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PURPOSE: Trochlear dysplasia is one of the main risk factors for recurrent patellar dislocation. The Dejour classification identifies four categories that can be used to classify trochlear dysplasia. The purpose of this study is to evaluate the inter- and intraobserver reliability of the Dejour classification for trochlear dysplasia. The hypothesis was that both intra- and interobserver reliability would be at least moderate. METHODS: This is a cross-sectional, reliability study. Twenty-eight examiners from the International Patellofemoral Study Group 2022 meeting evaluated lateral radiographs of the knee and axial magnetic resonance images from 15 cases of patellofemoral instability with trochlear dysplasia. They classified each case according to Dejour's classification for trochlear dysplasia (A-D). There were three rounds: one with only computed radiograph (CR), one with only magnetic resonance imaging (MRI) and one with both. Inter- and intraobserver reliability were calculated using κ coefficient (0-1). RESULTS: The mean age of patients was: 14.6 years; 60% were female and 53% had open physis. The interobserver reliability κ probabilities were 0.2 (CR), 0.13 (MRI) and 0.12 (CR and MRI). The intraobserver reliability κ probabilities were 0.45 (CR), 0.44 (MRI) and 0.65 (CR and MRI). CONCLUSION: The Dejour classification for trochlear dysplasia has slight interobserver reliability and substantial intraobserver reliability. LEVEL OF EVIDENCE: Level I.
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Imageamento por Ressonância Magnética , Variações Dependentes do Observador , Articulação Patelofemoral , Humanos , Estudos Transversais , Feminino , Reprodutibilidade dos Testes , Adolescente , Masculino , Articulação Patelofemoral/diagnóstico por imagem , Articulação Patelofemoral/patologia , Luxação Patelar/diagnóstico por imagem , Luxação Patelar/classificação , Instabilidade Articular/classificação , Instabilidade Articular/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Fêmur/diagnóstico por imagem , Fêmur/patologia , CriançaRESUMO
PURPOSE: Patellofemoral (PF) instability recurrence depends on several factors including the relative lateralisation of tibial tubercle (TT) regarding the trochlear groove (TG). TT relative lateralisation quantification has long been a topic of debate. Multiple measuring techniques have been described including TT-trochlear groove (TT-TG), TT-posterior cruciate ligament (TT-PCL) and TT-roman arch (TT-RA), with no clear consensus regarding the most reliable index or pathologic threshold. We set out to determine the normal value range of each index and their association with age, sex and PF instability status. Also, this study aims to determine a reliable pathologic distance threshold to effectively predict patellar dislocation. METHODS: Skeletally mature patients up to 45 years of age who presented a CT Scan and an MRI of the same knee between 2014 and 2018 were included and divided into subgroups based on history of PF instability. Three indexes (TT-TG, TT-PCL and TT-RA) were assessed by two independent observers blinded to instability history. ROC curves were performed for each index to obtain the cut point that better predicts instability. Univariate and multivariate models adjusted by age, sex, instability history and type of imaging technique were performed to test the influence of these variables. RESULTS: 208 patients were included. Mean age was 27.93 â± â8.48 years, 67.3% were female and 71 patients (34.1%) presented major instability history. Good or excellent inter and intraobserver reliability was found for all three indexes. All indexes presented significantly different distributions between subjects with and without major instability (p â< â0.001), except for TT-PCL. Different cut point values differing between imaging modalities were found: 11.4 âmm for MRI TT-TG, 17 âmm for CT TT-TG, 15.6 âmm for MRI TT-RA and 18.2 âmm for CT TT-RA. CONCLUSIONS: All indexes studied had good or excellent inter and intraobserver reliability. Measurements between imaging techniques (CT and MR) are not interchangeable. Both TT-TG and TT-RA correctly distinguish between subjects with and without major instability, while TT-PCL does not, recommending caution when evaluated on its own. Specific threshold values depending on imaging technique should be considered for surgical decision-making. LEVEL OF EVIDENCE: Level IV, Diagnostic Test.
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Instabilidade Articular , Imageamento por Ressonância Magnética , Articulação Patelofemoral , Tíbia , Tomografia Computadorizada por Raios X , Humanos , Feminino , Instabilidade Articular/cirurgia , Instabilidade Articular/diagnóstico por imagem , Masculino , Adulto , Tíbia/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Tomografia Computadorizada por Raios X/métodos , Articulação Patelofemoral/diagnóstico por imagem , Adulto Jovem , Adolescente , Luxação Patelar/cirurgia , Luxação Patelar/diagnóstico por imagem , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Ligamento Cruzado Posterior/cirurgia , Ligamento Cruzado Posterior/diagnóstico por imagem , Estudos Retrospectivos , Curva ROCRESUMO
Durante las últimas décadas, hemos visto un aumento exponencial de las lesiones traumáticas alrededor de la rodilla en niños y adolescentes. La rodilla pediátrica tiene características particulares, que la diferencian de los adultos, y la predisponen a lesiones distintivas que requieren un manejo acorde. El aumento de su incidencia obliga a los médicos a verse enfrentados con mayor frecuencia a patologías como la luxación patelar, la avulsión de espinas tibiales, la avulsión de la tuberosidad anterior de la tibia y la lesión meniscal en probable contexto de un menisco discoideo. Es fundamental conocer los diferentes diagnósticos diferenciales y su enfrentamiento inicial para realizar una derivación oportuna con el fin de que estos pacientes obtengan un tratamiento adecuado
Over the past few decades, we have seen an exponential increase in traumatic injuries around the knee in children and adolescents. The pediatric knee is different from the adult knee, with special characteristics that predispose it to certain types of injuries that require a specific management. The increase in its incidence has faced attendants more frequently with pathologies such as patellar dislocation, tibial eminence fracture, tibial tubercle fractures and meniscal injury in the setting of a discoid meniscus. It is essential to know the differential diagnoses of this age-group, how to obtain an adequate study for a prompt referral
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Humanos , Criança , Adolescente , Traumatismos do Joelho/diagnóstico , Traumatismos do Joelho/terapia , Traumatismos do Joelho/etiologiaRESUMO
Multiligament injuries in below-knee amputation patients are a severe condition, and its treatment is controversial. Its incidence is unknown, and it is highly underdiagnosed, representing a challenge for the physician. The case presented is about a patient with a left transtibial amputation secondary to a severe crushing of the ipsilateral lower limb to which during the process of physiotherapy, a multiligament injury was diagnosed. The patient underwent a tibiofibular fixation with a multiligament reconstruction with good functional results. In this complex situation, delay in diagnosis is frequent, ligament instability should always be suspected and explored further, allowing for proper rehabilitation and early treatment.
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OBJETIVO: Realizar la evaluación clínica, imagenológica y funcional de pacientes con fracturas avulsivas tibiales del ligamento cruzado posterior (FTALCPs) fijadas con tornillos canulados con técnica abierta. MÉTODOS: Los pacientes con FTALCP operados entre 2010 y 2017 fueron revisados retrospectivamente. Criterios de inclusión: fracturas agudas, desplazadas, test de cajón posterior grado III, lesiones combinadas de rodilla, seguimiento > 12 meses. Se excluyeron pacientes > 65 años, con FTALCPs bilaterales, lesiones del ligamento cruzado posterior (LCP) intrasustancia, test de cajón posterior grados I-II, fracturas expuestas, lesiones neurovasculares, y seguimientos < 12 meses. Objetivo primario: medir la estabilidad clínica mediante test de cajón posterior y radiografía de estrés arrodillada comparativa. Objetivos secundarios: nvaluar la consolidación en radiografías, complicaciones y funcionalidad con las escalas de Lysholm y Tegner. Resultados Se incluyeron 20 pacientes, con edad media de 41 años (rango: 32 a 61 años). El seguimiento promedio fue de 33,9 meses (rango: 12 a 82 meses). La estabilidad clínica mejoró en 93% (cajón posterior postoperatorio grados 0 y I) de los pacientes. La radiografía de estrés arrodillada mostró una diferencia promedio de 2,6 mm (rango: 0,1 mm a 6,8 mm) de traslación posterior al comparar con el lado sano. Todas las fracturas consolidaron. Siete pacientes presentaron complicaciones. El puntaje promedio de la escala de Lysholm al final del seguimiento fue de 85,17. El promedio preoperatorio del puntaje en la escala de Tegner no varió significativamente en comparación con el postoperatorio. CONCLUSIONES: La fijación de fracturas avulsivas tibiales del LCP con tornillos canulados con técnica abierta es efectiva en restaurar la estabilidad posterior y lograr la consolidación ósea. La funcionalidad clínica a mediano plazo es buena, a pesar del alto número de complicaciones y lesiones concomitantes. NIVEL DE EVIDENCIA: tipo IV.
OBJECTIVE: To report mid-term clinical, radiographic, and functional outcomes following open reduction and fixation of posterior cruciate ligament tibial avulsion fractures (PCLTAFs) with cannulated screws. METHODS: This is a retrospective analysis of patients with PCLTAF operated on from August 2010 to April 2017. Patients with acute fractures, with more than 2 mm of displacement and grade III on the posterior drawer test, combined or not to knee injuries, were included. Patients older than 65 years of age, with bilateral avulsion fractures, intrasubstance posterior cruciate ligament (PCL) lesions, stable grade-I to -II on the posterior drawer test, concomitant neurovascular injuries, mid-substance tears, open fractures, and less than 12 months of follow-up were excluded. Primary outcomes: the clinical stability was assessed using the posterior drawer test and a single comparative knee stress radiograph. Secondary outcomes: radiographic consolidation, complications, Lysholm score, and Tegner activity score. RESULTS: In total, 20 patients with a mean age of 41 years (range: 32 to 61 years) were included. The mean follow-up was of 33.9 months (range: 12 to 82 months). Clinical stability (grade 0 or I on the posterior drawer test) was observed in 93% of the patients. The mean difference in contralateral posterior displacement was of 2.6 mm (range: 0.1 mm to 6.8 mm) on a single comparative knee stress radiograph. All fractures presented radiological consolidation. Seven patients developed complications. The mean Lysholm score at the last follow-up visit was of 85.17. The postoperative Tegner activity scores did no vary significantly compared to the preinjury scores. CONCLUSIONS: Cannulated screw fixation of a displaced PCLTAF through a posterior approach restores clinical and radiographic stability and has excellent union rates. The mid-term functional outcomes are good despite the high rates of combined knee lesions and postoperative complications. LEVEL OF EVIDENCE: IV.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Fraturas da Tíbia/cirurgia , Fraturas da Tíbia/diagnóstico por imagem , Parafusos Ósseos , Ligamento Cruzado Posterior/cirurgia , Ligamento Cruzado Posterior/diagnóstico por imagem , Fixação de Fratura/métodos , Fraturas da Tíbia/fisiopatologia , Estudos Retrospectivos , Seguimentos , Ligamento Cruzado Posterior/fisiopatologia , Resultado do Tratamento , Fratura Avulsão , Fixação de Fratura/instrumentaçãoRESUMO
PURPOSE: In patients with open growth plates, the direction of tunneling that avoids distal femoral physis (DFP) damage in anatomic reconstructions of the medial patellofemoral ligament (MPFL) has been a topic of discussion. The objective of this study was to determine the ideal orientation for anatomic reconstructions of MPFL tunneling that minimized DFP damage while avoiding breaching the intercondylar notch. METHODS: Eighty magnetic resonance images of patients aged 10 through 17 were obtained, randomly sampled from the institutional database. A de novo software was developed to obtain 3D models of the distal femur and DFP. In each model, the anatomical insertion point of the MPFL was determined as defined by Stephen. A 20-mm-depth drilling was simulated, starting from the insertion point at every possible angle within a 90° cone using 5-, 6- and 7-mm drills. Physeal damage for each pair of angles and each drill size was determined. Damage was expressed as a percentage of total physis volume. Statistical analysis was conducted using Student's t test and one-way ANOVA. RESULTS: Maximum physeal damage (5.35% [4.47-6.24]) was obtained with the 7-mm drill when drilling 3° cephalic and 15° posterior from insertion without differences between sexes (n.s.). Minimal physeal damage (0.22% [0.07-0.37]) was obtained using the 5-mm drill aimed 45° distal and 0° anteroposterior, not affected by sex (n.s.). Considering intra-articular drilling avoidance, the safest zone was obtained when aiming 30°-40° distal and 5°-35° anterior, regardless of sex. CONCLUSION: Ideal femoral tunnel orientation, avoiding physeal damage and breaching of the intercondylar notch, was obtained when aiming 30°-40° distal and 5°-35° anterior, regardless of sex. This area is a safe zone that allows anatomic MPFL reconstruction of patients with an open physis.
Assuntos
Lâmina de Crescimento/cirurgia , Ligamentos Articulares/cirurgia , Luxação Patelar/cirurgia , Articulação Patelofemoral/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Adolescente , Criança , Feminino , Fêmur/diagnóstico por imagem , Fêmur/cirurgia , Lâmina de Crescimento/diagnóstico por imagem , Lâmina de Crescimento/patologia , Humanos , Articulação do Joelho/diagnóstico por imagem , Articulação do Joelho/cirurgia , Ligamentos Articulares/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Masculino , Orientação Espacial , Articulação Patelofemoral/diagnóstico por imagem , SoftwareRESUMO
OBJETIVOS: Determinar el rendimiento de las clasificaciones de Outerbridge (OB) e International Cartilage Repair Society (ICRS). MÉTODO: Estudio de test diagnóstico, diseño y recolección de datos prospectivo. Siete traumatólogos sub-especialistas observaron un mismo video donde se exponían 30 lesiones condrales bajo visión artroscópica, para luego clasificarlas según OB e ICRS y consignar el tratamiento de elección para cada una de las lesiones, eligiendo entre 6 alternativas: observación, debridamiento mecánico o térmico, microfractura, OATS o terapias biológicas. Tras 7 días, los evaluadores debían repetir el mismo procedimiento. RESULTADOS: La concordancia entre los observadores fue débil para clasificación de ICRS (k 0,25 p < 0,001) y moderada para la clasificación de OB (k 0,45 p < 0,001). La concordancia intra-observador para ICRS oscilaba entre moderada y excelente (k promedio de 0,67), y para la clasificación de OB entre buena y excelente (k promedio 0,83). Ninguna de las dos clasificaciones mostró correlación con la experiencia del cirujano. En la elección de tratamiento, la concordancia entre observadores fue débil (k 0,33 p < 0,001), sin embargo, la concordancia intra-observador fue en todos los casos buena o excelente (k 0,82), mostrando una correlación directamente proporcional a la experiencia del cirujano. La capacidad de discriminación terapéutica, evaluada mediante una regresión logística, mostró un área bajo la curva roc en el rango del no-efecto. CONCLUSIÓN: Ambas clasificaciones mostraron una baja correlación inter-observador y una elevada concordancia intra-observador. En ambas categorías, Outerbridge fue más concordante que ICRS. En cuanto al tratamiento, ninguna de las dos clasificaciones logra unificar criterios quirúrgicos. NIVEL DE EVIDENCIA: Nivel I (test diagnóstico).
OBJECTIVES: Assess de diagnostic accuracy of Outerbridge (OB) and ICRS (International Cartilage Repair Society) classifications. METHODS: We performed a diagnostic test study, with a prospective design and data collection. Seven knee surgeons were asked to observe a video were the 30 chondral lesions were shown through arthroscopic view. Simultaneously they were asked to classify them according to OB and ICRS. Besides, they had to define how they would manage the chondral lesion, choosing among six treatment options (observation, mechanical or thermic chondroplasty, microfracture, osteochondral autologous transfer system (OATS) or biological therapies). A week later, they repeated the same procedure. Intra and interobserver agreement were characterized by κ statistical analysis, and a logistic regression was used to assess the ability of both classifications to discriminate among treatment options. P values < 0,05 were considered significant. RESULTS: Interobserver agreement was weak (κ 0.25 p < 0.001) for ICRS classification and moderate for OB classification (κ 0.45 p < 0.001). Intraobserver agreement for ICRS ranged from moderate to excellent (average κ of 0.67), and for the OB classification ranged from good to excellent (average kappa 0.83). Neither classification correlated with the surgeon's experience. Interobserver agreement for therapeutic choice was poor (κ 0.33 p < 0.001). However, intraobserver agreement was good to excellent (κ 0.82) in all cases, showing a direct correlation with the surgeon's experience. Logistic regression used to assess the ability of both classifications to discriminate among treatment options, showed in both cases an area under the roc curve in the no-effect range. CONCLUSION: Both classifications showed low interobserver and high intraobserver agreements for arthroscopic grading of chondral lesions. In both, Outerbridge was more reliable than ICRS. As for guiding therapeutic management, none of the classifications could unify surgical criteria.
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Humanos , Artroscopia , Doenças das Cartilagens/classificação , Doenças das Cartilagens/diagnóstico , Traumatismos do Joelho/classificação , Traumatismos do Joelho/diagnóstico , Índice de Gravidade de Doença , Doenças das Cartilagens/cirurgia , Variações Dependentes do Observador , Estudos Prospectivos , Curva ROC , Traumatismos do Joelho/cirurgiaRESUMO
Discoid meniscus is the most frequent congenital malformation of the menisci, and primarily affects the lateral meniscus; it is highly prevalent in the Asian population.The anatomic, vascular, and ultrastructural features of the discoid meniscus make it susceptible to complex tears.Discoid meniscus anomalies are described according to their shape; however, there is consensus that peripheral stability of the meniscus should also be defined.Initial workup includes plain X-rays and magnetic resonance imaging, while arthroscopic evaluation confirms shape and stability of the meniscus.Clinical presentation is highly variable, depending on shape, associated hypermobility, and concomitant meniscal tears.Treatment seeks to re-establish typical anatomy using saucerization, tear reparation, and stable fixation of the meniscus. Cite this article: EFORT Open Rev 2020;5:371-379. DOI: 10.1302/2058-5241.5.190023.
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Fractures of the anterior tibial tuberosity during childhood are an infrequent pathology (around 3% of all proximal tibial fractures), but the incidence of this injury has risen over recent years, likely due to the increased involvement of this age group in sports activities.This fracture is more commonly seen in children 12-14 years old.It is vital to identify the anatomical structures associated with this type of fracture, along with the pathophysiological mechanisms involved.Treatment includes non-operative and operative options, with the goal of achieving articular congruency, restoring the extensor mechanism function, and avoiding damage to the proximal tibial physis.Understanding the management of this fracture, and the complications that might arise, is critical. The provision of an appropriate clinical management plan and the avoidance of complications are vital in the prevention of disability. Cite this article: EFORT Open Rev 2020;5:260-267. DOI: 10.1302/2058-5241.5.190026.
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OBJETIVO: Describir las tendencias en reconstrucción de LCA (R-LCA) entre los traumatólogos ejerciendo en Chile, delineando sus preferencias en cuanto a la técnica quirúrgica. MÉTODO: encuesta online de selección múltiple y recolección anónima de datos, dirigida a todos aquellos cirujanos que realizan R-LCA en Chile. Fue enviada por correo electrónico desde la Sociedad Chilena de Ortopedia y Traumatología a todos sus afiliados. RESULTADOS: 103 cirujanos completaron la encuesta, realizando su práctica quirúrgica en Santiago (53%) y regiones (47%). En el 53% de los encuestados la cirugía de rodilla representaba más del 75% de su práctica, mientras que sólo en 9 ellas eran menos del 25%. El autoinjerto de isquiotibiales es utilizado en el 70% de R-LCA, seguido por el autoinjerto de tendón patelar (27%). En cuanto a la preparación de túneles, 33% utiliza técnica transtibial y 67% túneles independientes (13% fresado retrógrado, 54% portal medial). Para la fijación de injerto isquiotibiales, botones corticales es lo más utilizado en el fémur (73%), y tornillos interferenciales en la tibia (82%). Para la fijación femoral y tibial de injerto de tendón patelar, los tornillos metálicos son los más utilizados (75%). Un 41% realiza un pretensado del injerto, un 59% lo ciclan una vez fijo, y sólo 8 aplican una solución antibiótica sobre el injerto. La mayoría (89%) realiza la fijación en 10°-20° de flexión, ya sea con rotación externa (36%) o neutra (53%). En un 7% de las R-LCA primarias y en un 27% de las revisiones agregan una reconstrucción anterolateral. CONCLUSIÓN: la tendencia en R-LCA en Chile es el uso de autoinjerto de isquiotibiales, con fresado independiente del túnel femoral y fijación en flexión con botones corticales y tornillos interferenciales.
OBJECTIVE: To describe the trends in anterior cruciate ligament reconstruction (ACL-R) among Orthopaedic surgeons working in Chile, outlining their preferences regarding surgical technique. METHOD: An online, multiple choice, anonymous survey was sent via email from the Chilean Orthopaedic and Trauma Society to all its members, with instructions to be completed by surgeons who perform ACL-R. RESULTS: 103 surgeons completed the survey from Santiago (53%) and other regions (47%). For 53% of the surgeons, knee surgeries represented more than 75% of their practice, and in only 9 cases it was less than 25% of it. The autologous hamstring tendon graft was in 70% of the ACL-R, while patellar tendon graft in 27%. For tunnel drilling, 33% of surgeons use transtibial technique, and 67% prefer independent tunnel drilling (13% retrodrill, 54% medial portal). Fixation method for hamstring tendon graft is mostly with cortical buttons on femur (73%), and interference screws for the tibia (82%). Patellar graft was fixed with metal screws (75%) in both femur and tibia. 41% of surgeons pretensed the graft, 59% cycle it once, and only 8 coated the graft with antibiotic solutions. Most (89%) fixate de graft in 10°-20° of knee flexion, with either external rotation (36%) or neutral (53%). Antero-lateral reconstruction is used in 7% of primary ACL-R and in 27% of revision surgeries. CONCLUSION: the chilean tendency for ACL-R is to use an autologous hamstring tendon graft, with independent drilling technique, and fixation with cortical buttons and interference screws for femur and tibia respectively.
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Humanos , Reconstrução do Ligamento Cruzado Anterior/tendências , Cirurgiões Ortopédicos/psicologia , Chile , Inquéritos e QuestionáriosRESUMO
PURPOSE OF REVIEW: To summarize and discuss the fundamentals of pediatric tibial tubercle avulsion fractures (TTAFs) including preferred imaging modalities, systems for fracture classification, frequently associated injuries, treatment options, outcomes, and common complications. RECENT FINDINGS: Although TTAFs amount to fewer than 1% of all physeal injuries in children, the incidence is increasing, likely because of greater participation in high-level athletics. SUMMARY: TTAFs tend to occur in adolescents nearing skeletal maturity who engage in sports with repetitive jumping. The most popular classification system was proposed by Ogden, which defines five fracture types based on the fracture pattern and extent of fragment displacement. Treatment can be nonsurgical or surgical, and indications depend on fracture type. Most fractures are surgical candidates and can be repaired with open reduction and internal fixation (ORIF) or arthroscopy. Arthroscopic approaches can reveal associated soft tissue injuries, such as meniscal tears, and confirm articular reduction. The most common postoperative complication is irritation because of hardware. With proper treatment, both nonsurgical and surgical outcomes are excellent. TTAFs have high rates of union and patients typically return to sports.
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Fratura Avulsão , Traumatismos do Joelho , Fraturas da Tíbia , Adolescente , Artroscopia , Criança , Tratamento Conservador , Fixação de Fratura , Fixação Interna de Fraturas , Fratura Avulsão/classificação , Fratura Avulsão/diagnóstico , Fratura Avulsão/etiologia , Fratura Avulsão/terapia , Humanos , Traumatismos do Joelho/classificação , Traumatismos do Joelho/diagnóstico , Traumatismos do Joelho/etiologia , Traumatismos do Joelho/terapia , Fraturas da Tíbia/classificação , Fraturas da Tíbia/diagnóstico , Fraturas da Tíbia/etiologia , Fraturas da Tíbia/terapia , Resultado do TratamentoRESUMO
La real incidencia de las lesiones meniscales en niños y adolescentes sigue siendo desconocida, aunque se estima que estas han aumentado en los últimos años. En este grupo de pacientes, tanto el examen físico como la resonancia magnética han reportado un menor rendimiento, por lo que la sospecha clínica debe ser alta. Aunque la literatura es escasa en niños y las bases del manejo de estas lesiones se extrapolan del manejo en adultos, la tendencia actual es la preservación meniscal. Dado el alto potencial de cicatrización y la mayor vascularización del menisco pediátrico, se extiende la indicación de sutura meniscal a toda aquella lesión reparable, independiente del patrón, extensión o tiempo de evolución en este grupo étareo. La literatura reporta buenos resultados tras la reparación meniscal en pacientes pediátricos, con tasas de cicatrización promedio por sobre el 70%, que son al menos comparable a lo reportado en adultos. A la fecha, la técnica todo-dentro es la más utilizada por su fácil utilización y menor tiempo quirúrgico. Sin embargo, debemos ser especialmente cuidadosos para evitar una lesión neurovascular iatrogénica dado el menor tamaño y proximidad del paquete neurovascular en rodillas pediátricas. La principal complicación es la falla de la sutura, reportándose tasas comparables a la población adulta a pesar de su indicación extendida en niños y adolescentes. Se han identificado como factores protectores para la reparación meniscal la menor edad, la fisis abierta, roturas de patrones simples y la reconstrucción concomitante de ligamento cruzado anterior. En el presente artículo realizamos una detallada revisión de la literatura disponible sobre reparación meniscal en niños y adolescentes, enfatizando las diferencias versus población adulta. También presentamos nuestra experiencia y protocolo de rehabilitación para sutura meniscal en pacientes pediátricos
The true incidence of meniscal injuries in children and adolescents remains unknown, though estimated to have increased during the last years. Clinical suspicion must remain high since physical examination and magnetic resonance imaging have reported less accuracy for meniscal tears in pediatric patients. Although literature is scarce in children and adolescents and the basis for managing these lesions is extrapolated from adult population, the current trend is meniscal preservation. Considering the greater healing potential and vascularization of the pediatric meniscus, indications for meniscal suture are extended to all those tears amenable to repair in spite of their size, tear pattern and time to repair. Literature has demonstrated good outcomes for meniscal repair in children, with healing rates above 70%, comparable to those reported for adults. To date, the all-inside technique is the most frequently used for meniscal repair thanks to its simplicity and shorter operative time. However, we must be especially careful to avoid iatrogenic neurovascular injury given the smaller size and proximity of the neurovascular package in the pediatric knee. Suture failure is the main complication, with rates comparable to adult population despite widespread indication of repair in children. Younger age, open physis, simple tear patterns and simultaneous anterior cruciate ligament reconstruction appear to benefit meniscal repair in children. This article summarizes the available literature regarding meniscal repair in children and adolescents, emphasizing the differences with adult population. We also present our experience in the treatment of these injuries and our preferred rehabilitation protocol
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Criança , Adolescente , Artroscopia/métodos , Meniscos Tibiais/cirurgia , Traumatismos do Joelho/cirurgiaRESUMO
PURPOSE OF REVIEW: The purpose of this review is to summarize and clarify the current framework for treating tibial spine avulsion fractures (TSAFs). We will discuss how these fractures are classified both on plain radiographs and MRI as well as report the incidence of concomitant soft tissue injury, an important consideration that guides treatment. We will also compare guidelines for nonsurgical versus surgical treatment and summarize frequently used surgical techniques. Finally, we will review outcomes following treatment, including common complications. RECENT FINDINGS: Although TSAFs only constitute 2-5% of all pediatric knee injuries, the incidence is increasing. A recently developed MRI-based system for evaluating TSAFs is another tool that aids in the treatment of these injuries. SUMMARY: TSAFs can be classified using plain radiographs as well as MRI. Type I fractures are usually treated with immobilization whereas type II fractures typically undergo an initial attempt at closed reduction followed by arthroscopic or open reduction and fixation if needed. Type III fractures are indicated directly for arthroscopic surgery and both suture and screw fixation produce good clinical outcomes. All-epiphyseal or transphyseal approaches can minimize the risk of physeal injury in skeletally immature patients. Common complications following TSAF injury and treatment are residual laxity, knee stiffness, and nonunion or malunion.
Assuntos
Fratura Avulsão , Traumatismos do Joelho , Fraturas da Tíbia , Artroscopia , Criança , Fixação Interna de Fraturas , Fratura Avulsão/terapia , Humanos , Traumatismos do Joelho/terapia , Articulação do Joelho , Fraturas da Tíbia/terapia , Resultado do TratamentoRESUMO
OJETIVO: Reportar la experiencia, después de 1 año de seguimiento, de una serie de 30 pacientes sometidos a reconstrucción de la esquina posteromedial (EPM) con la técnica descrita por La Prade. MÉTODO: Cohorte retrospectiva de 30 pacientes con lesión de EPM operados por el mismo equipo quirúrgico. Criterios de inclusión: diagnóstico clínico, radiografía con estrés y resonancia magnética compatibles con lesión de EPM, inestabilidad grado III luego de 3 meses de tratamiento ortopédico, técnica de reconstrucción de La Prade, al menos 12 meses de seguimiento. Criterios de exclusión: discordancia entre clínica e imagenología, inestabilidad grado I o II, y otra técnica quirúrgica. Evaluación con IKDC y Lysholm antes de la cirugía, a los 6 y 12 meses de seguimiento postcirugía. RESULTADOS: 30 pacientes cumplieron los criterios de inclusión. Promedio de edad 43 años (2469). Veintiocho pacientes presentaron lesiones de alta energía, 20 pacientes fueron diagnosticados en agudo, mientras que 10 fueron diagnosticados luego de malos resultados en reconstrucción de otros ligamentos. Veintiocho presentaron lesiones asociadas: 11 casos asociados a lesión de ligamento cruzado anterior, 3 casos asociados a lesión de ligamento cruzado posterior, 3 casos en asociación con lesiones meniscales, 9 casos con lesión asociada de ligamento cruzado anterior y posterior, y 2 casos en asociación con ligamento cruzado anterior, posterior y ligamento colateral lateral. Promedio de tiempo hasta la reconstrucción de EPM fue de 5 meses (rango 232). Puntuación en Lysholm e IKDC (preoperatorio 18,2 y 24,3 respectivamente), mejoraron a 76,7 y 70,7 después de 1 año de seguimiento. Al fin del seguimiento, el rango articular promedio era 113° (90140), la mayoría de los pacientes (24) tuvieron estabilidad tipo A según IKDC. CONCLUSIÓN: La reconstrucción de lesiones de EPM mejora los resultados clínicos en pacientes con inestabilidad crónica posteromedial de rodilla. Se observó mejoría en la estabilidad y scores funcionales de todos los pacientes.
OBJETIVE: Report the experience, after 1-year follow-up, of 30 patients with La Prade's anatomical reconstruction of posteromedial corner (PMC) injuries. METHODS: Retrospective cohort study. 30 patients with PMC injuries operated by the same surgical team. Inclusion criteria: clinical presentation, stress radiographs and MRI compatible with PMC injury, grade III chronic instability in spite of at least 3 months of orthopedic treatment, La Prade's anatomical technique reconstruction, 12 months follow-up at least. Exclusion criteria: discordance between clinical and image studies, grade I or II medial instability, any other surgical technique. IKDC and Lysholm at the preoperative evaluation, 6 and 12 months after surgery. RESULTS: Thirty patients met the inclusion criteria. Mean age 43 years (2469). 28 patients presented high-energy mechanism of injury. Twenty patients were diagnosed in the acute setting, while 10 had a delayed diagnosis after poor results of other ligament reconstruction. Majority (28) had associated injuries: 11 cases PMC + anterior cruciate ligament (ACL) injury, 3 PMC + posterior cruciate ligament (PCL) injury, 3 PMC + meniscal tears, 9 PMC + ACL + PCL injuries, and 2 PMC + ACL + PCL + lateral collateral ligament injuries. Mean time for PMC reconstruction was 5 months (range 232). Preoperative Lysholm and IKDC scores (18,2 and 24,3 respectively) improved to 76,7 and 70,7 after 1-year follow-up. At the end of follow-up, average ROM was 113° (90140), most patients (24) had type A IKDC stability. CONCLUSION: Acceptable results were achieved following reconstruction of PMC injuries in patients with chronic posteromedial knee instability. We observed instability and functional scores improvement in all patients.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Instabilidade Articular/cirurgia , Traumatismos do Joelho/cirurgia , Ligamento Colateral Médio do Joelho/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Seguimentos , Joelho/fisiologia , Escore de Lysholm para Joelho , Estudo Observacional , Procedimentos Ortopédicos/métodos , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Las lesiones meniscales en niños son cada día más frecuentes. La preservación meniscal es una prioridad en este grupo de pacientes, sin embargo, existen pocos artículos que muestran los resultados de suturas meniscales en niños. OBJETIVO: El objetivo de este estudio es identificar factores de riesgo de falla en pacientes sometidos a una sutura meniscal en niños menores de 18 años. MÉTODO: Estudio retrospectivo de 35 pacientes sometidos a una sutura meniscal, con una edad promedio de 16 años (1318) y un seguimiento de 71 meses de media (16115). Se evaluaron 6 variables: tipo, localización y tamaño de la lesión, edad, técnica quirúrgica y asociación a rotura de ligamento cruzado anterior (LCA). Los pacientes que presentaron falla de la sutura meniscal fueron identificados y sometidos a una regresión logística usando un modelo Stata V.14.0. RESULTADOS: 9 pacientes (24.3%) presentaron una falla en su cirugía durante el seguimiento. Lesiones iniciales mayores a 16 mm mostraron una tasa de re-rotura de un 73% independiente de la técnica quirúrgica. En lesiones menores a 16 mm, se obtuvo un 78% de reparaciones exitosas. No se encontró relación entre la re-rotura meniscal y lesión de LCA, tipo y localización de la lesión, técnica quirúrgica y edad de los pacientes. CONCLUSIÓN: Este estudio muestra que la reparación meniscal en niños tiene buenos resultados con una tasa de éxito promedio de un 75%. El riesgo de falla de sutura meniscal se correlacionó con el tamaño inicial de la lesión con un 73% de fallo en lesiones mayores a 16 mm independientemente del tipo de cirugía.
Meniscal tears are uncommon in the pediatric population, with an increasing number. Currently meniscal preservation is a priority when treating these injuries. However, only a few studies have reported the clinical outcomes of arthroscopic meniscal repair in children and its risk factors of failure. OBJECTIVE: Identify risk factors related to meniscal suture failure in patients under 18 years who underwent a meniscal repair. METHODS: Retrospective study of 35 patients with an average age of 16 years (13 - 18) who underwent arthroscopic meniscal repair with a mean follow up of 71.1 months (16115). We evaluate 6 variables: type, location and size of meniscal tear, age, surgical technique and anterior cruciate ligament (ACL) association. Patients with re-rupture were identified and statistical analysis was performed through a logistic regression model using Stata V.14.0. RESULTS: 9 patients (24.3%) presented a suture failure during follow-up. Average time for re-rupture was 16 months (460 months). With an initial tear size of 16 mm or bigger, 73% of the meniscal repair will fail despite surgery technique. With an initial tear size smaller than 16 mm, 78% of will heal. No association was found between meniscal re-rupture and ACL rupture, type and location of tear, surgical technique and age. Conclusion: In our study meniscal repairs in pediatric population had good overall results with a global healing rate of 75.7%. The risk of suture failure was related to the initial size of meniscal tear: when meniscal tear is bigger than 16 mm, 73% of them will fail despite surgery.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Meniscos Tibiais/cirurgia , Técnicas de Sutura/efeitos adversos , Suturas , Artroscopia , Falha de Equipamento , Seguimentos , Análise Multivariada , Prognóstico , Amplitude de Movimento Articular , Estudos Retrospectivos , Fatores de Risco , Técnicas de Sutura/estatística & dados numéricos , Lesões do Menisco TibialRESUMO
PURPOSE OF REVIEW: As anterior cruciate ligament (ACL) injury is becoming increasingly prevalent in the population of active children and young adolescents, it is crucial to be aware of both the modifiable and nonmodifiable factors that place this population at increased ACL injury risk. Historically, there has not been a definitive consensus on all of these risk factors-particularly the nonmodifiable ones. RECENT FINDINGS: The present review has accumulated the most recent evidence for the nonmodifiable risk factors in ACL injury focusing particularly on female gender, generalized joint laxity, knee recurvatum, increased lateral tibial slope, decreased intercondylar notch width, structural lower extremity valgus, limb length discrepancy, family history, and history of contralateral knee ACL injury. SUMMARY: Physicians should be aware of the nonmodifiable risk factors for ACL tears in active children and adolescents and should also encourage avoidance of modifiable risk factors in this population. Young athletes with nonmodifiable risk factors are at a particularly increased risk of recurrent injury following ACL reconstruction (ACLR). We believe that a primary extra-articular augmentation via iliotibial band tenodesis at the same time of ACLR may decrease the rate of reinjury for the high risk athlete with multiple nonmodifiable risk factors.
Assuntos
Lesões do Ligamento Cruzado Anterior/etiologia , Traumatismos em Atletas/etiologia , Adolescente , Lesões do Ligamento Cruzado Anterior/prevenção & controle , Traumatismos em Atletas/prevenção & controle , Criança , Humanos , Fatores de Risco , Fatores SexuaisRESUMO
PURPOSE: Increasing numbers of children and adolescents are being treated for ACL tears. In order for surgeons to safely optimize treatment during ACL surgery, we must better understand ACL growth and intercondylar notch patterns in the skeletally immature knee. The aim of this study is to measure ACL and intercondylar notch volume in paediatric patients and observe how these volumes change as a function of age and gender. METHODS: Data were extracted from the picture archiving and communication systems (PACS) computer records. Sample consisted of 137 MRI knee examinations performed between January 2006 and July 2010 in patients aged 3-13. Subjects were grouped into 1-year age intervals. Patients with imaging reports including ACL tears, previous surgeries, congenital structural anomalies, or syndromes were excluded. RESULTS: Measures of ACL volume significantly increased with age (P < 0.001). A linear increase in ACL volume was observed until the age 10, with a mean increase in volume of 148 mm(3) per age group. ACL volume plateaued at 10 years, after which minimal increase in ACL volume was observed. Sex was not found to be a significant predictor of ACL volume in the multiple linear regression (P = 0.57). Similar to ACL volume, there was a significant increase in intercondylar notch volume with age with a mean increase of 835 mm(3) per age group (P < 0.0001). Intercondylar notch volume reached a plateau at age 10, after which a minimal increase in notch volume was observed in older groups. Female patients had notch volumes that were on average 892 + 259 mm(3) smaller than male patients who were in the same age group (P = 0.0006). CONCLUSION: The plateau in the growth of ACL and notch volume occurs at age 10, prior to the halt in longitudinal growth of boys and girls. Female patients have significantly smaller intercondylar notch volumes than their age-matched male counterparts, while no gender difference was seen in ACL volume. These results suggest that notch volume is an intrinsically sex-specific difference, which may contribute to the higher rate of ACL tears among females. These growth patterns are clinically relevant as it allows surgeons to better understand the anatomy, pathology, and risk factors related to ACL tears and its reconstruction. LEVEL OF EVIDENCE: Observational Study, Level IV.
Assuntos
Ligamento Cruzado Anterior/crescimento & desenvolvimento , Articulação do Joelho/crescimento & desenvolvimento , Imageamento por Ressonância Magnética , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Modelos Lineares , Masculino , Caracteres SexuaisRESUMO
Con el objetivo de mejorar el acceso a una atención integral de los niños, niñas y adolescentes con VIH, esta publicación ofrece un aporte para el trabajo de los equipos de salud comprometidos con la temática en Argentina. Si definirse estrictamente como una guía el contenido contempla las recomendaciones basadas en la evidencia y la experiencia de los principales referentes de cada área y reúne los aspecto biomédicos y socio culturales de la infección, asumiendo que se trata de una mirada indispensable para el abordaje integral de los procesos salud enfermedad. El volumen pretende ser una fuente de consulta que facilite la tarea de los pediatras y hebiatras no infectologos de adultos que frecuentemente realizan el seguimiento de adolescentes con HIV, ya que resulta necesario promover el acercamiento de las pediatrías generales a las especifidades del VIH, y de los infectologos de adultos a las necesidades en la adolescencia, para reducir los obstáculos en el circuito de atención. Fortalecer esta tarea es un escalón esencial para lograr la mejor atención de los niños, niñas y adolescentes con VIH en nuestro país, entendiendo que constituyen una población especialmente vulnerable que requiere políticas especificas para una mejor respuesta desde el sector de salud, La presente demuestra, también el resultado de una experiencia innovadora de trabajo compartido entre los organismos del estado, la sociedad científica y las agencias del Sistema de Naciones Unidas