. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs.

PURPOSE: To evaluate the strength and suture-tendon interface security of various suture anchors triply and doubly loaded with ultrahigh-molecular weight polyethylene-containing sutures and to evaluate the relative effectiveness of placing these anchors in a single-row or double-row arrangement by cyclic loading and then destructive testing. METHODS: The infraspinatus muscle was reattached to the original humeral footprint by use of 1 of 5 different repair patterns in 40 bovine shoulders. Two single-row repairs and three double-row repairs were tested. High-strength sutures were used for all repairs. Five groups were studied: group 1, 2 triple-loaded screw suture anchors in a single row with simple stitches; group 2, 2 triple-loaded screw anchors in a single row with simple stitches over a fourth suture passed perpendicularly ("rip-stop" stitch); group 3, 2 medial and 2 lateral screw anchors with a single vertical mattress stitch passed from the medial anchors and 2 simple stitches passed from the lateral anchors; group 4, 2 medial double-loaded screw anchors tied in 2 mattress stitches and 2 push-in lateral anchors capturing the medial sutures in a "crisscross" spanning stitch; and group 5, 2 medial double-loaded screw anchors tied in 2 mattress stitches and 2 push-in lateral anchors creating a "suture-bridge" stitch. The specimens were cycled between 10 and 180 N at 1.0 Hz for 3,500 cycles or until failure. Endpoints were cyclic loading displacement (5 and 10 mm), total displacement, and ultimate failure load. RESULTS: A single row of triply loaded anchors was more resistant to stretching to a 5- and 10-mm gap than the double-row repairs with or without the addition of a rip-stop suture (P < .05). The addition of a rip-stop stitch made the repair more resistant to gap formation than a double row repair (P < .05). The crisscross double row created by 2 medial double-loaded suture anchors and 2 lateral push-in anchors stretched more than any other group (P < .05). CONCLUSIONS: Double-row repairs with either crossing sutures or 4 separate anchor points were more likely to fail (5- or 10-mm gap) than a single-row repair loaded with 3 simple sutures. CLINICAL RELEVANCE: The triple-loaded anchors with ultrahigh-molecular weight polyethylene-containing sutures placed in a single row were more resistant to stretching than the double-row groups.

[Slipped femoral epiphysis in children under 10 years of age. Clinical and radiologic evaluation of the surgical treatment]. / Epifisiolistesis femoral en menores de 10 años. Evaluación clínica y radiológica del tratamiento quirúrgico.

OBJECTIVE: Analyze the postoperative clinical and radiographic results of children under 10 years of age with slipped proximal femoral epiphysis and determine the differences compared to other age groups. MATERIAL AND METHODS: Retrospective study with a minimum follow-up of 2 years; Southwick's angle, treatment, and the rate of contralateral slip were all assessed. The Iowa scale was used for assessment purposes. RESULTS: A total of 18 patients and 23 hips were reported (5 cases were bilateral), mean age was 8.53 years, and Southwick's angle was 43 degrees. All cases were treated with in situ fixation, with a single screw in 19 hips, Kirschner's nails in 2 hips, and one screw and one nail in one hip; prophylactic fixation was used in one hip. Mean follow-up was 6.9 years. Three cases had contralateral slip occurring 6-13 months after the initial slip. The mean Iowa score was 85.69. A neck-shaft angle of 115 degrees was seen in the final X-ray; there were 3 complications: two cases of avascular necrosis and one chondrolysis. DISCUSSION: The clinical results were similarly good in this group of patients, who have typically been considered as very difficult to treat. Radiographically, a relatively normal anatomy was seen and only one case showed early arthrosis. The contralateral slip rate was not higher than in older patients.

Biomechanical testing of commercially available soft-tissue augmentation materials.

PURPOSE: To evaluate several physical properties and physical dimensions of commercially available soft-tissue augmentation devices. METHODS: After 2 x 5-cm strips of several graft materials were hydrated, load elongation, cyclic and permanent displacement, percent elastic displacement, tensile modulus, stiffness, and ultimate load-to-failure strength were determined. With a 5-N preload, 30 cyclic loads between 5 N and 50 N were applied at 12.5 mm/s followed by destructive testing. A vertical stitch suture retention test was also performed. RESULTS: SportMesh (Biomet Sports Medicine, Warsaw, IN) displaced more than any other material (P < .001). GraftJacket MaxForce Extreme (Wright Medical Technology, Arlington, TN) and Allopatch HD 2 (Musculoskeletal Tissue Foundation, Edison, NJ) displaced more than RC Allograft (Arthrex, Naples, FL) (P < .05). Percent elastic deformation did not differ among these materials. OrthAdapt (Pegasus Biologics, Irvine CA) had a higher tensile modulus than RC Allograft, SportMesh, and Allopatch HD 2 (P < .001). Allopatch HD 1 and GraftJacket MaxForce Extreme had a higher tensile modulus than RC Allograft and SportMesh. GraftJacket MaxForce had a higher tensile modulus than RC Allograft (P < .001). GraftJacket MaxForce Extreme stiffness was greater than that of OrthAdapt and SportMesh (P < .001), and GraftJacket MaxForce, RC Allograft, Allopatch HD 1, and Allopatch HD 2 stiffness was greater than that of SportMesh (P < .001). The ultimate strength of GraftJacket MaxForce, GraftJacket MaxForce Extreme, Allopatch HD 1, and Allopatch HD 2 was greater than that of OrthAdapt and SportMesh (P < .05). Acellular human collagen matrix grafts (GraftJacket and Allopatch HD) showed greater suture retention strength than RC Allograft and SportMesh, which were both stronger than OrthAdapt (P < .05). CONCLUSIONS: The acellular human collagen matrix grafts showed greater elongation than the cuff tendon allograft (RC Allograft), although SportMesh elongated more than all other materials tested. The tensile modulus, which is "normalized" to eliminate differences in the size of the tissue tested, was greater for the OrthAdapt material than for GraftJacket, Allopatch, RC Allograft, and SportMesh. Suture retention strength was greatest in the acellular human collagen matrix grafts (GraftJacket and Allopatch), whereas both SportMesh and RC Allograft had greater suture retention strength than OrthAdapt. CLINICAL RELEVANCE: Acellular human collagen matrix grafts (GraftJacket and Allopatch) are stronger after cyclic loading than SportMesh and OrthAdapt and show greater stiffness.

Biomechanical testing of new meniscal repair techniques containing ultra high-molecular weight polyethylene suture.

PURPOSE: To evaluate the biomechanical characteristics of current meniscal repair techniques containing ultra high-molecular weight polyethylene (UHMWPE) suture with and without cyclic loading. METHODS: Vertical longitudinal cuts made in porcine menisci were secured with a single repair device. Noncycled and cycled (500 cycles) biomechanical tests were performed on the following groups: group 1, No. 2-0 Mersilene vertical suture (Ethicon, Somerville, NJ); group 2, No. 2-0 Orthocord vertical suture (DePuy Mitek, Westwood, MA); group 3, No. 0 Ultrabraid vertical suture (Smith & Nephew Endoscopy, Andover, MA); group 4, No. 2-0 FiberWire vertical suture (Arthrex, Naples, FL); group 5, vertically oriented mattress suture by use of an Ultra FasT-Fix device (Smith & Nephew Endoscopy) with No. 0 Ultrabraid; group 6, vertically oriented mattress suture by use of a RapidLoc A2 device (DePuy Mitek) with No. 2-0 Orthocord suture; group 7, vertically oriented stitch by use of a MaxFire device with MaxBraid PE suture (Biomet Sports Medicine, Warsaw, IN); and group 8, an obliquely oriented stitch of No. 0 UHMWPE suture inserted by use of a CrossFix device (Cayenne Medical, Scottsdale, AZ). Endpoints were failure loads, failure modes, stiffness, and cyclic displacement. RESULTS: Mean single-pull loads were calculated for Ultra FasT-Fix (121 N), FiberWire (110 N), MaxFire (130 N), Mersilene (84 N), Orthocord (124 N), RapidLoc A2 (86 N), CrossFix (77 N), and Ultrabraid (109 N). After 500 cyclic loads, the Orthocord (222 N) repair was stronger than the others: Ultra FasT-Fix (110 N), FiberWire (117 N), MaxFire (132 N), Mersilene (89 N), RapidLoc A2 (108 N), CrossFix (95 N), and Ultrabraid (126 N) (P < .05). Ultrabraid suture showed significantly more elongation over 500 cycles than the other repairs (P < .05). The principal failure mode associated with the single destructive pull (suture breakage) changed to pulling through the meniscus after cyclic loading for most devices. Knot slippage or device failure was seldom observed as the failure mode with these techniques. CONCLUSIONS: Self-adjusting, UHMWPE suture-containing meniscal repair devices (Ultra FasT-Fix, RapidLoc A2, and MaxFire) were comparable to the isolated UHMWPE-containing suture repairs on single-failure load testing. UHMWPE-containing suture repairs are stronger than braided polyester suture repairs, but pure UHMWPE suture (Ultrabraid) elongated more during cycling. Orthocord suture is significantly stronger than the other meniscal repair techniques after cyclic loading (P < .05). CLINICAL RELEVANCE: Meniscal repair techniques using UHMWPE containing sutures provide greater strength than earlier generations of meniscal repair techniques.

Incidencia de fracturas de cadera en Corrientes, Bariloche y Comodoro Rivadavia / Incidence of hip fractures in Corrientes, Bariloche and Comodoro Rivadavia

La epidemiología de las fracturas de cadera fue estudiada durante 1 año en las ciudades de Corrientes, Bariloche y Comodoro Rivadavia, ubicadas en el nordeste y sur de la Argentina. Los resultados fueron comparados con estudios realizados previamente en el norte y centro del país. Sesenta y siete pacientes (43 mujeres, 24 hombres) de Corrientes, 36 pacientes (23 mujeres, 13 hombres) de Bariloche y 33 pacientes (25 mujeres, 8 hombres) de Comodoro Rivadavia de 50 años o más sufrieron una fractura atraumática de cadera. La incidencia de fracturas de cadera en las mujeres y los hombres fue la siguiente; Corrientes: 144 y 105, Bariloche 268 y 181, y Comodoro Rivadavia 252 y 78 fracturas de cadera /100.000 habitantes.año, respectivamente. La incidencia de fracturas de cadera en las mujeres del sur del país (Bariloche y Comodoro Rivadavia) fue similar entre sí pero inferior a los estudios realizados previamente. Los hombres de Comodoro Rivadavia tuvieron una incidencia inferior a la de Bariloche. La incidencia de fracturas de cadera en las mujeres de la ciudad de Corrientes fue la más baja. Los hombres de esta ciudad tuvieron una incidencia similar a la registrada previamente en otros estudios realizados en la región central. Los nuevos datos aportan información enriquecedora para completar la ya existente en el norte y centro de nuestro extenso territorio. Futuros estudios sobre factores de riesgo, realizados con similar metodología, serían de utilidad para poder comprender mejor las diferencias encontradas.

Is recovery faster for mobile-bearing unicompartmental than total knee arthroplasty?

UNLABELLED: How does unicompartmental compare with total knee arthroplasty in durability, incidence of complications and manipulations, recovery, postoperative function, and return to sport and work? We matched 103 patients (115 knees) treated with a mobile-bearing unicompartmental device through July 2005 to a selected group of 103 patients (115 knees) treated with cruciate retaining total knee arthroplasty for bilaterality, age, gender and body mass index. Patients who underwent a unicompartmental surgery had better range of motion at discharge and shorter hospital stay than those who had a total knee arthroplasty (77 degrees versus 67 degrees and 1.4 versus 2.2 days). At 6 weeks, Knee Society functional scores and range of motion were higher for unicompartmental than total knees (63 versus 55 and 115 degrees versus 110 degrees). Patient-perceived Oxford scores were similar between groups (unicompartmental 5.4 versus total 4.1). Average times to return to work and sport were similar for both groups. Minimally invasive unicompartmental knee arthroplasty demonstrated better early ROM, shorter hospital stays, and improved functional scores. No advantage was seen in terms of return to work, return to sport, or Oxford scores. The data suggest minimally invasive unicompartmental arthroplasty using a rapid recovery protocol allows patients a faster return to a more functional level than total knee arthroplasty. LEVEL OF EVIDENCE: Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.