E. Cáceres

Factors affecting meniscal extrusion: correlation with MRI, clinical, and arthroscopic findings.

The existence of meniscal extrusion is well known in the natural history of the osteoarthritic knee. However, extruded menisci are also seen in non-pathologic knees. To ascertain the prevalence of meniscal extrusion in non-arthritic patients, the MRIs of 100 knees were prospectively studied. The data were correlated both with clinical and operative arthroscopic findings. The results showed 68.5% of the medial menisci to have some degree of extrusion, averaging at 28% of the meniscal size. While the lateral meniscus were extruded in 18.8% of cases at an average of 15% of the meniscal size. Furthermore, a relationship between the anterior insertion variant of the anterior medial meniscus and meniscal extrusion was found (P=0.001) in this series. The results suggest meniscal extrusion to be much more common in non-arthritic knees than previously estimated. The results also suggest that when the anterior horn of the medial meniscus inserts anteriorly in the tibial plateau, the meniscus tends to be extruded. It must be kept in mind that one of the limitations of this work is that the MRIs are taken in a non-weightbearing position.

In Vivo Evaluation of 3-Dimensional Polycaprolactone Scaffolds for Cartilage Repair in Rabbits

Background Cartilage tissue engineering using synthetic scaffolds allows maintaining mechanical integrity and withstanding stress loads in the body, as well as providing a temporary substrate to which transplanted cells can adhere. Purpose This study evaluates the use of polycaprolactone (PCL) scaffolds for the regeneration of articular cartilage in a rabbit model. Study Design Controlled laboratory study. Methods Five conditions were tested to attempt cartilage repair. To compare spontaneous healing (from subchondral plate bleeding) and healing due to tissue engineering, the experiment considered the use of osteochondral defects (to allow blood flow into the defect site) alone or filled with bare PCL scaffold and the use of PCL-chondrocytes constructs in chondral defects. For the latter condition, 1 series of PCL scaffolds was seeded in vitro with rabbit chondrocytes for 7 days and the cell/scaffold constructs were transplanted into rabbits’ articular defects, avoiding compromising the subchondral bone. Cell pellets and bare scaffolds were implanted as controls in a chondral defect. Results After 3 months with PCL scaffolds or cells/PCL constructs, defects were filled with white cartilaginous tissue; integration into the surrounding native cartilage was much better than control (cell pellet). The engineered constructs showed histologically good integration to the subchondral bone and surrounding cartilage with accumulation of extracellular matrix including type II collagen and glycosaminoglycan. The elastic modulus measured in the zone of the defect with the PCL/cells constructs was very similar to that of native cartilage, while that of the pellet-repaired cartilage was much smaller than native cartilage. Conclusion The results are quite promising with respect to the use of PCL scaffolds as aids for the regeneration of articular cartilage using tissue engineering techniques.

T-Fix anchor sutures for arthroscopic meniscal repair

Abstract The results of arthroscopically repaired meniscal tears with the T-Fix system in a short-term follow-up of 6 months was assessed in a non-comparative, prospective study. The T-Fix device consists of a short, rigid Delrin T attached to a braided, non-absorbable, polyester suture which is preloaded inside and deployed through a delivery (spinal) needle. The T grabs inside the tissue and provides an anchor for the suture. Twenty menisci in 20 patients (mean age 29 years) were repaired. Sports-related injuries were documented in 18 patients. In 15 patients, meniscus tears were repaired 6 months or more after injury. Half of the patients had isolated meniscus injuries. Associated injuries included anterior cruciate ligament (ACL), medial or lateral collateral ligament ruptures. These were not treated at the time of meniscal surgery except for an ACL reconstruction. All tears were longitudinal and positioned mainly in the posterior horn of the medial meniscus. A total of 70 T-Fixes were used with an average of 3 per patient (range 2–7). Only 4 T-Fixes (6%) were unsuccessfully placed, and this occurred early on in the series in 4 patients. In 90% of the patients, the postoperative activity levels returned to preoperative levels, and the clinical symptoms had either resolved or were experienced at a higher level of activity. The T-Fix device was relatively easy to use and could be reliably placed in the meniscus. Postoperatively, there were no complications directly associated with the device. However, further studies are needed to confirmed these results in a long-term follow-up in a larger patient population.

Industrially Prefabricated Cement Spacers: Do Vancomycin- and Gentamicin-impregnated Spacers Offer Any Advantage?

BackgroundIndustrially preformed antibiotic-loaded cement spacers are useful to facilitate the second stage of two-stage exchange arthroplasty for infected THAs and TKAs. However, whether gentamicin alone or a combination of antibiotics (such as vancomycin and gentamicin) is more effective is not known.Questions/purposesWe therefore sought to compare industrially prefabricated spacers containing either gentamicin or gentamicin and vancomycin with respect to (1) infection control, (2) complications, and (3) quality of life, pain, and patient satisfaction.MethodsWe performed a review of 51 patients with chronic infections treated at one center using either gentamicin or vancomycin and gentamicin-prefabricated spacers. The former were used exclusively from January 2006 until May 2009, and the latter from June 2009 until July 2011, and there was no overlap. We collected data on demographics, immunologic status (McPherson classification), prosthetic joint infection location, type of prosthesis, microbiologic results, and time between stages. We evaluated the primary outcome of infection control or recurrence after at least 12 months followup. We also recorded complications. Each patient completed a quality-of-life survey, VAS, and a self-administered satisfaction scale.ResultsThe overall infection control rate was 83% after a mean followup of 35 months (range, 12.4–64.7 months). There were no differences between gentamicin and vancomycin and gentamicin spacers in terms of infection eradication (80 % versus 85 %, respectively; p = 0.73), nor in terms of complications, quality of life, pain, or satisfaction scores.ConclusionsPrefabricated, antibiotic-loaded cement spacers has been proven effective for infection control in TKAs and THAs but with the numbers available, we did not find any differences between a gentamicin or vancomycin and gentamicin-prefabricated spacer, and therefore, we are unable to validate the superiority of the combination of vancomycin and gentamicin over gentamicin alone. Because of the higher costs involved with vancomycin and gentamicin spacers, and the potential risks of unselective use of vancomycin, further comparative studies are necessary to evaluate their role in the treatment of infected THAs or TKAs.Level of EvidenceLevel III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Bilateral hypoplasia of the medial meniscus

Only a few cases of the nearly unknown hypoplastic meniscus abnormality have been described. A case report of an incidental finding in a young female with a bilateral hypoplastic medial menisci is presented and, as far as we know, is the first report of bilateral hypoplasia of the medial meniscus in the literature.

The visual analog scale and a five-item verbal rating scale are not interchangeable for back pain assessment in lumbar spine disorders.

Study Design. Prospective study of patients with chronic back pain from lumbar spine disorders. Objective. To evaluate the degree of interchangeability of a 100-mm visual analog scale (VAS) and a 5-point verbal rating scale (VRS) for the assessment of pain intensity. Summary of Background Data. The fact that VAS and Likert scales are highly intercorrelated does not mean that both types of scales can be used interchangeably. Methods. A total of 151 patients (mean age, 52 ± 14.6 years) undergoing elective spine surgery completed a 100-mm VAS and a discrete 5-category VRS corresponding to the first item question of the core set (“How severe was your back pain in the last week?”). Pain intensity on the VAS was rated using the same question than for the VRS. The level of order-consistency (monotonic agreement), disordered pairs (D), percentage of agreement, and systematic disagreement (relative position), and relative concentration ([RC]) were estimated. VAS assessments were transformed into a discrete 5-category, with the cut-off VAS positions being defined by quintiles and equidistantly. Results. For VAS defined equidistantly, monotonic agreement was 0.840, D was 0.080, and the percentage of identical pairs was 53%. The corresponding figures for VAS defined by quintiles were 0.809, 0.096, and 27.8%. Inconsistencies between the VAS and the VRS scales were also demonstrated by the marginal distributions, with PR values of −0.005 (95% confidence interval [CI], −0.011 to −0.002) and RC values of 0.144 (95% CI, 0.137-0.152) for VAS defined equidistantly, and PR values of 0.391 (95% CI, 0.384-0.397) and RC values of 0.265 (95% CI, 0.255-0.275) for VAS defined by quintiles. Conclusion. The order-consistency level was low with overlapping of pain records between the 2 scales, indicating that VAS and VRS are not interchangeable and, therefore, a results obtained with the use of each scale cannot be compared.

Cirugía del ligamento cruzado anterior sin ingreso hospitalario

Objetivo Analizar de forma prospectiva la eficacia, seguridad y coste-efectividad del procedimiento de reconstruccion artroscopica del ligamento cruzado anterior en regimen de cirugia mayor ambulatoria. Material y metodo Entre noviembre de 2001 y diciembre de 2002 se realizaron 96 reconstrucciones del ligamento cruzado anterior, utilizando autoinjertos hueso-tendon-hueso o isquiotibiales en 4 haces. Se realizaron gestos quirurgicos adicionales en 39 pacientes. Los resultados se valoraron a los 5 dias del postoperatorio mediante la escala de dolor visual analogica (EVA) y encuesta de control del dolor, y se reevaluaron a los 6 meses estudiando el resultado clinico segun el cuestionario del International Knee Documentation Committee (IKDC), tasa de complicaciones, satisfaccion de los pacientes y coste-efectividad del proceso. Resultados A los 5 dias postoperatorios el 88,5% de pacientes refirieron un buen nivel analgesico (EVA de 1,9 ± 0,4). Ningun paciente requirio reingreso para control del dolor. A los 6 meses el IKDC era normal o casi normal en el 90,6% de pacientes y un 89,5% se mostraron satisfechos con el procedimiento ambulatorio. El ahorro economico por paciente fue del 7,9% cuando se comparo con la cirugia con ingreso. Conclusiones Los resultados sugieren que la reconstruccion del ligamento cruzado anterior puede realizarse con seguridad de forma ambulatoria. Los analgesicos orales han resultado adecuados para el control domiciliario del dolor postoperatorio. El analisis economico demostro el costeefectividad del procedimiento.

Management of degenerative lumbar spinal stenosis: an evidence-based review

Lumbar spinal stenosis has become one of the most disabling pathologies in the elderly population. Some additional conditions such as foraminal stenosis or degenerative spondylosis with a history of back pain and leg pain must be considered before treatment. A completely appropriate protocol and unified management of spinal stenosis have not yet been well defined. The objective of this literature review is to provide evidence-based recommendations reflected in the highest-quality clinical literature available to address key clinical questions surrounding the management of degenerative lumbar spinal stenosis. Cite this article: Covaro A, Vilà-Canet G, García de Frutos A, Ubierna MT, Ciccolo F, Caceres E. Management of degenerative lumbar spinal stenosis: an evidence-based review article. EFORT Open Rev 2016;1:267-274. DOI: 10.1302/2058-5241.1.000030.

Fracture of the anteromedial tibial plateau associated with posterolateral complex injury: case study and literature review.

We report an unusual case of anteromedial tibial plateau compression fracture following hyperextension and forced varus of the knee, resulting in an anterior bone fragment large enough to require osteosynthesis. This uncommon lesion was associated with posterolateral complex injury, diagnosed with magnetic resonance imaging (MRI), while both cruciate ligaments were preserved. After proceeding with tibial plateau osteosynthesis, a peroneal tendon allograft was used for supplementation repair of the lateral collateral ligament and biceps tendon in a single surgical intervention. Tibial plateau fractures are often associated with soft-tissue involvement, mainly of the anterior cruciate ligament and external meniscus. Posterolateral complex injuries also occur with a mechanism of forced varus and hyperextension. These lesions require an accurate diagnosis to avoid future knee instability; moreover, adequate treatment in the acute phase provides a better functional outcome. Physicians should suspect associated posterolateral complex injury when an anteromedial tibial plateau fracture is diagnosed. MRI allows adequate diagnosis and permits surgical treatment in one procedure.

Tratamiento quirúrgico de la escoliosis idiopática del adolescente

Resumen El tratamiento quirurgico de la escoliosis ha sufrido por una evolucion muy dinamica los ultimos 50 anos con aparicion rapida de nuevas tecnicas los ultimos 10 a 15 anos. Desde el inicio del siglo xx hasta finales de los 50 la norma de tratamiento quirurgico era una fusion posterior con yeso postoperatorio. El concepto de instrumentacion segmentaria se extendio al uso de ganchos y barras para la instrumentacion. Los ultimos anos se ha introducido la instrumentacion multisegmentaria y el uso de tornillos pediculares con aumento en la estabilidad y correccion, y los pacientes pueden salir del hospital sin corse o yeso. Los avances en anestesia y el cuidado postoperatorio han permitido que los cirujanos ejecuten cirugia mas compleja, incluso abordajes anteriores y posteriores en el mismo dia y el indice de complicaciones ha disminuido dramaticamente.