Releasing the circumferential fixation of the medial meniscus does not affect its kinematic
A.C.T. Vrancken , T.G. van Tienen , G. Hannink , D. Janssen , N. Verdonschot , P. Buma
The Knee: Publication date: Available online 26 September 2014
Background
Meniscal functioning depends on the fixation between the meniscal horns and the surrounding tissues. It is unknown, however, whether the integration between the outer circumference of the medial meniscus and the knee capsule/medial collateral ligament also influences the biomechanical behavior of the meniscus. Therefore, we aimed to determine whether detaching and resuturing the circumferential fixation of the medial meniscus influence its kinematic pattern.
Methods
Human cadaveric knee joints were flexed (0°–30°–60°–90°) in a knee loading rig, in neutral orientation and under internal and external tibial torques. Roentgen stereophotogrammetric analysis was used to determine the motion of the meniscus in anteroposterior (AP) and mediolateral (ML) directions. Three fixation conditions were evaluated: (I) intact, (II) detached and (III) resutured.
Results
Detaching and resuturing the circumferential fixation did not alter the meniscal motion pattern in either the AP or ML direction. Applying an additional internal tibial torque caused the medial meniscus to move slightly anteriorly, and an external torque caused a little posterior translation with respect to the neutral situation. These patterns did not change when the circumferential fixation condition was altered.
Conclusions
This study demonstrated that the motion pattern of the medial meniscus is independent of its fixation to the knee capsule and medial collateral ligament.
Clinical relevance
The outcomes of this study can be deployed to design the fixation strategy of a permanent meniscus prosthesis. As peripheral fixation is a complicated step during meniscal replacement, the surgical procedure is considerably simplified when non-resorbable implants do not require circumferential fixation.
30 septiembre 2014
29 septiembre 2014
Rodilla/Knee/Knie/Genou: 30 años después de la PTR
Total Knee Replacement in Young, Active Patients: Long-Term Follow-up and Functional Outcome: A Concise Follow-up of a Previous Report
Long, W. J., Bryce, C. D., Hollenbeak, C. S., Benner, R. W., Scott, W. N.
The Journal of Bone & Joint Surgery, 17 Septiembre 2014 19:30
Abstract:
Concern exists regarding the long-term durability and effectiveness of total knee arthroplasty in young patients.
We reviewed our experience with total knee arthroplasty in patients fifty-five years old and younger with severe osteoarthritis to determine the long-term outcomes. One hundred and fourteen total knee arthroplasties were performed in eighty-eight patients at an average patient age of fifty-one years. Clinical outcomes, survival analysis, and radiographs were all reviewed at the most recent follow-up. One hundred and eight knees (eighty-four patients) were followed up from May 2011 to 2012.
At thirty years, survivorship without revision for any cause was 70.1% (twenty-five revisions) and survivorship with failure defined as aseptic revision of the tibial or femoral components was 82.5%. At thirty years, a significant difference existed in the survivorship free from tibial or femoral aseptic revision (p = 0.003) between the non-modular Insall-Burstein I component (92.3%) and the modular Insall-Burstein II component (68.3%). All patients were evaluated at an average time from the index total knee arthroplasty to the latest follow-up of 25.1 years (range, twenty to thirty-five years). Clinical evaluation was obtained in thirty-six patients with forty-five total knee arthroplasties. The average Hospital for Special Surgery score had improved from 57.9 points preoperatively to 85.3 points. The average Knee Society score was 87.4 points and the average Knee Society functional score was 62.1 points; the average knee motion was 110°. The mean Tegner and Lysholm activity score improved from 1.5 points preoperatively to 3.0 points. Radiographic review of forty-two knees that had undergone total knee arthroplasty demonstrated a mean 3.2° of valgus, with no cases of radiographically loose components.
Total knee arthroplasty with use of a cemented posterior stabilized system, particularly a non-modular Insall-Burstein I design, was an effective treatment option with durable results for end-stage symptomatic osteoarthritis in this young cohort. These data should provide comparison for modern total knee arthroplasties and alternative procedures in young patients.
Level of Evidence:
Therapeutic Level IV
Long, W. J., Bryce, C. D., Hollenbeak, C. S., Benner, R. W., Scott, W. N.
The Journal of Bone & Joint Surgery, 17 Septiembre 2014 19:30
Abstract:
Concern exists regarding the long-term durability and effectiveness of total knee arthroplasty in young patients.
We reviewed our experience with total knee arthroplasty in patients fifty-five years old and younger with severe osteoarthritis to determine the long-term outcomes. One hundred and fourteen total knee arthroplasties were performed in eighty-eight patients at an average patient age of fifty-one years. Clinical outcomes, survival analysis, and radiographs were all reviewed at the most recent follow-up. One hundred and eight knees (eighty-four patients) were followed up from May 2011 to 2012.
At thirty years, survivorship without revision for any cause was 70.1% (twenty-five revisions) and survivorship with failure defined as aseptic revision of the tibial or femoral components was 82.5%. At thirty years, a significant difference existed in the survivorship free from tibial or femoral aseptic revision (p = 0.003) between the non-modular Insall-Burstein I component (92.3%) and the modular Insall-Burstein II component (68.3%). All patients were evaluated at an average time from the index total knee arthroplasty to the latest follow-up of 25.1 years (range, twenty to thirty-five years). Clinical evaluation was obtained in thirty-six patients with forty-five total knee arthroplasties. The average Hospital for Special Surgery score had improved from 57.9 points preoperatively to 85.3 points. The average Knee Society score was 87.4 points and the average Knee Society functional score was 62.1 points; the average knee motion was 110°. The mean Tegner and Lysholm activity score improved from 1.5 points preoperatively to 3.0 points. Radiographic review of forty-two knees that had undergone total knee arthroplasty demonstrated a mean 3.2° of valgus, with no cases of radiographically loose components.
Total knee arthroplasty with use of a cemented posterior stabilized system, particularly a non-modular Insall-Burstein I design, was an effective treatment option with durable results for end-stage symptomatic osteoarthritis in this young cohort. These data should provide comparison for modern total knee arthroplasties and alternative procedures in young patients.
Level of Evidence:
Therapeutic Level IV
Codo/Elbow/Ellbogen/Coude: Epicondilitis para perder los nervios
Epicondylitis and denervation surgery
Rose, Nicholas E.a; Dellon, A. Leeb
Current Orthopaedic Practice:
September/October 2014 - Volume 25 - Issue 5 - p 446-452
Abstract
Lateral and medial epicondylitis are two of the most common musculoskeletal conditions affecting the upper extremity. Yet, their exact etiology and optimal treatment remain controversial. Even the efficacy of traditional nonoperative treatments, such as physical therapy and corticosteroid injections, is disputed, with many studies failing to demonstrate long-term benefits with either modality. Newer treatments, such as extracorporeal shock wave therapy and platelet rich plasma, show promise. However, despite the theoretic advantages of these treatments, clinical results remain mixed. When nonoperative treatments fail, traditional surgery in the form of a medial or lateral release remains the mainstay of treatment. However, recovery times from these open release procedures remain prolonged. Recent clinical trials evaluating medial and lateral elbow denervation surgery show that these less invasive techniques may bring permanent resolution to this difficult problem with less pain and shorter recovery times.
Rose, Nicholas E.a; Dellon, A. Leeb
Current Orthopaedic Practice:
September/October 2014 - Volume 25 - Issue 5 - p 446-452
Abstract
Lateral and medial epicondylitis are two of the most common musculoskeletal conditions affecting the upper extremity. Yet, their exact etiology and optimal treatment remain controversial. Even the efficacy of traditional nonoperative treatments, such as physical therapy and corticosteroid injections, is disputed, with many studies failing to demonstrate long-term benefits with either modality. Newer treatments, such as extracorporeal shock wave therapy and platelet rich plasma, show promise. However, despite the theoretic advantages of these treatments, clinical results remain mixed. When nonoperative treatments fail, traditional surgery in the form of a medial or lateral release remains the mainstay of treatment. However, recovery times from these open release procedures remain prolonged. Recent clinical trials evaluating medial and lateral elbow denervation surgery show that these less invasive techniques may bring permanent resolution to this difficult problem with less pain and shorter recovery times.
28 septiembre 2014
Cadera/Hip/Hüfte/Hanche: Tratar el choque femoroacetabular en pacientes muy jóvenes
Femoroacetabular Impingement in Skeletally Immature Patients: A Systematic Review Examining Indications, Outcomes, and Complications of Open and Arthroscopic Treatment
Author(s): Darren de SA , Stephanie Cargnelli , Michael Catapano , Asheesh Bedi , Nicole Simunovic , Sarah Burrow , Olufemi R. Ayeni
Source:Arthroscopy: The Journal of Arthroscopic & Related Surgery. Publication date: Available online 26 September 2014
Purpose
Improvements in physical examination and radiographic appreciation of symptomatic femoroacetabular impingement (FAI) has increased the focus on early diagnosis and treatment in an adolescent population. This systematic review aimed to establish specific indications, outcomes, and complications of surgical management of adolescent FAI.
Methods
The Medline, Embase, and PubMed online databases were searched from inception until April 21, 2014, for English-language studies that addressed open and/or arthroscopic treatment of FAI in patients aged 10 to 19 years inclusively. The studies were systematically screened and data abstracted in duplicate, with qualitative findings presented.
Results
There were 6 eligible case series (4 with arthroscopic and 2 with open technique) and 2 conference abstracts examining 388 patients in total (435 hips), 81% of which were treated with hip arthroscopy. Overall, patients were followed up for a mean of 23.4 months postoperatively (range, 3 to 75 months). The main indication for surgery was a confirmed diagnosis of FAI with persistent pain and impaired function refractory to nonoperative interventions (activity modification, intra-articular injections, and so on). Specific contraindications included Tönnis grade 2, 3, or 4 chondral changes and acetabular dysplasia. All studies reported significant improvements in patient pain, function (e.g., no patients were “abnormally” or “severely abnormally” impaired), and satisfaction rates (84% to 100% with arthroscopic technique v 79% with open technique). Improvements also were observed in range of motion and alpha angle correction, as well as across a variety of patient-reported functional scores, with all but 7 of 388 patients (1.8%) returning to activity/sport. No major complications were reported, with only 13 of 354 hips (3.7%) treated by arthroscopy requiring revision arthroscopy for lysis of adhesions and 1 of 81 open surgical dislocation hips (1%) having asymptomatic heterotopic ossification not requiring additional management. No cases of avascular necrosis, physeal arrest or growth disturbance, or iatrogenic deformity were reported.
Conclusions
Both arthroscopic and open surgical dislocation approaches for the treatment of adolescent FAI appear to be safe and effective options for patients with persistent pain and limited function after an appropriate trial of nonoperative therapy.
Level of Evidence
Level IV, systematic review of Level IV studies.
Trauma: Más atrás de lo que parece
An anatomical study of the entry point in the greater trochanter for intramedullary nailing
Farhang, K., Desai, R., Wilber, J. H., Cooperman, D. R., Liu, R. W.
Bone Joint J 2014;96-B:1274–81.
Malpositioning of the trochanteric entry point during the introduction of an intramedullary nail may cause iatrogenic fracture or malreduction. Although the optimal point of insertion in the coronal plane has been well described, positioning in the sagittal plane is poorly defined.
The paired femora from 374 cadavers were placed both in the anatomical position and in internal rotation to neutralise femoral anteversion. A marker was placed at the apparent apex of the greater trochanter, and the lateral and anterior offsets from the axis of the femoral shaft were measured on anteroposterior and lateral photographs. Greater trochanteric morphology and trochanteric overhang were graded.
The mean anterior offset of the apex of the trochanter relative to the axis of the femoral shaft was 5.1 mm (sd 4.0) and 4.6 mm (sd 4.2) for the anatomical and neutralised positions, respectively. The mean lateral offset of the apex was 7.1 mm (sd 4.6) and 6.4 mm (sd 4.6), respectively.
Placement of the entry position at the apex of the greater trochanter in the anteroposterior view does not reliably centre an intramedullary nail in the sagittal plane. Based on our findings, the site of insertion should be about 5 mm posterior to the apex of the trochanter to allow for its anterior offset.
Farhang, K., Desai, R., Wilber, J. H., Cooperman, D. R., Liu, R. W.
Bone Joint J 2014;96-B:1274–81.
Malpositioning of the trochanteric entry point during the introduction of an intramedullary nail may cause iatrogenic fracture or malreduction. Although the optimal point of insertion in the coronal plane has been well described, positioning in the sagittal plane is poorly defined.
The paired femora from 374 cadavers were placed both in the anatomical position and in internal rotation to neutralise femoral anteversion. A marker was placed at the apparent apex of the greater trochanter, and the lateral and anterior offsets from the axis of the femoral shaft were measured on anteroposterior and lateral photographs. Greater trochanteric morphology and trochanteric overhang were graded.
The mean anterior offset of the apex of the trochanter relative to the axis of the femoral shaft was 5.1 mm (sd 4.0) and 4.6 mm (sd 4.2) for the anatomical and neutralised positions, respectively. The mean lateral offset of the apex was 7.1 mm (sd 4.6) and 6.4 mm (sd 4.6), respectively.
Placement of the entry position at the apex of the greater trochanter in the anteroposterior view does not reliably centre an intramedullary nail in the sagittal plane. Based on our findings, the site of insertion should be about 5 mm posterior to the apex of the trochanter to allow for its anterior offset.
Ciencia/Science/Wissenshaft: olor a tierra mojada...
Por qué nos gusta tánto el olor a tierra mojada...
http://labitacoradehumboldt.blogspot.com.es/2011/12/olor-tierra-mojada-el-sagrado-aroma-del.html
https://www.flickr.com/photos/73629850@N00/315123483/in/photostream/
http://labitacoradehumboldt.blogspot.com.es/2011/12/olor-tierra-mojada-el-sagrado-aroma-del.html
https://www.flickr.com/photos/73629850@N00/315123483/in/photostream/
Hombro/Shoulder/Schulter/Épaule: En casos dolorosos de pseudoartrosis de húmero proximal, prótesis invertida
Reverse total shoulder replacement for nonunion of a fracture of the proximal humerus
Zafra, M., Uceda, P., Flores, M., Carpintero, P.
Bone Joint J 2014;96-B:1239–43
Patients with pain and loss of shoulder function due to nonunion of a fracture of the proximal third of the humerus may benefit from reverse total shoulder replacement.
This paper reports a prospective, multicentre study, involving three hospitals and three surgeons, of 35 patients (28 women, seven men) with a mean age of 69 years (46 to 83) who underwent a reverse total shoulder replacement for the treatment of nonunion of a fracture of the proximal humerus.
Using Checchia’s classification, nine nonunions were type I, eight as type II, 12 as type III and six as type IV. The mean follow-up was 51 months (24 to 99). Post-operatively, the patients had a significant decrease in pain (p < 0.001), and a significant improvement in flexion, abduction, external rotation and Constant score (p < 0.001), but not in internal rotation. A total of nine complications were recorded in seven patients: six dislocations, one glenoid loosening in a patient who had previously suffered dislocation, one transitory paresis of the axillary nerve and one infection.
Reverse total shoulder replacement may lead to a significant reduction in pain, improvement in function and a high degree of satisfaction. However, the rate of complications, particularly dislocation, was high.
Zafra, M., Uceda, P., Flores, M., Carpintero, P.
Bone Joint J 2014;96-B:1239–43
Patients with pain and loss of shoulder function due to nonunion of a fracture of the proximal third of the humerus may benefit from reverse total shoulder replacement.
This paper reports a prospective, multicentre study, involving three hospitals and three surgeons, of 35 patients (28 women, seven men) with a mean age of 69 years (46 to 83) who underwent a reverse total shoulder replacement for the treatment of nonunion of a fracture of the proximal humerus.
Using Checchia’s classification, nine nonunions were type I, eight as type II, 12 as type III and six as type IV. The mean follow-up was 51 months (24 to 99). Post-operatively, the patients had a significant decrease in pain (p < 0.001), and a significant improvement in flexion, abduction, external rotation and Constant score (p < 0.001), but not in internal rotation. A total of nine complications were recorded in seven patients: six dislocations, one glenoid loosening in a patient who had previously suffered dislocation, one transitory paresis of the axillary nerve and one infection.
Reverse total shoulder replacement may lead to a significant reduction in pain, improvement in function and a high degree of satisfaction. However, the rate of complications, particularly dislocation, was high.
24 septiembre 2014
Rodilla/Knee/Knie/Genou: Cuando la rótula no encaja... hay remedios
Medial patellofemoral ligament reconstruction for patellar maltracking following total knee arthroplasty is effective
Stijn van Gennip, Janneke J P Schimmel, Gijs G van Hellemondt, Koen C Defoort, Ate B Wymenga
Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA 2014, 22 (10): 2569-73
PURPOSE: Maltracking of the patella after total knee arthroplasty (TKA) remains a well-recognized problem. The medial patellofemoral ligament (MPFL) has shown to be important for patellar stabilization and reconstructions of the MPFL have already shown excellent functional outcomes for patellar instability of the native knee. Nevertheless, there is only limited literature on using an MPFL reconstruction for correction of patellar maltracking after TKA. In this retrospective study, a consecutive case series was evaluated.
METHODS: Between 2007 and 2010, nine patients (nine knees) with anterior knee pain and symptomatic (sub)luxations of the patella after primary or revision TKA were treated by reconstruction of the MPFL in combination with a lateral release. In two cases, an additional tibial tuberosity transfer was performed, due to insufficient per-operative correction. Pre-operative work-up included a CT scan to rule out component malrotation and disorders in limb alignment. Pre- and post-operative patellar displacement and lateral patellar tilt were measured on axial radiographs. Clinical outcome was evaluated using the visual analogue scale (VAS) satisfaction, VAS pain, dislocation rate and Bartlett patella score.
RESULTS: Median patellar displacement improved from 29 mm (0-44) to 0 mm (0-9) post-operatively. Median lateral patellar tilt was 45° (23-62) pre-operative and changed to a median 15° (-3 to 21) post-operative. Median VAS satisfaction was 8 (5-9) and only one patient reported a subluxing feeling afterwards. The Bartlett patella score displayed a diverse picture.
CONCLUSIONS: Patellar maltracking after primary or revision TKA without malrotation can effectively be treated by MPFL reconstruction in combination with a lateral release. Only in limited cases, an additional tibial tuberosity transfer is needed.
LEVEL OF EVIDENCE: IV.
Stijn van Gennip, Janneke J P Schimmel, Gijs G van Hellemondt, Koen C Defoort, Ate B Wymenga
Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA 2014, 22 (10): 2569-73
PURPOSE: Maltracking of the patella after total knee arthroplasty (TKA) remains a well-recognized problem. The medial patellofemoral ligament (MPFL) has shown to be important for patellar stabilization and reconstructions of the MPFL have already shown excellent functional outcomes for patellar instability of the native knee. Nevertheless, there is only limited literature on using an MPFL reconstruction for correction of patellar maltracking after TKA. In this retrospective study, a consecutive case series was evaluated.
METHODS: Between 2007 and 2010, nine patients (nine knees) with anterior knee pain and symptomatic (sub)luxations of the patella after primary or revision TKA were treated by reconstruction of the MPFL in combination with a lateral release. In two cases, an additional tibial tuberosity transfer was performed, due to insufficient per-operative correction. Pre-operative work-up included a CT scan to rule out component malrotation and disorders in limb alignment. Pre- and post-operative patellar displacement and lateral patellar tilt were measured on axial radiographs. Clinical outcome was evaluated using the visual analogue scale (VAS) satisfaction, VAS pain, dislocation rate and Bartlett patella score.
RESULTS: Median patellar displacement improved from 29 mm (0-44) to 0 mm (0-9) post-operatively. Median lateral patellar tilt was 45° (23-62) pre-operative and changed to a median 15° (-3 to 21) post-operative. Median VAS satisfaction was 8 (5-9) and only one patient reported a subluxing feeling afterwards. The Bartlett patella score displayed a diverse picture.
CONCLUSIONS: Patellar maltracking after primary or revision TKA without malrotation can effectively be treated by MPFL reconstruction in combination with a lateral release. Only in limited cases, an additional tibial tuberosity transfer is needed.
LEVEL OF EVIDENCE: IV.
23 septiembre 2014
Hombro/Shoulder/Schulter/Épaule: Reparar o no reparar el manguito rotador, he ahí el dilema
Tendon Repair Compared with Physiotherapy in the Treatment of Rotator Cuff Tears: A Randomized Controlled Study in 103 Cases with a Five-Year Follow-up
Stefan Moosmayer, Gerty Lund, Unni S Seljom, Benjamin Haldorsen, Ida C Svege, Toril Hennig, Are H Pripp, Hans-Jørgen Smith
Journal of Bone and Joint Surgery. American Volume 2014 September 17, 96 (18): 1504-14
BACKGROUND: There is limited Level-I evidence that compares operative and nonoperative treatment of rotator cuff tears. We compared outcomes of patients treated with primary tendon repair with outcomes of those treated with physiotherapy and optional secondary tendon repair if needed.
METHODS: A single-center, pragmatic, randomized controlled study with follow-ups after six months and one, two, and five years was conducted in a secondary-care institution. One hundred and three patients with a rotator cuff tear not exceeding 3 cm were randomized to primary tendon repair (n = 52) or physiotherapy (n = 51). The primary outcome measure was the Constant score. Secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score; the physical component summary measure of the Short Form 36 Health Survey; the measurement of pain, strength, and shoulder motion; patient satisfaction; and findings from magnetic resonance imaging and sonography. Analysis was by intention to treat.
RESULTS: The five-year follow-up rate was 98%. Twelve of the fifty-one patients in the physiotherapy group were treated with secondary tendon repair. The results from primary tendon repair were superior to those from physiotherapy plus secondary repair, with between-group mean differences of 5.3 points on the Constant score (p = 0.05), 9.0 points on the American Shoulder and Elbow Surgeons score (p < 0.001), 1.1 cm on a 10-cm visual analog scale for pain (p < 0.001), and 1.0 cm on a 10-cm visual analog scale for patient satisfaction (p = 0.03). In 37% of tears treated with physiotherapy only, there were increasing tear sizes on ultrasound of >5 mm, over five years, associated with an inferior outcome.
CONCLUSIONS: Although primary repair of small and medium-sized rotator cuff tears was associated with better outcome than physiotherapy treatment, the differences were small and may be below clinical importance. In the physiotherapy treatment group, there were increasing tear sizes and inferior outcomes in one-third of patients who did not undergo repair.
LEVEL OF EVIDENCE: Therapeutic Level I.
Stefan Moosmayer, Gerty Lund, Unni S Seljom, Benjamin Haldorsen, Ida C Svege, Toril Hennig, Are H Pripp, Hans-Jørgen Smith
Journal of Bone and Joint Surgery. American Volume 2014 September 17, 96 (18): 1504-14
BACKGROUND: There is limited Level-I evidence that compares operative and nonoperative treatment of rotator cuff tears. We compared outcomes of patients treated with primary tendon repair with outcomes of those treated with physiotherapy and optional secondary tendon repair if needed.
METHODS: A single-center, pragmatic, randomized controlled study with follow-ups after six months and one, two, and five years was conducted in a secondary-care institution. One hundred and three patients with a rotator cuff tear not exceeding 3 cm were randomized to primary tendon repair (n = 52) or physiotherapy (n = 51). The primary outcome measure was the Constant score. Secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score; the physical component summary measure of the Short Form 36 Health Survey; the measurement of pain, strength, and shoulder motion; patient satisfaction; and findings from magnetic resonance imaging and sonography. Analysis was by intention to treat.
RESULTS: The five-year follow-up rate was 98%. Twelve of the fifty-one patients in the physiotherapy group were treated with secondary tendon repair. The results from primary tendon repair were superior to those from physiotherapy plus secondary repair, with between-group mean differences of 5.3 points on the Constant score (p = 0.05), 9.0 points on the American Shoulder and Elbow Surgeons score (p < 0.001), 1.1 cm on a 10-cm visual analog scale for pain (p < 0.001), and 1.0 cm on a 10-cm visual analog scale for patient satisfaction (p = 0.03). In 37% of tears treated with physiotherapy only, there were increasing tear sizes on ultrasound of >5 mm, over five years, associated with an inferior outcome.
CONCLUSIONS: Although primary repair of small and medium-sized rotator cuff tears was associated with better outcome than physiotherapy treatment, the differences were small and may be below clinical importance. In the physiotherapy treatment group, there were increasing tear sizes and inferior outcomes in one-third of patients who did not undergo repair.
LEVEL OF EVIDENCE: Therapeutic Level I.
Tobillo/Ankle/Knöchel/Cheville: Parece magia, pero operando un Aquiles se cura el otro
Unilateral surgical treatment for patients with midportion Achilles tendinopathy may result in bilateral recovery
Håkan Alfredson, Christoph Spang, Sture Forsgren
British Journal of Sports Medicine 2014, 48 (19): 1421-4
BACKGROUND: Bilateral midportion Achilles tendinopathy/tendinosis is not unusual, and treatment of both sides is often carried out. Experiments in animals suggest of the potential involvement of central neuronal mechanisms in Achilles tendinosis.
OBJECTIVES: To evaluate the outcome of surgery for Achilles tendinopathy.
METHODS: This observational study included 13 patients (7 men and 6 women, mean age 53 years) with a long duration (6-120 months) of chronic painful bilateral midportion Achilles tendinopathy. The most painful side at the time for investigation was selected to be operated on first. Treatment was ultrasound-guided and Doppler-guided scraping procedure outside the ventral part of the tendon under local anaesthetic. The patients started walking on the first day after surgery. Follow-ups were conducted and the primary outcome was pain by visual analogue scale. In an additional part of the study, specimens from Achilles and plantaris tendons in three patients with bilateral Achilles tendinosis were examined.
RESULTS: Short-term follow-ups showed postoperative improvement on the non-operated side as well as the operated side in 11 of 13 patients. Final follow-up after 37 (mean) months showed significant pain relief and patient satisfaction on both sides for these 11 patients. In 2 of 13 patients operation on the other, initially non-operated side, was instituted due to persisting pain. Morphologically, it was found that there were similar morphological effects, and immunohistochemical patterns of enzyme involved in signal substance production, bilaterally.
CONCLUSION: Unilateral treatment with a scraping operation can have benefits contralaterally; the clinical implication is that unilateral surgery may be a logical first treatment in cases of bilateral Achilles tendinopathy.
Håkan Alfredson, Christoph Spang, Sture Forsgren
British Journal of Sports Medicine 2014, 48 (19): 1421-4
BACKGROUND: Bilateral midportion Achilles tendinopathy/tendinosis is not unusual, and treatment of both sides is often carried out. Experiments in animals suggest of the potential involvement of central neuronal mechanisms in Achilles tendinosis.
OBJECTIVES: To evaluate the outcome of surgery for Achilles tendinopathy.
METHODS: This observational study included 13 patients (7 men and 6 women, mean age 53 years) with a long duration (6-120 months) of chronic painful bilateral midportion Achilles tendinopathy. The most painful side at the time for investigation was selected to be operated on first. Treatment was ultrasound-guided and Doppler-guided scraping procedure outside the ventral part of the tendon under local anaesthetic. The patients started walking on the first day after surgery. Follow-ups were conducted and the primary outcome was pain by visual analogue scale. In an additional part of the study, specimens from Achilles and plantaris tendons in three patients with bilateral Achilles tendinosis were examined.
RESULTS: Short-term follow-ups showed postoperative improvement on the non-operated side as well as the operated side in 11 of 13 patients. Final follow-up after 37 (mean) months showed significant pain relief and patient satisfaction on both sides for these 11 patients. In 2 of 13 patients operation on the other, initially non-operated side, was instituted due to persisting pain. Morphologically, it was found that there were similar morphological effects, and immunohistochemical patterns of enzyme involved in signal substance production, bilaterally.
CONCLUSION: Unilateral treatment with a scraping operation can have benefits contralaterally; the clinical implication is that unilateral surgery may be a logical first treatment in cases of bilateral Achilles tendinopathy.
22 septiembre 2014
Rodilla/Knee/Knie/Genou: No sirven las plantillas para la gonartrosis medial
Lateral wedge insoles as a conservative treatment for pain in patients with medial knee osteoarthritis: a meta-analysis
Matthew J Parkes, Nasimah Maricar, Mark Lunt, Michael P LaValley, Richard K Jones, Neil A Segal, Kayoko Takahashi-Narita, David T Felson
JAMA: the Journal of the American Medical Association 2013 August 21, 310 (7): 722-30
IMPORTANCE:
There is no consensus regarding the efficacy of lateral wedge insoles as a treatment for pain in medial knee osteoarthritis.
OBJECTIVE:
To evaluate whether lateral wedge insoles reduce pain in patients with medial knee osteoarthritis compared with an appropriate control.
DATA SOURCES:
Databases searched include the Cochrane Central Register of Controlled Trials, EMBASE, AMED, MEDLINE, CINAHL Plus, ScienceDirect, SCOPUS, Web of Science, and BIOSIS from inception to May 2013, with no limits on study date or language. The metaRegister of Controlled Trials and the NHS Evidence website were also searched.
STUDY SELECTION:
Included were randomized trials comparing shoe-based treatments (lateral heel wedge insoles or shoes with variable stiffness soles) aimed at reducing medial knee load, with a neutral or no wedge control condition in patients with painful medial knee osteoarthritis. Studies must have included patient-reported pain as an outcome.
DATA EXTRACTION AND SYNTHESIS:
Trial data were extracted independently by 2 researchers using a standardized form. Risk of bias was assessed using the Cochrane Risk of Bias tool by 2 observers. Eligible studies were pooled using a random-effects approach.
MAIN OUTCOME AND MEASURES:
Change in self-reported knee pain at follow-up.
RESULTS:
Twelve trials met inclusion criteria with a total of 885 participants of whom 502 received lateral wedge treatment. The pooled standardized mean difference (SMD) suggested a favorable association with lateral wedges compared with control (SMD, -0.47; 95% CI, -0.80 to -0.14); however, substantial heterogeneity was present (I2 = 82.7%). This effect size represents an effect of -2.12 points on the 20-point Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scale. Larger trials with a lower risk of bias suggested a null association. Meta-regression analyses showed that higher effect sizes (unstandardized β, 1.07 [95% CI, 0.28 to 1.87] for trials using a no treatment control) were seen in trials using a no wedge treatment control group (n = 4 trials; SMD, -1.20 [95% CI, -2.09 to -0.30]) and lower effect sizes (unstandardized β, 0.26 [95% CI, 0.002 to 0.52] for each bias category deemed low risk) when the study method was deemed at low risk of bias. Among trials in which the control treatment was a neutral insole (n = 7), lateral wedges showed no association (SMD, -0.03 [95% CI, -0.18 to 0.12] on WOMAC; this represents an effect of -0.12 points), and results showed little heterogeneity (I2 = 7.1%).
CONCLUSIONS AND RELEVANCE: Although meta-analytic pooling of all studies showed a statistically significant association between use of lateral wedges and lower pain in medial knee osteoarthritis, restriction of studies to those using a neutral insole comparator did not show a significant or clinically important association. These findings do not support the use of lateral wedges for this indication.
Matthew J Parkes, Nasimah Maricar, Mark Lunt, Michael P LaValley, Richard K Jones, Neil A Segal, Kayoko Takahashi-Narita, David T Felson
JAMA: the Journal of the American Medical Association 2013 August 21, 310 (7): 722-30
IMPORTANCE:
There is no consensus regarding the efficacy of lateral wedge insoles as a treatment for pain in medial knee osteoarthritis.
OBJECTIVE:
To evaluate whether lateral wedge insoles reduce pain in patients with medial knee osteoarthritis compared with an appropriate control.
DATA SOURCES:
Databases searched include the Cochrane Central Register of Controlled Trials, EMBASE, AMED, MEDLINE, CINAHL Plus, ScienceDirect, SCOPUS, Web of Science, and BIOSIS from inception to May 2013, with no limits on study date or language. The metaRegister of Controlled Trials and the NHS Evidence website were also searched.
STUDY SELECTION:
Included were randomized trials comparing shoe-based treatments (lateral heel wedge insoles or shoes with variable stiffness soles) aimed at reducing medial knee load, with a neutral or no wedge control condition in patients with painful medial knee osteoarthritis. Studies must have included patient-reported pain as an outcome.
DATA EXTRACTION AND SYNTHESIS:
Trial data were extracted independently by 2 researchers using a standardized form. Risk of bias was assessed using the Cochrane Risk of Bias tool by 2 observers. Eligible studies were pooled using a random-effects approach.
MAIN OUTCOME AND MEASURES:
Change in self-reported knee pain at follow-up.
RESULTS:
Twelve trials met inclusion criteria with a total of 885 participants of whom 502 received lateral wedge treatment. The pooled standardized mean difference (SMD) suggested a favorable association with lateral wedges compared with control (SMD, -0.47; 95% CI, -0.80 to -0.14); however, substantial heterogeneity was present (I2 = 82.7%). This effect size represents an effect of -2.12 points on the 20-point Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scale. Larger trials with a lower risk of bias suggested a null association. Meta-regression analyses showed that higher effect sizes (unstandardized β, 1.07 [95% CI, 0.28 to 1.87] for trials using a no treatment control) were seen in trials using a no wedge treatment control group (n = 4 trials; SMD, -1.20 [95% CI, -2.09 to -0.30]) and lower effect sizes (unstandardized β, 0.26 [95% CI, 0.002 to 0.52] for each bias category deemed low risk) when the study method was deemed at low risk of bias. Among trials in which the control treatment was a neutral insole (n = 7), lateral wedges showed no association (SMD, -0.03 [95% CI, -0.18 to 0.12] on WOMAC; this represents an effect of -0.12 points), and results showed little heterogeneity (I2 = 7.1%).
CONCLUSIONS AND RELEVANCE: Although meta-analytic pooling of all studies showed a statistically significant association between use of lateral wedges and lower pain in medial knee osteoarthritis, restriction of studies to those using a neutral insole comparator did not show a significant or clinically important association. These findings do not support the use of lateral wedges for this indication.
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