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Purpose:To review the anatomy of the shoulder joint and of the physiology of glenohumeral stability is essential to manage correctly shoulder instability.Methods:It was reviewed a large number of recently published research studies related to the shoulder instability that received a higher Level of Evidence grade.Results:It is reviewed the bony anatomy, the anatomy and function of the ligaments that act on this joint, the physiology and physiopathology of glenohumeral instability and the therapeutic implications of the injured structures.Conclusion:This knowledge allows the surgeon to evaluate the possible causes of instability, to assess which are the structures that must be reconstructed and to decide which surgical technique must be performed.

To evaluate the risk of injury to the inferior lateral geniculate artery with two different techniques for lateral meniscus repair.Eight cadaveric knees were used. Inside-out sutures and an all-inside suture device were placed at the most lateral edge of the popliteal hiatus, and 15 and 30 mm anterior to this point. The minimum distances between the sutures and the inferior lateral geniculate artery were measured through a limited lateral arthrotomy. Artery penetration or collapse due to the sutures was also evaluated.The median distance between the sutures and the artery when inserted at the lateral edge of the popliteal hiatus was 1.5 mm (interquartile range: 1.3) for the inside-out technique and 1.5 mm (1.3) for the all-inside technique (differences not significant, n.s.). When the sutures were inserted 15 mm anterior to the popliteal hiatus the distances were 1.0 mm (1.1) and 1.3 mm (1.0) for the inside-out technique and the all-inside technique, respectively (n.s.). When the sutures were inserted 30 mm anterior to the popliteal hiatus the distances were 1.0 mm (1.0) and 1.5 mm (1.0) for the inside-out technique and the all-inside technique, respectively (n.s.). The artery was punctured with two of the inside-out sutures placed 15 mm from the popliteal hiatus, no puncturing occurred in the all-inside technique (n.s.). Tying of the inside-out sutures resulted in obliteration of the artery in four of eight sutures placed at 15 mm from the popliteal hiatus and three of eight sutures at 30 mm; no obliteration of the artery was found using the all-inside device (significant differences, p = 0.002).Although both all-inside and inside-out lateral meniscal repair techniques place sutures very close to the lateral geniculate artery, the inside-out technique is riskier as extra-articular knot tying can cause artery obliteration when suturing the part of the meniscus immediately lateral to the popliteal hiatus. Therefore, all-inside meniscal repair technique shows less risk of injury to the major blood supply of the lateral meniscus.

ResumenObjetivoValorar los resultados funcionales de la artrólisis artroscópica de hombro para el tratamiento de la rigidez postraumática de hombro secundaria a fracturas de extremo proximal del húmero tratadas conservadoramente.Material y métodoEstudio retrospectivo de 9 pacientes que presentaban rigidez de hombro tras sufrir una fractura de húmero proximal pese a haber realizado al menos seis meses de tratamiento rehabilitador sin respuesta satisfactoria. En todos ellos se realizó una artrólisis artroscópica de hombro abordando tanto el espacio subacromiodeltoideo como el glenohumeral. Se evaluó el rango de movilidad pasivo, el nivel de dolor con una escala numérica simple de 0 a 10 y la función con el test de Constant antes de la artrólisis y al finalizar el seguimiento.ResultadosTras un seguimiento de 12 meses (desviación estándar: 1,5) los valores en el test de Constant pasaron de 37,6 (19,9) a 74,1 (12,8) (diferencias significativas, p=0,004). El rango de movilidad del hombro aumentó de forma significativa en su conjunto: de 213° (84,1°) a 377 (53,6)° (p

Resumen Objetivo Analizar los factores prequirurgicos que pueden tener efecto sobre los niveles de dolor posquirurgico en pacientes que van a ser sometidos a una artroplastia de cadera (ATC) o rodilla (ATR). Metodos Revision sistematica de la literatura. Se definio una estrategia de busqueda sensible en Medline, Embase y Cochrane Library hasta mayo de 2013; se definio la poblacion con los siguientes criterios: pacientes adultos con indicacion de ATC o ATR y en los que se identificasen factores predictores prequirurgicos de dolor posquirurgico. Se incluyeron revisiones sistematicas, metaanalisis, ensayos clinicos y estudios observacionales. Se excluyeron estudios en animales, ciencia basica, estudios sobre revisiones de protesis, protesis por fracturas, pacientes que tenian una enfermedad inflamatoria articular de base (artritis reumatoide, lupus, etc.) o estudios con poblacion mixta donde fue imposible desagregar datos. Resultados Se seleccionaron 37 articulos de calidad moderada. Incluian pacientes representativos de aquellos a los que se les indica una ATC o ATR en nuestro pais, la gran mayoria tenian artrosis de rodilla y/o cadera y mas de 60 anos, muchos obesos y con comorbilidades. Existe una gran variabilidad en el tipo de estudios y factores estudiados. Se encontro una fuerte y consistente asociacion con mayor dolor posquirurgico de los siguientes factores prequirurgicos: el sexo femenino, el bajo nivel socioeconomico, un mayor nivel de dolor preoperatorio, la presencia de comorbilidades o dolor lumbar, un peor estado funcional preoperatorio, la presencia de factores psicologicos (depresion, ansiedad o catastrofismo). Conclusiones Existen factores prequirurgicos que pueden influir en la presencia de dolor posquirurgico en pacientes sometidos a ATC y/o ATR que deben tenerse en cuenta en el momento de la indicacion y hasta que se realiza la misma.

The author claims that his name is incorrectly listed on PubMed. The first name should be Jorge and the last name should be Diaz Heredia. On SpringerLink the name is listed correctly, but on PubMed he is listed as Heredia JD.

ResumenObjetivoAnalizar la evolución temporal que ha tenido el empleo de la artroscopia de cadera como técnica para el tratamiento de patología de cadera.MétodoAnálisis retrospectivo de los datos (edad, sexo, diagnóstico, año de intervención, técnica quirúrgica realizada y reintervenciones) de la base de datos del sistema de salud pública vasca (Osakidetza) y de los registros de intervenciones de 2 centros privados entre los años 2008 y 2013.ResultadosEn esos 6 años se realizaron 542 artroscopias de cadera (530 procedimientos primarios y 12 reintervenciones). Se produjo un incremento del número de intervenciones: de 15 (2,77%) en 2008 a 149 (27,5%) en 2013 (diferencias estadísticamente significativas, p

ResumenLa situación anatómica de la articulación acromioclavicular nos permite realizar una evaluación mediante la observación y la palpación más sencilla que en la articulación glenohumeral. Sin embargo, el dolor proveniente de la misma puede irradiar a diferentes zonas del hombro, del brazo y del cuello y solaparse con otras afecciones. Por ello, es importante conocer las diferentes maniobras exploratorias, así como estar familiarizado con la interpretación de las pruebas de imagen.En este artículo se revisan de forma sistemática los test más utilizados en la exploración de la articulación acromioclavicular, valorando sensibilidad, especificidad y valores predictivos, así como la forma correcta de realizarlos. Además, se analizan las peculiaridades radiológicas de dicha articulación y las utilidades de las diferentes proyecciones y técnicas en el diagnóstico de enfermedad acromioclavicular.AbstractThe subcutaneous location of the acromioclavicular joint allows the clinician to evaluate deformities directly and palpate the joint. This is more complicated in the glenohumeral joint. However, pain arising from the joint can irradiate to different areas of the shoulder, arm and neck, and can be misleading. Thus, it is important to be familiar with the spectrum of physical examination tests, specific radiological projections and MRI findings in order to reach an accurate diagnosis.The aim of this article is to systematically describe the most commonly used physical examination tests for acromioclavicular pathology, including sensitivity, specificity, and predictive values for all of them. Secondly, to analyse the radiological particularities of this joint and to establish the usefulness of the specific projections and imaging techniques.

Long-bone segmental defects caused by infection, fracture, or tumour are a challenge for orthopaedic surgeons. Structural allografts are sometimes used in their treatment but their poor biological characteristics are a liability. The objective of this study was to determine whether the addition of recombinant vascular endothelial growth factor-A (VEGF) to a structural allograft improved its integration into a rabbit tibial segmental defect in a non-union model. Tibial segmental defects were filled with heat sterilized allogenic tubular tibiae sections and then stabilized with a screw plate. In the VEGF treatment group (n = 6 tibiae), 2 μg of VEGF added to a 50 μl matrigel solution was inserted into the allograft cavity. In the control group (n = 6 tibiae), only matrigel was added. After 12 weeks, macroscopic and microscopic analysis, radiographs, and computerized micro-tomography (micro-CT) were performed. If allograft consolidation was present, a torsional resistance analysis was performed. Addition of VEGF to the allograft decreased the rate of osteosynthesis failure compared with the control group (1/6 vs. 5/6, p = 0.08), increased trabecular continuity evaluated by micro-CT in the bone–allograft interphases (8/12 vs. 2/12, p = 0.036) and histological trabecular continuity (7/12 vs. 0/12, p = 0.0046). Full consolidation was observed in three tibiae of the VEGF group and one in the control group (differences not significant); however, torsional resistance showed no significant differences (n.s.). Addition of VEGF to a structural allograph inserted into a rabbit tibial segmental defect increased allograft integration rate. Further research in this direction might help clinicians in dealing with large bone defects.

A 42-year-old athletic woman attended our clinic complaining of right groin pain. The pain had begun 2 years previously when jogging. The pain had gradually become worse, limiting her daily activities and any sporting activities. Clinical examination showed a positive impingement test and limitation of internal rotation of up to 20o at 90o of hip flexion. Plain radiogrpahs showed a normal alpha angle, and a 12 × 14 mm “os acetabuli” was present at the superolateral acetabular rim (Figure 1). The joint was mildly dysplastic with a center-edge angle (CEA) (excluding the “os acetabuli”) of 15o (25o in the contralateral hip). The Tonnis angle was 24o. Differential diagnoses were an “os acetabuli” in a dysplastic hip, chronic avulsion fracture of de anteroinferior iliac spine (Larson et al. 2011), stress fracture (Martinez et al. 2006), or enchondroma-like lesion. The CT described the presence of an “os acetabuli” beside the joint surface with an intact anteroinferior iliac spine (Figure 2). Figure 1. Plain AP (A) and lateral view (B) showing a normal alpha angle. A 12 × 14 mm calcified irregular-shaped image was seen at the superolateral acetabular rim. Excluding the “os acetabuli”, the center-edge angle was 15o (25o ... Figure 2. Sagittal plane CT scan image optimized for bone density, showing the “os acetabuli” (arrow). The patient’s pain persisted, and we made a hip arthroscopy. She was placed supine on the traction table. Due to the shape, size, and location of the lesion, access to the central compartment was difficult and an “outside-in” technique with a T-shaped capsulotomy was performed (Horisberger et al. 2010, Cuellar et al. 2013). Dynamic intraoperative assessment showed impingement between the “os acetabuli” and the superior labrum, which was slightly frayed and detached from the acetabulum (Figure 3). The bony lesion was dissected and resected, keeping the underlying labrum intact. The labrum was reinserted with three 2.3-mm Bioraptor bone anchors (Smith and Nephew). The capsule was then repaired with interrupted Ultrabride sutures, with 2 side-to-side sutures. No femoral osteochondroplasty was performed. Figure 3. View of the peripheral compartment from the anteromedial portal with a 30o scope. The close relation between the detached labrum (L) and the “os acetabuli” (O) can be seen. F: femoral head. After surgery, the patient was instructed not to bear weight for 4 weeks and then to resume partial weight bearing for another 4 weeks. Hyperextension was restricted for the first 3 months, to protect capsular healing. At 4-month follow-up, the patient was walking unaided and was free from pain; she had a full range of motion and radiographs confirmed the complete resection of the “os acetabuli”—but a slight joint narrowing was detected. At 6-month follow-up, she had again developed groin pain. At 10 months, radiographs showed a Tonnis-III degenerative stage (Figure 4). A total hip replacement was required at 12 months. During the joint replacement, we found osteoarthritis and a reduction of femoral head coverage. Figure 4. A. At 4-month follow-up, complete resection of the “os acetabuli” and a slight narrowing of the joint space. B. At 10-month follow-up anterosuperior subluxation and clear degenerative joint disease with sclerotic joint line and subchondral ...

Pectoralis major transfer is indicated for irreparable subscapularis tendon tears. One surgical option is transferring the sternal part of the pectoralis major to the humeral insertion of the subscapularis under the conjoined tendon of the coracobrachialis and biceps muscles. The purpose of this study is to define the anatomical relationship between the transferred tendon and the musculocutaneous nerve. In 52 cadaveric fresh-frozen shoulders, the relevant structures were dissected and a pectoralis major transfer was performed. The relationship between the transferred tendon, the musculocutaneous nerve branches distally and the coracoid process proximally was examined. Measurements were taken at the conjoined tendon level. The distance between the coracoid process and the most proximal musculocutaneous nerve branch was 54.2 ± 33.2 mm. In 25 cases (48 %), the transferred tendon passed freely between both structures. In 16 cases (31 %), there was contact distally with the musculocutaneous nerve. In 11 cases (21 %), there was contact both proximally with the coracoid process and distally with the musculocutaneous nerve, making a safe transfer impossible. When performing a pectoralis major transfer, it is essential to identify the musculocutaneous nerve and its branches. In some cases, a subcoracobicipital transfer may not be feasible and a more superficial transfer should be considered.

Background and Objective: Hip and knee osteoarthritis is highly prevalent in the elderly, and the incidence is estimated to increase in the coming decades. Prior to surgery, symptomatic treatment, starting with non-pharmacological therapies, should be prescribed. Paracetamol (acetaminophen) is the recommended first pharmacological treatment for osteoarthritis. If paracetamol is ineffective, non-steroidal anti-inflammatory drug (NSAID) treatment is indicated. The superiority of NSAIDs over paracetamol has been demonstrated in several studies. Furthermore, the assessment of patient satisfaction could be an adequate indicator of the quality of care given and is likely related to the evolution of the condition and the therapeutic regimen. The objective of this study was to assess the satisfaction of patients diagnosed with hip and/or knee osteoarthritis who had been previously treated with paracetamol and switched to NSAID treatment due to a lack of effectiveness by paracetamol. Methods: An observational, prospective, multicentre and comparative study was conducted in 2009 among patients diagnosed with hip and knee OA who visited outpatient orthopaedic clinics. The evaluation of treatment effectiveness was carried out using a patient-based visual analogue scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The satisfaction regarding change of treatment due to a lack of effectiveness and/or the presence of adverse effects was evaluated using the osteoARthritis Treatment Satisfaction (ARTS) questionnaire. Results: A total of 2437 patients were evaluated (knee OA: 1438 [59%]; hip OA: 621 [25.5%]; knee and hip OA: 124 [5.1%]; and without OA location registered: 254 [10.4%]). The study findings showed an increase in patient satisfaction after abandoning the use of paracetamol to treat OA. Statistically significant increases in both overall satisfaction mean (from 57.7 [SD 13.5] to 71.3 [SD 12.0]) and in each of the four domains of the ARTS questionnaire were observed (p < 0.0001 in all cases). According to the WOMAC and a VAS, treatment effectiveness increased significantly after 3 months (p < 0.0001) and significant correlations with satisfaction were observed (r = −0.32 and r = −0.29, respectively; p < 0.0001). The mean (SD) change in global satisfaction in patients treated with NSAIDs was 14.9 (15.5) versus 7.2 (14.4) for patients treated with non-NSAIDs (p < 0.0001). Patients taking NSAID treatment showed substantially more improvement over those taking non-NSAID treatment. Conclusion: NSAIDs relieve pain due to O A in paracetamol-resistant patients and improve treatment effectiveness and patient satisfaction with treatment. Furthermore, paracetamol-refractory subjects under conventional medical treatment with NSAIDs experienced the drug as more effective and also tended to be more satisfied with treatment than those treated with non-NSAIDs.

Autologous matrix-induced chondrogenesis (AMIC) is often used for treating chondral defects in different joints. We describe an all-arthroscopic approach for the treatment of glenoid and humeral chondral lesions with this technique. AMIC starts with the use of microfractures of the damaged cartilage, followed by coverage of the defect with a type I/III collagen matrix (Chondro-Gide; Geistlich Pharma, Wolhusen, Switzerland) that is fixed with fibrin glue (Tissucol; Baxter, Warsaw, Poland). In a 1-step approach, the unstable cartilage is debrided, microfractures that penetrate up to the subchondral bone are performed, and the membranes are pasted to the lesion. Our technique reduces morbidity rates compared with traditional open surgery. The arthroscopic AMIC procedure is a viable, cost-effective treatment for the repair of chondral lesions of the shoulder.

To evaluate the risk of injuring the axillary nerve during an inferior glenohumeral ligament (IGHL) plication and finding out whether shoulder position (either beach chair position or lateral decubitus position) has any effect in this risk. The axillary nerve (AN) was identified through a 3-cm posterior incision in 12 cadaveric shoulders. Under arthroscopic visualization, a curved indirect suture-passing device was placed through the posterior and anterior bands of the IGHL. The distances between the device and the AN were measured with the shoulder specimen placed at simulated lateral decubitus position and beach chair position. There were no cases of nerve injury nor the suture-passing device came closer than 10 mm to the nerve. There was an increase in the injury risk to the AN when inserting the device at the posterior band of the IGHL in the beach chair position [median 13 mm (range 10–21 mm)] compared to the risk in the lateral decubitus position [22.5 mm (20–26 mm), significant differences, p

Background:Tibial plateau fractures are frequently associated with meniscal tears. Little is known about the results of meniscal repair in this group of patients.Purpose:To determine the results of repair of meniscal tears found during arthroscopically assisted reduction and internal fixation (ARIF) of tibial plateau fractures.Study Design:Case series; Level of evidence, 4.Methods:In a cohort of 51 tibial plateau fractures treated with ARIF, 15 associated meniscal tears (15 knees) in 14 patients were repaired. There were 12 peripheral longitudinal tears of the lateral meniscus, 1 longitudinal peripheral tear of the medial meniscus, 1 full-thickness radial tear of the lateral meniscus, and 1 bird-beak tear of the lateral meniscus. Repairs were performed using an outside-in technique for the anterior horn and all-inside repair for the body and posterior horn lesions. Mean (SD) age at operation was 47.3 (14.0) years. Patients were followed for a mean (SD) of 4.83 (1.01) years and evaluated using the Rasmussen, Honkonen, Lysholm, Tegner, and International Knee Documentation Committee (IKDC) scores. A second-look arthroscopy was performed in 13 knees a mean (SD) of 14.2 (10.1) months after the initial surgery.Results:The mean (SD) Rasmussen score was 29.1 (0.96). Thirteen of 15 patients scored good or excellent results in all Honkonen sections. The mean (SD) Lysholm score was 88.6 (12.4). The mean (SD) IKDC score was 79.3 (19.3). There was a small decrease of the activity level according to the Tegner score when compared with the preoperative situation (1.20 [1.82], P = .022). There were not any meniscal symptoms in any case. Of the 13 menisci evaluated with second-look arthroscopy, 12 had healed completely and a radial tear had healed partially in the vascular zone. In one of the cases that healed, a new tear was found in a different location.Conclusion:Meniscal repair of tears associated with tibial plateau fractures has good results. All patients had good or excellent clinical results. Second-look arthroscopy confirmed complete healing in 92% of meniscal tears when performed.

Resumen La profilaxis de eventos tromboembolicos venosos (ETV) tras artroplastia electiva de cadera o rodilla es un tema controvertido. Recientemente, 3 guias clinicas sobre este tema (las guias NICE, ACCP y AAOS) han sido actualizadas. Las guias presentan puntos en comun: es necesario de hacer profilaxis; es recomendable asociar profilaxis mecanica y farmacologica en los pacientes que han sufrido un ETV previo; las medidas mecanicas aisladas son efectivas y las heparinas de bajo peso molecular, los nuevos anticoagulantes orales y el fondaparinux son farmacos eficaces. Hay cierto consenso en recomendar la anestesia regional, en desaconsejar estudios ecograficos en pacientes asintomaticos y en promover la movilizacion precoz del paciente. Hay discrepancias sobre la terapia farmacologica mas adecuada y, el momento de inicio y duracion de esta, sobre los filtros de vena cava, los antiagregantes y los factores de riesgo de ETV o sangrado.

The aims of this paper are to generate estimates of the association between the severity and frequency of pain in Spain and (i) labor force participation and workforce status and (ii) patterns of absenteeism and presenteeism for the employed workforce.Data are from the internet-based 2010 National Health and Wellness Survey (NHWS). This survey covers both those who report experiencing pain in the last month as well as the no-pain population. An estimated 17.25% of adults in Spain report experiencing pain in the past month. A series of regression models are developed with the no-pain group as the reference category. The impact of pain, categorized by severity and frequency, is assessed within a labor supply framework for (i) labor force participation and (ii) absenteeism and presenteeism. Both binomial and multinomial logistic models are estimated.The results demonstrate that severe and moderate pain has a significant, substantive, and negative association with labor force participation and, together with the experience of mild pain, a substantive impact on absenteeism and presenteeism within the employed workforce. Compared to no-pain controls, the strongest association is seen in the case of severe pain, notably severe daily pain and labor force participation (odds ratio 0.363; 95% CI: 0.206-0.637). The association of severe pain with labor force participation is also significant (odds ratio 0.356; 95% CI: 0.217-0.585). There is a clear gradient in the association of pain severity and frequency with labor force participation. The impact of pain is far greater than the potential impact of other health status measures (e.g., chronic comorbidities and BMI). Labor force participation is also adversely associated with pain experience. Persons reporting severe daily pain are far more likely not to be in the labor force (relative probabilities 0.339 vs 0.611). The experience of pain, notably severe and frequent pain, also outstrips the impact of other health status factors in absenteeism and presenteeism. In the former case, the odds ratio associated with severe daily pain is 16.216 (95% CI: 5.127-51.283), which contrasts to the odds ratio for the Charlson comorbidity index of 1.460 (95%CI: 1.279-1.666). Similar results hold for presenteeism. The contribution of moderate and mild pain to absenteeism and presenteeism is more marked than for labor force participation.The experience of pain, in particular severe daily pain, has a substantial negative impact both on labor force participation in Spain as well as reported absenteeism and presenteeism. As a measure of health status, it clearly has an impact that outstrips other health status measures. Whether or not pain is considered as a disease in its own right, the experience of chronic pain, as defined here, presents policy-makers with a major challenge. Programs to relieve the burden of pain in the community clearly have the potential for substantial benefits from societal, individual, and employer perspectives.

Objetivo Analizar los factores que afectan a la supervivencia de sujetos tratados con hemiartroplastia tras una fractura subcapital de femur. Material y metodo Estudio retrospectivo de 1.196 fracturas subcapitales consecutivas en 1.166 pacientes tratados con hemiartroplastia de Thompson tras una fractura subcapital de femur entre 1989 y 2001. Se realizo seguimiento clinico de una muestra aleatoria de 220 fracturas; de estas, 210 casos fueron seguidos al menos dos anos o hasta el fallecimiento (95,5%). Se realizo un analisis multivariante del efecto de la edad, el sexo, las enfermedades asociadas, la demora de la intervencion quirurgica y las complicaciones postoperatorias en la supervivencia. Se analizo tambien la supervivencia de los implantes. Resultados La mediana de supervivencia fue de 4,5 anos. El sexo masculino incrementaba la mortalidad (riesgo relativo [RR]= 2,47; intervalo de confianza para un 95% [IC 95%]: 1,65-3,70; p odds ratio [OR] = 4,38; IC 95%:1,12-16,5; p = 0,03). Solo tres implantes fueron retirados, todos ellos por aflojamiento aseptico. Conclusiones Los factores que mas aumentan la mortalidad en este grupo de pacientes son el sexo masculino, la edad y la presencia de enfermedades. Una demora de la intervencion de 24 horas puede aumentar la supervivencia a corto plazo. Los implantes rara vez fracasan.

Background Pie crusting (PC) of the medial collateral ligament (MCL) in the knee has been used empirically to achieve more space in the medial compartment during knee arthroscopy. However, there are no reported studies analyzing the functional results of the application of the PC technique to the MCL in patients undergoing arthroscopic meniscectomy of the medial meniscus, and to determine the rate of iatrogenic injury and associated morbidity. Description of technique The patient was in a supine position with a tourniquet and a side post. Percutaneous controlled release of the posterior part of the MCL was performed using an intramuscular needle, and a mild valgus force was applied while viewing with the arthroscope of the controlled progressive gain in medial compartment space. Patients and methods A retrospective clinical study of 140 patients undergoing arthroscopic meniscectomy with or without MCL PC was conducted. Tegner and Lysholm tests and visual analogue scales were used to assess pain and functional results. Results The patients in the group with meniscectomy and PC had higher scores on the Lysholm scale, less pain at rest after two months, and achieved significantly better pain control during physical activity at six months. No complication, residual instability, or iatrogenic injury to the cartilage were observed in the meniscectomy plus PC group. Conclusion The MCL PC technique for medial meniscectomy is a safe and effective way to reduce iatrogenic injury to the cartilage and does not affect knee stability. Decompression of the medial compartment results in better functional outcomes at two months and lesser pain during physical activity at six months.

Study design A retrospective review of spinal deformity in patients with congenital heart disease surgically treated through a median sternotomy before the age of 8 years. Assessment was done on chest roentgenograms at skeletal maturity. Objectives To determine if patients surgically treated through a median sternotomy present a higher prevalence of spinal deformity. Summary of background data Congenital heart disease is associated with a higher prevalence of scoliosis. The etiology of scoliosis in this group of patients is unknown. Thoracotomy causes scoliosis, but median sternotomy has not been identified as a causal agent in these patients. Methods Chest roentgenograms were done after skeletal maturity in 128 patients to assess for the presence of a spinal deformity in the sagittal or coronal plane as a result of a median sternotomy for treatment of congenital heart disease before the age of 8 years in patients without any prior radiographic evidence of spinal or costal deformity before surgery. Results Forty-four (34.3%) of these patients had scoliosis greater than 10 degrees , 16 of them (12.5%) had curves greater than 20 degrees , and 33 (25.8%) had thoracic kyphosis lesser than 20 degrees . Patients operated before the age of 18 months had a significantly increased risk of developing scoliosis than those operated at a later age (odds ratio = 3.5; confidence interval = 1.3-9.6; P = 0.016). The presence of scoliosis was not related to the type of congenital heart disease. Conclusions There is a high prevalence of scoliosis in patients with congenital heart disease surgically treated through a median sternotomy. The prevalence of scoliosis increases in patients operated at an earlier age.

Resumen Las alteraciones de la inclinacion pelvica en el plano sagital en bipedestacion son importantes en el dolor lumbar cronico y la espondilolistesis. Los metodos habituales que se usan para medir este parametro necesitan de la realizacion de radiografias o requieren de aparataje complejo. Se describe un nuevo sistema de medida rapido y facil de utilizar. El sistema determina la altura respecto al suelo de las espinas iliacas anterosuperiores y posterosuperiores y las distancias entre si, y calcula la inclinacion del plano que pasa por estos cuatro puntos. Se analizo la reproducibilidad del sistema midiendo de manera repetida un grupo de 12 sujetos. El coeficiente de correlacion intraclase intraobservador fue de 0,90 y el interobservador fue de 0,80, por lo que el sistema tiene una buena reproducibilidad. Se analizo la validez del metodo comparando las medidas obtenidas con las realizadas sobre radiografias laterales de pelvis en 27 sujetos. Se observaron errores medios de 1,3° con una gran correlacion entre ambos datos (R2 = 0,68; p Se realizaron medidas sobre 75 voluntarios sanos. La inclinacion pelvica media fue de 9,88° (desviacion estandar [DE]: 5,43°). El analisis de regresion lineal multivariante observo una inclinacion pelvica menor en los hombres que en las mujeres (p = 0,044) y que la edad se relaciona inversamente con la inclinacion pelvica (p = 0,004).

To evaluate if different knee flexion angles can modify the neurovascular injury risk during lateral meniscus repair.Twenty cadaveric knees were studied. An all-inside suture device (FasT-Fix; SmithNephew, Andover, MA) was placed at the posterior horn and at the medial and lateral limits of the popliteal hiatus. The minimal distances between the device and the popliteal artery and peroneal nerve were measured with the knee at 90°, 45°, and 0° of flexion through a limited posterolateral arthrotomy.The distance between the device when inserted at the lateral edge of the popliteal hiatus and the peroneal nerve decreased from a median of 26 mm (interquartile range [IQR], 3.5 mm; range, 19 to 29 mm) at 90° to 21.5 mm (IQR, 4.5 mm; range, 14 to 25 mm) at 45° and 15.5 mm (IQR, 6.5 mm; range, 4 to 20 mm) at 0° (significant differences, P.001). The distance between the device when inserted at the medial edge of the popliteal hiatus and the peroneal nerve decreased from 16 mm (IQR, 3.3 mm; range, 9 to 21 mm) at 90° to 12 mm (IQR, 4.3 mm; range, 9 to 16 mm) at 45° and 7 mm (IQR, 4.0; range, 4 to 15 mm) at 0° (significant differences, P.001). The distance between the device when inserted at the medial edge of the popliteal hiatus and the popliteal artery decreased from 21 mm (IQR, 5.0 mm; range, 11 to 27 mm) at 90° to 19 mm (IQR, 5.0 mm; range, 10 to 23 mm) at 45° and 16 mm (IQR, 7.5 mm; range, 10 to 23 mm) at 0° (significant differences, P.001). The distance between the device when inserted 5 mm lateral to the posterior root of the lateral meniscus and the popliteal artery decreased from 13 mm (IQR, 4.3 mm; range, 7 to 27 mm) at 90° to 10.5 mm (IQR, 4.3 mm; range, 4 to 19 mm) at 45° and 5.5 mm (IQR, 4.0 mm; range, 0 to 14 mm) at 0° (significant differences, P.001).The risk of injury to the popliteal artery or to the peroneal nerve during all-inside repair of the posterior half of the lateral meniscus is lower at 90° of flexion and increases with knee extension to 45° and 0°.All-inside meniscal repair of the lateral meniscus is safer with the knee at 90° of flexion.

Objective To analyze pre-surgical predictive factors of post-surgical pain in patients undergoing hip or knee arthoplasty. Methods A systematic literature review was performed. We defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undertaking knee and/or hip arthroplasty, adults with moderate or severe pain (≥4 on a Visual Analog Scale) in whom predictive factors of post-surgical pain were evaluated before surgery. Systematic reviews, meta-analyses, controlled trials and observational studies were selected. We excluded animals and basic science articles, reviews of prosthesis, prosthesis due to fractures, patients with rheumatic diseases or studies with mixed population in which disaggregated data was not possible to obtain. Results A total 37 articles of moderate quality were selected. The articles included representative patients undergoing a knee or hip arthroplasty in our country; most of them were aged 60 years or above, with osteoarthritis, and with a high rate of obesity and comorbidities. We found great variability regarding the type of studies and predictive factors. There was a strong association between post-surgical pain and the following pre-surgical factors: female gender, low socio-economic status, higher pain, comorbidities, low back pain, poor functional status, and psychological factors (depression, anxiety or catastrophic pain). Conclusions There are pre-surgical factors that might influence post-surgical pain in patients undergoing a knee or hip arthroplasty. Therefore, they should be taken into account when considering an arthroplasty.

We describe an arthroscopic approach for the treatment of patellar chondral lesions with the patient in the supine position. This approach can be used to perform certain procedures such as matrix autologous chondrocyte implantation and autologous matrix–induced chondrogenesis. It is possible to perform these arthroscopic techniques working at an angle perpendicular to the patellar joint surface. First, with the patient in the supine position, arthroscopic longitudinal sectioning of the lateral patellar retinaculum is performed, and the patella is reverted with the help of a Codivilla forceps. It is then possible to place the chondral surface perpendicular to the floor, and it can be accessed directly through a lateral parapatellar portal. Short-term follow-up has shown the benignity of opening the patellar retinaculum. This procedure reduces morbidity compared with the traditional open surgery.

Objective The present epidemiological research evaluated the prevalence of neuropathic pain characteristics in patients with painful knee osteoarthritis (OA) and the plausibility that such neuropathic features were specific of OA. Methods Outpatients with chronic pain associated with knee OA who attended orthopedic surgery or rehabilitation clinics were systematically screened for neuropathic pain with the Douleur Neuropathique in 4 questions (DN4) questionnaire. Data from medical files and those obtained during a single structured clinical interview were correlated with the DN4 scores. Information on potential confounders of neuropathic-like qualities of knee pain was collected to evaluate as much as possible only the symptoms attributable to OA. Results Of 2,776 patients recruited, 2,167 patients provided valid data from 2,992 knees. The DN4 was scored positively (≥ 4) in 1,125 patients (51.9%) and 1,459 knees (48.8%). When patients with potential confounders were excluded, the respective prevalences were 33.3% and 29.4%. Patients who scored positively in the DN4 had more severe pain, greater structural damage, and more potential confounders of neuropathic pain. Three potential confounders conveyed much of the variability explained by regression analyses. However, latent class analyses revealed that the concourse of other factors is required to explain the neuropathic pain qualities. Conclusions A relevant proportion of patients with chronic pain associated with knee OA featured neuropathic pain qualities that were not explained by other conditions. The present research has provided reasonable epidemiological grounds to attempt their definite diagnosis and classification.

Coracoid impingement syndrome results from subscapularis tendon entrapment between the humerus and the coracoid. This syndrome is an uncommon cause of shoulder pain that has many different aetiologies. Although synovial cysts have been reported as cause of coracoid impingement at this level, solid tumoural lesions are a rare cause of symptoms in this location. Two cases of benign soft tissue solid tumours are presented. Both patients developed symptoms compatible with coracoid impingement syndrome. The lesions were fully resected under arthroscopic visualization. Both patients had complete resolution of the symptoms and are asymptomatic at 2-year follow-up. Arthroscopic removal of benign soft tissue tumours that cause coracoid impingement syndrome has good results.

When performing arthroscopic procedures, the hip joint is divided into central and peripheral compartments. Currently, both compartments are evaluated in most of the procedures, but the procedures are usually started by accessing the central compartment. When a direct approach to the central compartment is significantly impeded, it is necessary to perform the initial arthroscopic approach to the hip from the peripheral compartment using either an intracapsular technique or an extracapsular technique. The technical pearls that might be required in these patients are discussed, and typical clinical cases are presented.

C-reactive protein (CRP) is often used as an infection marker in orthopaedic patients and in particular after anterior cruciate ligament (ACL) reconstruction surgery. The aim of this study is to obtain the reference values of CRP during the first month after an ACL reconstruction and to analyse the epidemiological and surgical parameters that affect these values.One hundred and twenty ACL reconstructions were included. A CRP determination was performed preoperatively and 1, 7, 14, 21 and 28 days after surgery. CRP values under 5 mg/l were considered to be normal.One patient developed a septic arthritis in the second week postoperatively and was excluded. One hundred and seventeen patients [93 males and 24 females; mean age (standard deviation) 31.6 years (7.6)] underwent 119 ACL reconstructions with different techniques and grafts. Preoperative CRP (n = 119) was 1.80 mg/ml (2.6). Mean values at 1, 7, 14, 21 and 28 days were, respectively, 8.5 mg/ml (11.6), 10.5 mg/ml (17.0), 4.5 mg/ml (3.43), 4.4 mg/ml (7.59) and 3.4 mg/ml (3.03). Multivariate analysis showed that males had postoperative CRP levels 1.7 higher than females (p0.0001; 95 % CI 1.8-2.5); the patients operated by less experienced surgeons had levels 2.5 times higher than those operated by a highly experienced surgeons (p = 0.007; 95 % CI 1.2-3.4) and that if microfracture of a chondral lesion was associated, the levels increased 1.9 times (p = 0.021; 95 % CI 1.1-3.4).There are significant variations in CRP levels after ACL reconstruction in half of patients without infectious complications. Males, patients operated by less experienced surgeons and those with chondral lesions treated with microfracture had increased postoperative CRP levels. CRP values up to five times the normal limit are common in the month after an ACL reconstruction and are not necessarily associated with infection, especially in these groups.

The aims of this paper are to report on the prevalence, correlates and treatment of pain in the adult Spanish population. The analysis also explores the association between the experience of pain and health-related quality of life (HRQoL), employment and productivity, and healthcare resource utilization.Data are from the Internet-based, 2010 National Health and Wellness Survey (NHWS) Spain. The sample was weighted by age and sex to correspond to the 2010 adult Spanish population. All respondents to the NHWS reported on socio-demographic and economic characteristics, medication adherence and major health conditions. They also reported on their HRQoL (the SF-12), their employment status and workplace productivity experience (WPAI instrument) and their healthcare resource utilization. Persons reporting experiencing pain gave details on conditions causing pain, prescription and over the counter (OTC) medication utilization, duration of utilization and satisfaction with medications. A supplementary analysis evaluated the population prevalence of pain for the five most populous Spanish autonomous communities (regions).An estimated 6.10 million (17.25%) of the adult population of Spain reported experiencing pain in the last month. Of these 11.69% experienced severe pain, 64.17% moderate pain and 24.14% mild pain. Daily pain was experienced by 6.95% of the population The major conditions causing pain are back pain (60.53%) followed by joint pain (40.21%). Sleep difficulties (42.24%) and anxiety (40.62%) were most commonly cited as comorbidities. Prescription medication utilization was most important in the severe and moderate pain categories, with 71.62% reporting they were satisfied with their prescription pain medications. Adherence to pain medications was high with an overall Morisky score of 0.99 (range 0-4). Pain had a major negative effect on labor force participation for those reporting moderate and severe pain with a participation rate of only 42.62% for those with severe pain. Pain was associated with substantial health-related quality of life deficits as measured by the physical and mental score components of the SF-12. In the case of SF-6D utilities, the utility score for the pain population was markedly below that for the no-pain population (0.65 vs. 0.75; p 0.05).The experience of pain also negatively impacted rates of absenteeism and presenteeism, as well as being associated with greater healthcare resource utilization. Finally, for the five most populous autonomous communities of Spain estimated pain prevalence ranged from 14.80% for Madrid to 18.79% for Comunidad Valenciana. The are a number of limitations which should be noted. First, this is an internet-based sample study and the respondent population may not be representative of the Spanish adult population. Second, respondents are asked to report their experience of pain with no independent clinical conformation. Finally, while a number of obvious acute pain categories are excluded, there is no attempt to arbitrarily define a chronic pain population or to identify pain categories such as neuropathic pain.The experience of pain represents a substantial burden on both individuals and the Spanish economy. The experience of pain is associated with a substantial reduction in both the PCS component of the SF-12 and SF-6D absolute utilities--most notably in respect of severe pain. The experience of pain is also associated, not only with reduced labor force participation and increased absenteeism and presenteeism, but with substantially higher patterns of healthcare resource utilization.

Purpose To determine whether adipose-derived mesenchymal stem cells (ASCs) affect the healing rate of meniscal lesions sutured in the avascular zone in rabbits. Methods Four groups were used. In group A (n = 12) a short, 5-mm-long longitudinal lesion in the avascular zone of the anterior horn of the medial meniscus was created and immediately sutured. In group B (n = 8) the same short lesion was created but suture was delayed 3 weeks. In group C (n = 12) a larger, 15-mm-long lesion that spanned the whole meniscus was created and sutured immediately. In group D (n = 8) the same large lesion was sutured 3 weeks later. Both knees in each rabbit were used: 1 served as the control, and in the other, 1 × 10 5 allogeneic ASCs marked with bromodeoxyuridine were placed in the lesion immediately before suturing. The animals were killed at 12 weeks. Results In group A (short lesion, acute repair) 6 of 12 ASC-treated menisci and 0 of 12 controls had some healing ( P = .014). In group B (short lesion, delayed repair) 2 of 8 ASC-treated menisci and 1 of 8 controls had some healing ( P = .5). In group C (long lesion, acute repair) 6 of 12 ASC-treated menisci and 0 of 12 controls had some healing ( P = .014). In group D (long lesion, delayed repair) 4 of 8 ASC-treated menisci and 0 of 8 controls had some healing ( P = .07). The addition of ASCs increased the healing rate (odds ratio, 32 [range, 3.69 to 277]; P = .002). The histologic analysis of the healed zones identified well-formed meniscal fibrocartilage with persistence of cells derived from the ASCs (immunolocated with anti-bromodeoxyuridine antibodies). Conclusions Adding ASCs to a repair in the avascular zone of rabbit menisci increases the chances of healing. Healing is improved in small and larger lesions. When suture is delayed, the effect is not as evident. Clinical Relevance In the future, ASCs might help in meniscal repair in the avascular zone.