[The postsurgical rotator cuff: surgical techniques, clinical outcome, and MRI evaluation]. / El manguito rotador intervenido: técnicas quirúrgicas, resultados clínicos y evaluación con resonancia magnética.

Surgical treatment of rotator cuff tears significantly reduces painful symptoms and improves functional capacity in many patients. However, despite recent advances, up to 25% of patients remain symptomatic after surgery. This has led to research into the reasons for these poor outcomes, including how to identify them with imaging methods and how to avoid them through new therapeutic approaches. Based on our clinical experience, we review the available treatment alternatives for rotator cuff tears, analyzing the main areas of controversy and the possible causes of unsatisfactory outcome after surgery. Furthermore, we review the expectations, difficulties, and requirements of diagnostic imaging in the follow-up of surgically treated rotator cuffs, with special emphasis on the MRI findings and their clinical impact.

El manguito rotador intervenido: técnicas quirúrgicas, resultados clínicos y evaluación con resonancia magnética / The postsurgical rotator cuff: surgical techniques, clinical outcome, and MRI evaluation

El tratamiento quirúrgico de las roturas del manguito rotador mejora significativamente la sintomatología dolorosa y la capacidad funcional de muchos pacientes. A pesar de los avances recientes, hasta un 25% de los enfermos permanecen sintomáticos después de la cirugía. Esto ha llevado a investigar las causas de los malos resultados, su identificación por métodos de imagen y su evitación con nuevos esquemas terapéuticos. Basándonos en nuestra experiencia clínica revisamos las alternativas disponibles en el tratamiento de las roturas del manguito rotador, analizando los principales motivos de controversia y las posibles causas del fracaso quirúrgico. Además, repasamos las expectativas, dificultades y requisitos del diagnóstico por la imagen durante el seguimiento del manguito rotador intervenido, haciendo especial énfasis en los hallazgos y aportaciones clínicas de la resonancia magnética (AU)

Surgical treatment of rotator cuff tears significantly reduces painful symptoms and improves functional capacity in many patients. However, despite recent advances, up to 25% of patients remain symptomatic after surgery. This has led to research into the reasons for these poor outcomes, including how to identify them with imaging methods and how to avoid them through new therapeutic approaches. Based on our clinical experience, we review the available treatment alternatives for rotator cuff tears, analyzing the main areas of controversy and the possible causes of unsatisfactory outcome after surgery. Furthermore, we review the expectations, difficulties, and requirements of diagnostic imaging in the follow-up of surgically treated rotator cuffs, with special emphasis on the MRI findings and their clinical impact (AU)

MR assessment of the repaired rotator cuff: prevalence, size, location, and clinical relevance of tendon rerupture.

The objectives of this study were to use magnetic resonance (MR) imaging to evaluate the prevalence, size, location, and clinical relevance of tendon rerupture following complete repair of full-thickness rotator cuff tear (RCT). A total of 78 surgically proven full-thickness rotator cuff tears in 74 patients were retrospectively included in the study. Clinical assessment was performed using the University of California at Los Angeles score. Postoperative MR imaging was evaluated to determine prevalence, size, and location of tendon rerupture. At a mean 48.4 months' follow-up, 62 shoulders (79.5%) had favorable outcomes and 45 shoulders (57.6%) showed rerupture on MR imaging studies. Reruptures were significantly more prevalent among patients with intermediate-to-bad outcomes (81.3%), with surgically demonstrated two-tendon tears (78.9%) or three-tendon tears (100%), and with preoperative fatty degeneration of the supraspinatus muscle greater than 1 (91.6%). Reruptures were also significantly larger in those subgroups. Complete repair of RCT of all sizes may have favorable outcomes in a significant proportion of patients in spite of a high prevalence of reruptures. Preoperative tear size and degree of muscle fatty degeneration influence the prevalence and rerupture size. After repair of supraspinatus tears, reruptures tend to invade the posterior aspect of the tendon.

Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty degeneration, and muscle atrophy correlated with intraoperative and clinical findings.

OBJECTIVE: Our goal in this study was to evaluate by means of MRI the clinical significance of tendon integrity, muscle fatty degeneration, and muscle atrophy in surgically repaired massive rotator cuff tears and to correlate these and other prognostic factors with intraoperative and clinical findings. MATERIALS AND METHODS: Twenty-eight surgically proven massive rotator cuff tears were retrospectively included in the study. Twenty-two patients underwent complete repair, and six patients underwent partial repair. Preoperative and postoperative clinical assessment was performed by using the University of California at Los Angeles score. Preoperative and postoperative MRI studies were evaluated for the presence and extent of rotator cuff tear and for the degree of fatty degeneration and atrophy of the rotator cuff muscles. RESULTS: At a mean 44.4 months' follow-up, 20 patients (71.4%) had a favorable result. A total of 25 patients (89.2%) showed postoperative full-thickness rotator cuff tear, 19 of which were reruptures. A sagittal preoperative rotator cuff tear of less than or equal to 34 mm showed a specificity of 100% for predicting a favorable outcome. A coronal postoperative rotator cuff tear of less than or equal to 34 mm showed a specificity of 85.7% and a positive predictive value of 92.9% for predicting a favorable outcome. A postoperative fatty degeneration of infraspinatus muscle less than or equal to 2 had a specificity of 87.5% and a positive predictive value of 90.9% for predicting a favorable outcome. CONCLUSION: Open repair of massive rotator cuff tears may reach a favorable outcome in a significant proportion of patients, despite a high rate of recurrent or residual tears. Oblique coronal sizes of the recurrent or residual tear of less than or equal to 34 mm and postoperative fatty degenerations of infraspinatus muscle of less than or equal to 2 may allow a favorable outcome.

Early intrathoracic migration of Kirschner wires used for percutaneous osteosynthesis of a two-part humeral neck fracture: a case report.

We present an unusual case of early migration of three Kirschner wires used for percutaneous osteosynthesis of a two-part humeral neck fracture, causing hemothorax. An 85-year-old woman was admitted to the emergency room after casual accident. She was found to have suffered a two-part fracture of the surgical neck of the right humerus. The humeral fracture was treated by closed reduction and percutaneous osteosynthesis with three threaded Kirschner wires, which were bent subcutaneously. Ten days after the accident the patient presented with dyspnea and laterocervical pain. Plain X-rays and complementary CT demonstrated intrathoracic migration of the three Kirschner wires with hemothorax. Two of the wires were seen under the right clavicle and adjacent to the C7 vertebra. The third wire reached the lateral chest wall. Immediate surgery was performed, with withdrawal of the wires and placement of a drainage tube. The patient had an uneventful recovery after surgery. The humeral fracture resulted in a nonunion, which was well tolerated by the patient and was left untreated. The use of Kirschner wires for osteosynthesis of proximal humeral fractures may cause significant thoracic morbidity, even if various prophylactic measures, including the use of threaded wires, subcutaneous bending, and close radiographic follow-up, are adopted. The use of Kirschner wires should anyway be restricted to carefully selected cases, in order to avoid major complications.

Analgesic effect of intra-articular ketorolac in knee arthroscopy: comparison of morphine and bupivacaine.

This prospective study assessed the postoperative analgesic effect of intra-articular ketorolac, morphine, and bupivacaine during arthroscopic outpatient partial meniscectomy. Group 1 patients (n=20) received postoperative injection of 60 mg intra-articular ketorolac, group 2 patients (n=20) 10 cc intra-articular bupivacaine 0.25%, group 3 patients (n=20) 1 mg intra-articular morphine diluted in 10 cc saline, and group 4 patients (n=20, controls) only 10 cc saline. We evaluated the postoperative analgesic effect (period measured from the end of the surgery until further analgesia was demanded), the level of postoperative pain (by visual analog scale 1, 2, 3, 12, and 24 h after surgery), and the need for additional pain medication (during the first 24 h after surgery). The best analgesic effect was in patients treated with intra-articular ketorolac, and this was statistically significant in: postoperative analgesic effect and the need for additional pain medication immediately after surgery, and after 24 h. No complications were found related to the intra-articular treatment. We conclude that 60 mg intra-articular ketorolac provides better analgesic effect than 10 cc intra-articular bupivacaine 0.25% or 1 mg intra-articular morphine.

Open bicondylar Hoffa fracture associated with extensor mechanism injury.

Two cases of open bicondylar Hoffa fracture of the knee associated with extensor mechanism injury are described in two active young patients with multiple fractures. The level of the fracture was determined by the proximal insertion of the posterior cruciate ligament and anterior cruciate ligament in the medial and lateral condyle. The level of the extensor mechanism injury was determined by the degree of flexion of the knee at the moment of impact. No ligament or meniscal tears were found. Open reduction and internal fixation with four lag screws and bone-to-tendon repair of the patellar and quadriceps tendon gave excellent results after more than 2 years of follow-up. The mechanism of injury and the therapeutic implications are discussed, and the literature is reviewed.

Magnetic resonance imaging of anterior cruciate ligament tears: reevaluation of quantitative parameters and imaging findings including a simplified method for measuring the anterior cruciate ligament angle.

We evaluated the diagnostic utility of magnetic resonance imaging (MRI) for predicting anterior cruciate ligament (ACL) tears using both quantitative parameters and nonquantitative imaging findings. MRI examinations were retrospectively evaluated in a group of patients with arthroscopically confirmed complete ACL tear and in a control group with arthroscopically confirmed intact ACL. We evaluated multiple MRI features to compare their sensitivity and specificity for detecting ACL tears. Particular emphasis is put on the evaluation of three different quantitative parameters, including a simplified method for measuring the ACL angle. With a threshold value of 45 degrees the ACL angle reached a sensitivity and specificity of 100% for detecting ACL tears. With a threshold value of 0 degrees the Blumensaat angle had a sensitivity of 90% and a specificity of 98%. Finally, a threshold value of 115 degrees gave the posterior cruciate ligament angle a sensitivity of 70% and a specificity of 82%. Discontinuity was found to be the most useful of the ACL abnormalities. Of the secondary findings anterior tibial displacement was the best predictor of ligamentous injury. However, ACL abnormalities and secondary findings, alone or combined, failed to surpass the diagnostic value of the ACL angle for predicting ACL tears. Quantitative parameters are thus good predictors of ACL tears and may increase the overall sensitivity and specificity of MRI. The ACL angle may be confidently measured in a single MRI section and can be considered to be the most reliable quantitative parameter for detecting ACL tears.

Clinically significant skeletal variations of the shoulder and the wrist: role of MR imaging.

Several skeletal variations of the upper extremity may cause painful conditions or precipitate early degenerative changes, either spontaneously or in response to overuse and trauma. Magnetic resonance imaging has proved particularly useful for accurate interpretation of many of these clinically significant skeletal variations; however, the widespread use of MR imaging may have contributed to over-emphasizing their clinical importance, which is still controversial in many cases. We review, illustrate, and discuss clinically significant skeletal variations of the upper extremity as seen on MR images, particularly those involving the shoulder and the wrist. In the shoulder region, we evaluate variations of acromial and coracoid processes as well as variations and minor dysplastic deformities of the glenoid fossa. We also review different skeletal variations of the carpal region, including ulnar variance, ulnar styloid, lunate morphology, carpal coalition, and carpal accessory ossicles. The role of MR imaging in assessing the clinical importance of such conditions, whether potential, controversial, or well established, is emphasized in this review.

Avulsion fractures and chronic avulsion injuries of the knee: role of MR imaging.

Avulsion fractures and chronic avulsion injuries of the knee are common lesions in sports-related trauma, especially among adolescents. Magnetic resonance imaging may prove useful in detecting and characterizing such lesions, and has several advantages with regard to other imaging modalities. We review, illustrate, and discuss the MR imaging features of some of the more frequent avulsion fractures and chronic avulsion injuries of the knee, including avulsion fractures of the cruciate ligaments, avulsion fractures of lateral and medial stabilizers, avulsion fractures and chronic avulsion injuries of the extensor mechanism, and avulsive cortical irregularities of the distal femur. The role of MR imaging in evaluating such lesions is emphasized.

Rotura masiva del manguito de los rotadores. Resultados del tratamiento quirúrgico / Massive rupture of the rotator cuff. Results of surgical treatment

Objetivo: Evaluar de forma retrospectiva los resultados clínicos de 25 pacientes diagnosticados de rotura masiva del manguito de los rotadores tratados quirúrgicamente, de forma consecutiva. Pacientes: La serie está compuesta por 13 hombres y 12 mujeres con una edad media de 57 años. La indicación para el tratamiento quirúrgico ha sido el dolor importante después de un período de tratamiento conservador superior a 3 meses. El diagnóstico de rotura masiva se ha realizado en el momento de la intervención quirúrgica cuando el tamaño de la rotura, en su diámetro mayor ha sido = 5 cm. Se han excluido aquellos pacientes con rotura masiva del manguito con excentricidad de la cabeza humeral respecto a la glenoides por subluxación proximal con signos de artropatía secundaria a lesión del manguito. Se ha realizado una descompresión del espacio subacromial a cielo abierto mediante la técnica de Neer y reparación de la lesión después de movilización de los extremos tendinosos siguiendo un proceso sistemático, sutura tendinosa por convergencia de márgenes y sutura al troquíter mediante anclajes óseos. Los pacientes se han evaluado desde el punto de vista clínico mediante la escala de UCLA con un seguimiento mínimo de 1 año. Resultados: Antes de la intervención la puntuación media fue de 11,6; mientras que en la revisión fue de 32,2 (13 resultados excelentes, 8 buenos, 3 regulares y 1 malo). Los 3 pacientes que tenían un antecedente traumático de luxación glenohumeral obtuvieron los peores resultados. Conclusiones: Con el tratamiento quirúrgico de las roturas masivas del manguito de los rotadores puede obtenerse un nivel de resultados satisfactorios parecido a los obtenidos con el tratamiento de lesiones de menor tamaño. (AU)

Fluid collections and juxta-articular cystic lesions of the shoulder: spectrum of MRI findings.

The MR imaging features of fluid collections and juxta-articular cystic lesions of the shoulder are discussed, with special focus on those related to subacromial impingement and rotator cuff tears. Other more unusual fluid collections and cystic lesions are described, including rice-bodies bursitis, idiopathic synovial osteochondromatosis, dialysis-related amyloid arthropathy, hemophilic arthropathy, infectious conditions, non-infectious inflammatory arthritis, and paralabral cysts.

Efectos sistémicos del implante de partículas de desgaste del polietileno en el hueso. Estudio experimental / Systemic effects of implantation of polyethylene wear particles on bone. Experimental study

Objetivo: Se ha estudiado el efecto que provoca el implante de partículas de desgaste de polietileno de alta densidad sobre los ganglios linfáticos, el hígado y el pulmón de la rata.Diseño experimental: Se ha implantado 1 mg de polvo de polietileno, constituido por una mezcla hetereogénea de partículas de un tamaño entre 1 y 100 micras, en un orificio practicado en la tibia de 16 ratas de la cepa Sprague-Dawley y se han examinado las muestras de los ganglios de la cadena ilíaca y cervical, tejido hepático y pulmonar a los 15 y 60 días de la intervención. El grupo control ha quedado constituido por 16 ratas a las que se ha realizado la misma intervención pero a las que no se han implantado partículas.Resultados: Un gran número de ganglios presentan hiperplasia difusa con un gran infiltrado macrofágico.Estos cambios no se observan en el grupo control. No se han observado partículas de polietileno en el interior de los ganglios linfáticos. No se han detectado cambios patológicos en las muestras de tejido hepático. En la mitad de las ratas que recibieron partículas se han detectado infiltrados inflamatorios peribronquiales y perivasculares en el pulmón, que no se han observado en el grupo control.Conclusiones: Las partículas de desgaste del polietileno provocan cambios patológicos en órganos a distancia de su lugar de implante. El mecanismo fisiopatológico y las consecuencias de estas alteraciones no son aun bien conocidos (AU)

Intraosseous neurilemmoma of the radius: a case report.

Neurilemmomas are benign tumors that arise from Schwann cells. They are rarely found on bone. We describe a neurilemmoma in a 45-year-old patient that affected the distal metaphysis of the radius. Only 1 previous case has been described in the literature. We discuss the clinical presentation, the radiographic aspect, particularly the magnetic resonance imaging characteristics, and the microscopic findings.

Las asociaciones de pacientes y el control de la leishmaniasis en el Perú / Patients' associations and the control of leishmaniasis in Perú

La leishmaniasis mucocutánea americana es un grave problema de salud en el Perú, particularmente en la región montañosa de Cuzco, donde se produjeron 25 por ciento de todos los nuevos casos notificados en 1989. El número de casos ha aumentado notablemente desde principios del denenio de 1980, cuando hubo una emigración estacional en gran escala a las zonas endémicas, especialmente a la región forestal de Madre de Dios, debido al descubrimiento de nuevas minas de oro en esa zona y al deterioro económico en el Perú. Ante la falta de respuesta oficial del Gobierno peruano, centenares de enfermos de leishmaniasis en la zona de Cuzco formaron asociaciones de autoayuda con el objetivo de obtener los medicamentos necesarios para tratar su afección. El logro principal de este movimiento que surgió espontáneamente, apoyado por varias instituciones públicas y privadas, fue animar a los enfermos, particularmente a los pacientes con lesiones de las mucosas, a salir del aislamiento. Como resultado, se han reducido mucho la prevalencia e incidencia de la enfermedad en ese territorio

Las asociaciones de pacientes y el control de la leishmaniasis en el Perú / Patients' associations and the control of leishmaniasis in Perú

La leishmaniasis mucocutánea americana es un grave problema de salud en el Perú, particularmente en la región montañosa de Cuzco, donde se produjeron 25 por ciento de todos los nuevos casos notificados en 1989. El número de casos ha aumentado notablemente desde principios del denenio de 1980, cuando hubo una emigración estacional en gran escala a las zonas endémicas, especialmente a la región forestal de Madre de Dios, debido al descubrimiento de nuevas minas de oro en esa zona y al deterioro económico en el Perú. Ante la falta de respuesta oficial del Gobierno peruano, centenares de enfermos de leishmaniasis en la zona de Cuzco formaron asociaciones de autoayuda con el objetivo de obtener los medicamentos necesarios para tratar su afección. El logro principal de este movimiento que surgió espontáneamente, apoyado por varias instituciones públicas y privadas, fue animar a los enfermos, particularmente a los pacientes con lesiones de las mucosas, a salir del aislamiento. Como resultado, se han reducido mucho la prevalencia e incidencia de la enfermedad en ese territorio

American mucocutaneous leishmaniasis is an important health problem in Peru, particularly in the mountainous Cuzco Region, where 25% of all new cases reported in 1989 were located. Cases have increased considerably since the beginning of the 1980s, when large-scale seasonal migration to endemic zones occurred, particularly in the forest area of Madre de Dios, following the discovery of new gold deposits there and the deterioration in the economic situation in Peru. Following the lack of official response from the Peruvian government, hundreds of people suffering from leishmaniasis in the Cuzco area formed self-help associations with the objective of obtaining the drugs needed to treat their disease. The major achievement of this spontaneous movement, which was supported by several public and private institutions, was to encourage sick people, particularly patients with mucosal lesions, to emerge from isolation. As a result, the prevalence and incidence of the disease have now considerably decreased in the region.

Patients' associations and the control of leishmaniasis in Peru.

American mucocutaneous leishmaniasis is an important health problem in Peru, particularly in the mountainous Cuzco Region, where 25% of all new cases reported in 1989 were located. Cases have increased considerably since the beginning of the 1980s, when large-scale seasonal migration to endemic zones occurred, particularly the forest area of Madre de Dios, following the discovery of new gold deposits there, and the deterioration in the economic situation in Peru. Following the lack of official response from the Peruvian government, hundreds of people suffering from leishmaniasis in the Cuzco area formed self-help associations with the objective of obtaining the drugs needed to treat their disease. The major achievement of this spontaneous movement, which was supported by several public and private institutions, was to encourage sick people, particularly patients with mucosal lesions, to emerge from isolation. As a result, the prevalence and incidence of the disease have now considerably decreased in the region.

PIP: The deterioration in Peru's economic situation and the discovery of new gold deposits in the mountainous Cuzco Region have been associated with a considerable increase in cases of American mucocutaneous leishmaniasis. Following a lack of government response to this serious health problem, people with leishmaniasis in the town of Sicuani formed a patients' association in 1983 to try to obtain appropriate drugs for treatment. In 1983-93, eight additional patients' associations were established and, in 1990, these associations (representing 1648 members) united with health authorities and other institutions in the Cuzco Region to form a committee to coordinate their activities. The role of these associations was studied in field work conducted in the region in 1993. In interviews, association activists expressed demands that the government make free drugs available, offer financial compensation to those who acquire the disease through work, improve working conditions in the mines and living conditions for migrant workers, and identify other seasonal employment opportunities in order to prevent migration to the mining areas. The leishmaniasis movement, which originated as a spontaneous initiative, has become more structured and organized over time. A control strategy based on active case finding, early diagnosis, and early treatment of disease has been defined. A major achievement of the patients' associations, especially in Sicuani and Ocongate, has been to encourage sick people to emerge from their isolation. This program provides an example of successful multisectoral coordination and community participation of potential relevance in other countries where mucocutaneous leishmaniasis is endemic.

[The initial symptom attributable to cancer in digestive tube tumors. A study of agreement between the patient and the physician]. / El síntoma inicial atribuible al cáncer en los tumores del tubo digestivo. Un análisis de la concordancia entre el paciente y el médico.

BACKGROUND: Clinical practice shows that certain patients may underestimate and others overestimate some initial symptoms of their disease. In studies on the interval between first symptoms and treatment onset, estimating the date in which symptoms first appeared is crucial. The study analyzed patient-physician agreement in assessing first symptom attributable to cancer. METHODS: During two years, two physicians personally interviewed, through a structured questionnaire, all symptomatic patients with a neoplasm of the digestive tract admitted to Hospital del Mar (Barcelona, Spain). Patients had a mid-low sociocultural profile and most had been admitted through the Emergency Department. RESULTS: Absolute agreement (symptom and date) occurred in 85% of the 183 subjects. In most discordant cases, patients had overlooked some component of the "toxic syndrome", and the date of symptom onset was, based on physician's assessment, chronologically prior to the date elicited from the patient. Disagreement was directly related to the patient's health status (p < 0.05) and to the number of reported symptoms until hospital admittance (p = 0.002), but not to tumour stage. Agreement increased with the importance attributed by the patient to the first symptom (p < 0.05). CONCLUSIONS: In spite of difficulties inherent to measuring symptomatic onset of diseases, structured patient interviews appear to be a reasonably valid method and deserve further development in this and other areas of research.