The effect of Imatinib Mesylate in diffuse-type Tenosynovial Giant Cell Tumours on MR imaging and PET-CT.

INTRODUCTION: Recurrence rates remain high after surgical treatment of diffuse-type Tenosynovial Giant Cell Tumour (TGCT). Imatinib Mesylate (IM) blocks Colony Stimulating Factor1 Receptor (CSF1R), the driver mechanism in TGCT. The aim of this study was to determine if IM reduces the tumour metabolic activity evaluated by PET-CT and to compare this response with the response seen on MR imaging. MATERIALS AND METHODS: 25 Consecutive patients treated with IM (off label use) for locally advanced (N = 12) or recurrent (N = 13) diffuse-type TGCT were included, 15 male and median age at diagnosis 39 (IQR 31-47) years. The knee was most frequently affected (n = 16; 64%). The effect of IM was assessed pre- and post-IM treatment by comparing MR scans and PET-CT. MR scans were assessed by Tumour Volume Score (TVS), an estimation of the tumour volume as a percentage of the total synovial cavity. PET-CT scans were evaluated based on maximum standardized uptake value (SUV-max). Partial response was defined as more than 50% tumour reduction with TVS and a decrease of at least 30% on SUV-max. RESULTS: Median duration of IM treatment was 7.0 (IQR 4.2-11.5) months. Twenty patients (80%) discontinued IM treatment for poor response or intended surgery. Twenty patients experienced an adverse event grade 1-2, three patients grade 3 (creatinine increment, neutropenic sepsis, liver dysfunction). MR assessment of all joints showed 32% (6/19) partial response and 63% (12/19) stable disease, with a mean difference of 12% (P = 0.467; CI -22.4-46.0) TVS between pre- and post-IM and a significant mean difference of 23% (P = 0.021; CI 4.2-21.6) in all knee lesions. PET-CT, all joints, showed a significantly decreased mean difference of 5.3 (P = 0.004; CI 1.9-8.7) SUV-max between pre- and post-IM treatment (58% (11/19) partial response, 37% (7/19) stable disease). No correlation between MR imaging and PET-CT could be appreciated in 15 patients with complete radiological data. CONCLUSION: This study confirms the moderate radiological response of IM in diffuse-type TGCT. PET-CT is a valuable additional diagnostic tool to quantify response to tyrosine kinase inhibitor treatment. Its value should be assessed further to validate its efficacy in the objective measurement of biological response in targeted systemic treatment of TGCT.

Síndrome de atrapamiento funcional de la arteria poplítea en joven deportista de taekwondo / Functional popliteal artery entrapment syndrome in a young taekwondo athlete

La claudicación intermitente se define como fatiga, malestar o dolor en grupos musculares de las extremidades inferiores durante el esfuerzo, resultante de la isquemia inducida por el ejercicio. La arterioesclerosis es la causa más común en personas mayores, pero cuando la claudicación aparece en personas jóvenes debemos pensar en otras causas vasculares. Presentamos el caso de una deportista de élite de taekwondo de 24 años con dolor intenso en las pantorrillas durante el ejercicio físico, ya anteriormente intervenida mediante fasciotomía bilateral, en la que se diagnostica un atrapamiento de la arteria poplítea bilateral funcional. Se describen los resultados tras la cirugía mediante adhesiólisis de la arteria poplítea y sección proximal de las fibras profundas del gemelo interno bilateral, así como tras la infiltración de toxina botulínica en el gastrocnemio medial izquierdo. Es importante conocer las distintas causas de claudicación intermitente no arterioesclerótica para plantear el diagnóstico diferencial adecuado y poder orientar las pruebas diagnósticas o la derivación de los pacientes a los especialistas oportunos

Intermittent claudication is defined as fatigue, discomfort or pain in muscle groups of the lower limbs during exertion, resulting from exercise-induced ischaemia. Atherosclerosis is the most common cause in older people, but when claudication occurs in young people other vascular causes should be sought. We present the case of a 24-year-old elite Taekwondo athlete with severe pain in the calves during physical exercise, who had had previously undergone bilateral fasciotomy. The patient was diagnosed with functional bilateral popliteal artery entrapment. The results after surgery are described, with adhesiolysis of the popliteal artery and proximal section of the deep fibres of the bilateral internal gastrocnemius, as well as infiltration of botulinum toxin into the left medial gastrocnemius. It is important to be familiar with the various causes of non-atherosclerotic intermittent claudication in order to establish the appropriate differential diagnosis and guide diagnostic tests or patient referral to the appropriate specialists

The delayed presentation of atlantoaxial rotatory fixation in children: a review of the management.

AIMS: Although atlantoaxial rotatory fixation (AARF) is a common cause of torticollis in children, the diagnosis may be delayed. The condition is characterised by a lack of rotation at the atlantoaxial joint which becomes fixed in a rotated and subluxed position. The management of children with a delayed presentation of this condition is controversial. This is a retrospective study of a group of such children. PATIENTS AND METHODS: Children who were admitted to two institutions between 1988 and 2014 with a diagnosis of AARF were included. We identified 12 children (four boys, eight girls), with a mean age of 7.3 years (1.5 to 13.4), in whom the duration of symptoms on presentation was at least four weeks (four to 39). All were treated with halo traction followed by a period of cervical immobilisation in a halo vest or a Minerva jacket. We describe a simple modification to the halo traction that allows the child to move their head whilst maintaining traction. The mean follow-up was 59.6 weeks (24 to 156). RESULTS: Despite the delay in referral, the subluxation was successfully reduced in all children. Only two children required atlantoaxial fusion. CONCLUSION: The results of our study suggest that normal anatomy with restoration of movement may be achieved even in cases of AARF presenting late, obviating the need for fusion. We also show a simple modification to the halo traction that allows the child to move their head about while still maintaining traction. TAKE HOME MESSAGE: Prompt diagnosis and management with halo traction (with a simple modification as described) is associated with good results in patients with AARF who present late. Cite this article: Bone Joint J 2016;98-B:715-20.

Wound swab use and misuse at a regional general hospital.

OBJECTIVE: Guidelines for swab use at our centre cover lower-limb wounds, ulcers and postoperative wound infections but not all types of wound. The objective of this study was to assess current practices in wound management at Mater Dei Hospital and to identify areas for improvement. METHOD: Wound swabs received at the microbiology department between February and April 2013 from adult inpatients departments were included. Wound swabs from the ophthalmology and paediatric departments were excluded. Patient comorbidities, detailed wound descriptions, acknowledgement of and documentation of culture and sensitivity results, and antibiotic changes during treatment were collected. Indictors of infection including white cell counts (WCCs) and C-reactive protein (CRP) were recorded. RESULTS: The study included 134 patients. Diabetes mellitus (61.9%, n=83) was the most common underlying comorbidity. Postoperative wounds were the most common type of wounds swabbed (34.3%). The wound swab characteristics were not fully documented in 27 patients (20.1%). The CRP results were not recorded in 39.6% and WCCs were not taken in 10.4% of patients. Wound swab results were not acknowledged in the medical notes of 76% of cases. CONCLUSION: Wound swabs that were not indicated, lack of documentation and untimely acknowledgement of results were evident. This suggests that a significant proportion of wound swabs may not have been justified and had no impact on wound management. Our study clearly underlines the need for a more comprehensive guideline. DECLARATION OF INTEREST: There was no sponsorship of this study. The authors have no conflict of interest to declare.

Utilidad de la ecografía para el diagnóstico y tratamiento del neuroma ciático en un amputado femoral / Usefulness of ultrasonography for the diagnosis and treatment of sciatic nerve neuroma in femoral amputation

La ecografía es una técnica de imagen que permite el diagnóstico y la realización de procedimientos intervencionistas. Entre sus ventajas, ofrece una imagen dinámica, sin radiación ionizante, que permite el control continuo de la aguja en tiempo real. Se presenta un caso clínico de un varón amputado femoral traumático con dolor en muñón secundario a un neuroma del nervio ciático, que fue tratado mediante infiltración ecodirigida con bloqueo anestésico de lidocaína y posterior infiltración perilesional de corticosteroides. El paciente presentó mejoría del dolor valorado con la escala numérica del dolor tras 2 infiltraciones. El objetivo del trabajo es presentar la ecografía como una herramienta segura y eficaz para realizar procedimientos diagnósticos y terapéuticos en patologías del aparato locomotor en la consulta de rehabilitación (AU)

Ultrasound is an imaging technique that allows diagnostic and interventional procedures. One of the advantages of this technique is to provide dynamic imaging, without ionizingradiation, and to allow the continuous monitoring of the needle in real time. We present the case of a man with traumatic femoral amputation and stump pain due to a sciatic nerve neuroma. He was treated using ultrasound-guided injection with lidocaine anesthetic blockade and perilesional steroid injection. The patient reported pain improvement, assessed using a numerical pain scale, after two injections. The aim of this article is to present ultrasonography as a safe and effective technique for the diagnosis and treatment of musculoskeletal disorders in rehabilitation (AU)

Escuela de espalda: una forma sencilla de mejorar el dolor y los hábitos posturales / Back school: A simple way to improve pain and postural behaviour

INTRODUCCIÓN: El dolor inespecífico de espalda en niños y adolescentes es muy prevalente. El objetivo de este estudio es presentar un programa de Escuela de espalda juvenil (EDEJ) y sus resultados en nuestro servicio. MATERIAL Y MÉTODO: Estudio observacional y prospectivo con 139 pacientes, remitidos a la consulta de raquis juvenil por dolor, deformidad o asimetría en la espalda. VARIABLES: edad, sexo, dolor, adopción de posturas correctas, actividad deportiva, adherencia a la EDEJ y percepción de estos parámetros por sus padres. Se midieron las variables mediante una escala numérica del dolor y una encuesta administradas en la primera sesión y a los 3 meses tras la EDEJ. RESULTADOS: El estudio fue completado por 119 pacientes (78 mujeres y 41 hombres) con una edad media ± desviación estándar de 13,97±2,29 años (9-20). La mediana de la intensidad del dolor se redujo de 3 a 0 a los 3 meses tras EDEJ (p < 0,0001). Aumentaron los pacientes que mejoraron su actitud postural, del 21 al 83% (p < 0,0001). No se confirmó un aumento de práctica deportiva post-EDEJ, aunque su práctica habitual se relacionó con una mejoría de dolor post-EDEJ (p < 0,02). La realización de los ejercicios no asoció disminución del dolor. Existió mala correlación entre la valoración de padres e hijos sobre el dolor post-EDEJ. CONCLUSIÓN: Un programa de escuela de espalda podría contribuir a disminuir el dolor inespecífico de espalda y mejorar los hábitos posturales en jóvenes

INTRODUCTION: Non-specific back pain in children and adolescents has a high prevalence. The aim of this study is to show a Juvenile Back School (JBS) programme and its results in our hospital. MATERIAL AND METHOD: A total of 139 patients referred to a Juvenile Back School for advice due to of pain, deformity or back asymmetry were included in a prospective observational study. VARIABLES: age, gender, pain, correct postures, sports activities, adherence to JBS and appreciation of these parameters by their parents. Variables were measured with a numerical pain scale and with a survey completed in the first session and 3 months after finishing the JBS. RESULTS: A total of 119 patients finished the study (78 female and 41 male).The average was 13.97±2.29 years (9-20). Three months after JBS, the median pain intensity was reduced from 3 to 0 (P<0.0001). There was an improvement in patient postures from 21% to 83% (P<0.0001). Patients did not increase their sport activity after the JBS, although its regular practice was linked with pain improvement after JBS (P<0.02).Performing exercises did not lead to a decrease in pain. There was a poor correlation between parents and children in the evaluation of post-JBS pain. CONCLUSION: A back school programme could probably contribute to reduce non-specific back pain and improve postural behaviour in young people

[Back school: a simple way to improve pain and postural behaviour]. / Escuela de espalda: una forma sencilla de mejorar el dolor y los hábitos posturales.

INTRODUCTION: Non-specific back pain in children and adolescents has a high prevalence. The aim of this study is to show a Juvenile Back School (JBS) programme and its results in our hospital. MATERIAL AND METHOD: A total of 139 patients referred to a Juvenile Back School for advice due to of pain, deformity or back asymmetry were included in a prospective observational study. VARIABLES: age, gender, pain, correct postures, sports activities, adherence to JBS and appreciation of these parameters by their parents. VARIABLES were measured with a numerical pain scale and with a survey completed in the first session and 3 months after finishing the JBS. RESULTS: A total of 119 patients finished the study (78 female and 41 male).The average was 13.97±2.29 years (9-20). Three months after JBS, the median pain intensity was reduced from 3 to 0 (P<.0001). There was an improvement in patient postures from 21% to 83% (P<.0001). Patients did not increase their sport activity after the JBS, although its regular practice was linked with pain improvement after JBS (P<.02).Performing exercises did not lead to a decrease in pain. There was a poor correlation between parents and children in the evaluation of post-JBS pain. CONCLUSION: A back school programme could probably contribute to reduce non-specific back pain and improve postural behaviour in young people.

Desarticulación coxofemoral por fascitis necrotizante y síndrome del shock tóxico estreptocócico / Coxofemoral disarticulation by necrotizing fasciitis and streptococcal toxic shock syndrome

La fascitis necrotizante es una infección rápidamente progresiva de la piel y los tejidos blandos, asociada a una rápida destrucción y necrosis de la fascia y de la grasa, que se acompaña de importante toxicidad sistémica y alta mortalidad. Supone la forma más grave de infección de partes blandas, y en un tercio de los pacientes da lugar a la aparición de shock y fracaso multiorgánico. Existen 2 tipos: tipo I, polimicrobiana, en la que existen factores predisponentes para su aparición, y la tipo II o estreptocócica en jóvenes sin comorbilidad asociada. El diagnóstico es clínico y no debe retrasarse la exploración quirúrgica, ya que su pronóstico depende en gran medida de un diagnóstico precoz y de un tratamiento agresivo inmediato. Presentamos un caso de fascitis necrotizante tipo II de miembro inferior derecho complicada con un síndrome del shock tóxico estreptocócico y que fue necesario realizar una desarticulación de cadera (AU)

Necrotizing fasciitis is a rapidly progressive infection of the skin and soft tissue characterized by widespread necrosis of the subcutaneous tissue and the fascia, which usually involves severe systemic toxicity and high index of mortality. This disease is the most serious form of skin and soft tissue infection. About one third of the patients develops shock and multiorgan failure. There are two types: type I, polymicrobial, for which there are predisposing risk factors and type II, or streptococcal in young patients without associated comorbidity. The diagnosis is based on the clinical manifestations and surgical intervention should not be delayed as its prognosis largely depends on an early diagnosis and immediate aggressive treatment. We report the case of a patient with necrotizing fasciitis type II of the lower right limb, who suffered streptococcal toxic shock syndrome and in whom hip disarticulation was required (AU)