Inferior lateral genicular artery injury during anterior cruciate ligament reconstruction surgery

We report a case of inferior lateral genicular artery (ILG) injury during anterior cruciate ligament (ACL) reconstruction surgery with lateral partial meniscectomy. This is a rare arthroscopy complication. A review of the literature has been made with the aim to define the anatomy of ILG across the lateral articular line and the risk of lesion during knee arthroscopy. We propose embolization as a good treatment option for this type of injurie

Inestabilidad patelofemoral en niños con Síndrome de Down

La inestabilidad patelofemoral en el síndrome de Down se presenta en el contexto de hiperlaxitud e inmadurez esquelética suponiendo un reto en el tratamiento. Nuestro objetivo es valorar el resultado clínico-funcional de la cirugía de partes blandas, en estos pacientes hiperlaxos e inmaduros esqueléticamente. Hemos revisado retrospectivamente a los pacientes con síndrome de Down e inmadurez esquelética intervenidos por inestabilidad patelofemoral con seguimiento hasta el cierre fisario. Seis pacientes (9 rodillas) con media de edad de 12,4 años fueron incluidos. El grado de inestabilidad patelofemoral prequirúrgica (clasificación de Dugdale) mostró 1 (11,1%) caso grado 2; 2 (22,2%) casos grado 3 y 6 (66,6%) casos grado 4. El grado de función patelar (según Insall) al alcanzar la madurez esquelética fue malo en un caso (recidiva de la luxación), bueno en 2 y excelente en 6. En definitiva, los procedimientos sobre partes blandas pueden ser suficientes en pacientes con síndrome de Down.Patelofemoral instability in Down syndrome´s patients appears in hiperlaxity and open physis context. Our aim is to make a retrospective clinical-functional assessment of the soft tissue procedure treatment of patellofemoral instability in patients with Down Syndrome skeletally immature (open physeal), following them until the physeal closure. We have included six patients (9 knees) with a mean age of 12.4 years old. Patellar instability (Dugdale´s classification) distribution was 1 (11.1%) cases degree ll; 2 (22.2%) cases degree lll and 6 (66.6%) cases degree IV. Patellar function assessed by Insall score at follow up was excellent in 6 of the cases, good in 2 cases and bad in one case (recurrent dislocation). In summary, a proximal soft tissues procedure in Down syndrome patients could be enough for patellar instability treatment

Surco en cabeza femoral como signo de inestabilidad de cadera en pacientes con Síndrome de Down.

La inestabilidad de cadera en pacientes afectos de síndrome de Down es una entidad poco frecuente, en la actualidad todavía existe controversia sobre las anomalías anatómicas asociadas. El objetivo de este trabajo es describir los cambios anatómicos en las caderas de pacientes con inestabilidad en el síndrome de Down (SD). Hemos revisado las tomografías computarizadas (TC) de los pacientes afectos de luxación de cadera con SD. A tres de los 7 pacientes intervenidos en nuestro centro, se les había realizado TC de caderas. En todas las TC mostraban la presen - cia de lesión lineal vertical (surco) localizada en región epifisaria, atravesando la fisis, de localización antero-interna. Creemos que la posición adoptada cuando duermen (flexión, aducto y rotación interna) puede producir hiperpresión de la cabeza femoral sobre la ceja acetabular posterior, produciendo un surco vertical. La presencia de esta lesión puede ser sugestiva de inestabilidad subclínica de cadera en ausencia de episodio de luxación.Hip instability in patients with Down syndrome is a rare entity, currently there is still controversy about the associated anatomical anomalies. The aim of the study is to describe the anatomical changes in the hips of patients with instability in Down syndrome (DS). We have reviewed the computed tomography (CT) of patients with hip dislocation with SD. Three of the 7 patients treated in our center are performed CT had hips. All CT showed the presence of vertical linear lesion (groove) located in epiphyseal region, crossing the physis, antero-internal location. We believe that the position taken when sleeping (flexion, adduction and internal rotation) can produce overpressure of the femoral head over the posterior acetabular rim, producing a vertical groove. The presence of this lesion can be suggestive of subclinical instability in the absence of hip dislocation

Biology and technology in the surgical treatment of malignant bone tumours in children and adolescents, with a special note on the very young

Purpose: The main challenge in reconstruction after malignant bone tumour resection in young children remains how and when growth-plates can be preserved and which options remain if impossible.Methods: We describe different strategies to assure best possible long-term function for young children undergoing resection of malignant bone tumours.Results: Different resources are available to treat children with malignant bones tumours: a) preoperative planning simulates scenarios for tumour resection and limb reconstruction, facilitating decision-making for surgical and reconstructive techniques in individual patients; b) allograft reconstruction offers bone-stock preservation for future needs. Most allografts are intact at long-term follow-up, but limb-length inequalities and corrective/revision surgery are common in young patients; c) free vascularized fibula can be used as stand-alone reconstruction, vascularized augmentation of structural allograft or devitalized autograft. Longitudinal growth and joint remodelling potential can be preserved, if transferred with vascularized proximal physis; d) epiphysiolysis before resection with continuous physeal distraction provides safe resection margins and maintains growth-plate and epiphysis; e) 3D printing may facilitate joint salvage by reconstruction with patient-specific instruments. Very short stems can be created for fixation in (epi-)metaphysis, preserving native joints; f) growing endoprosthesis can provide for remaining growth after resection of epi-metaphyseal tumours. At ten-year follow-up, limb survival was 89%, but multiple surgeries are often required; g) rotationplasty and amputation should be considered if limb salvage is impossible and/or would result in decreased function and quality of life.Conclusion: Several biological and technological reconstruction options must be merged and used to yield best outcomes when treating young children with malignant bone tumours.Orthopaedics, Trauma Surgery and Rehabilitatio

Dose volume histogram constraints in patients with soft tissue sarcomas of the extremities and the superficial trunk treated with surgery and perioperative HDR brachytherapy

Background: Wound healing complications (WHC), osteoradionecrosis (ORN), and nerve damage (ND) are common adverse effects in adult patients with soft tissue sarcomas of the extremities and the superficial trunk treated with surgery and perioperative high dose rate brachytherapy (PHDRB) alone or combined with external beam radiotherapy (EBRT). Rationale: Analysis of the treatment factors contributing to these complications can potentially minimize their occurrence and severity. Patients: A total of 169 patients enrolled in two parallel prospective studies were included in this analysis. Previously Unirradiated cases (Group 1; n = 139) were treated with surgical resection, 16–24 Gy of PHDRB and 45 Gy of EBRT. Adjuvant chemotherapy was given to selected patients with high-grade tumors. Previously irradiated cases (Group 2; n = 30) were treated with surgical resection and 32– 40 Gy of PHDRB without further EBRT. Methods: Patient factors, tumor factors, surgical factors, PHDRB factors and EBRT factors were analyzed using Cox univariate and multivariate analysis. Results: In Previously Unirradiated cases, WHC, ORN and ND occurred in 38.8%, 5.0% and 19.4%. Multivariate analysis indicated that WHC increased with CTV size (p = 0.02) and CTV2cm3 Physical dose (p = 0.02). ORN increased with Bone2cm3 EQD2 67 Gy (p = 0.01) and ND was more frequent in patients with TV100 DVH-based dose (tissue volume encompassed by the 100% isodose) 84 Gy (p < 0.01). In Previously Irradiated cases, WHC, ORN and ND occurred in 63.3%, 3.3% and 23.3%. Multivariate analysis showed that WHC was more frequent in patients with Skin2cm3 Lifetime EQD2 84 Gy (p = 0.01) and ND was more frequent after CTVD90 Physical Doses 40 Gy (p < 0.01). Conclusions: WHC in Previously Unirradiated patients can be minimized by using a more conservative CTV definition together with a meticulous implant technique and planning aimed to minimize hyperdose CTV2cm3 areas. In Previously Irradiated patients WHC may be mimimized considering Lifetime EQD2 Skin2cm3 doses. ORN can be reduced by using the Bone2cm3 EQD2 constraint. ND occurs more frequently in patients with large tumors receiving high treated volume doses, but no specific constraints can be recommended due to the lack of peripheral nerve definition during brachytherapy planning

Intra-articular injection of two different doses of autologous bone marrow mesenchymal stem cells versus hyaluronic acid in the treatment of knee osteoarthritis: long-term follow up of a multicenter randomized controlled clinical trial (phase I/II)

Background: Mesenchymal stromal cells (MSCs) are a promising option to treat knee osteoarthritis (OA). Their safety and usefulness have been reported in several short-term clinical trials but less information is available on the longterm efects of MSC in patients with osteoarthritis. We have evaluated patients included in our previous randomized clinical trial (CMM-ART, NCT02123368) to determine their long-term clinical efect. Materials: A phase I/II multicenter randomized clinical trial with active control was conducted between 2012 and 2014. Thirty patients diagnosed with knee OA were randomly assigned to Control group, intraarticularly administered hyaluronic acid alone, or to two treatment groups, hyaluronic acid together with 10×106 or 100×106 cultured autol‑ ogous bone marrow-derived MSCs (BM-MSCs), and followed up for 12 months. After a follow up of 4 years adverse efects and clinical evolution, assessed using VAS and WOMAC scorings are reported. Results: No adverse efects were reported after BM-MSCs administration or during the follow-up. BM-MSCs-adminis‑ tered patients improved according to VAS, median value (IQR) for Control, Low-dose and High-dose groups changed from 5 (3, 7), 7 (5, 8) and 6 (4, 8) to 7 (6, 7), 2 (2, 5) and 3 (3, 4), respectively at the end of follow up (Low-dose vs Control group, p=0.01; High-dose vs Control group, p=0.004). Patients receiving BM-MSCs also improved clinically accord‑ ing to WOMAC. Control group showed an increase median value of 4 points (−11;10) while Low-dose and Highdose groups exhibited values of −18 (−28;−9) and −10 (−21;−3) points, respectively (Low-dose vs Control group p=0.043). No clinical diferences between the BM-MSCs receiving groups were found. Conclusions: Single intraarticular injection of in vitro expanded autologous BM-MSCs is a safe and feasible proce‑ dure that results in long-term clinical and functional improvement of knee OA

Nonreferral of possible soft tissue sarcomas in adults: a dangerous omission in policy

Introduction. The aim of this study is to compare outcomes in three groups of STS patients treated in our specialist centre: patients referred immediately after an inadequate initial treatment, patients referred after a local recurrence, and patients referred directly, prior to any treatment. Patients and methods. We reviewed all our nonmetastatic extremity-STS patients with a minimum follow-up of 2 years. We compared three patient groups: those referred directly to our centre (group A), those referred after an inadequate initial excision (group B), and patients with local recurrence (group C). Results. The study included 174 patients. Disease-free survival was 73%, 76%, and 28% in groups A, B, and C, respectively (P < .001). Depth, size, and histologic grade influenced the outcome in groups A and B, but not in C. Conclusion. Initial wide surgical treatment is the main factor that determines local control, being even more important than the known intrinsic prognostic factors of tumour size, depth, and histologic grade. The influence on outcome of initial wide local excision (WLE), which is made possible by referral to a specialist centre, is paramount

Preneoplastic somatic mutations including MYD88(L265P) in lymphoplasmacytic lymphoma

Normal cell counterparts of solid and myeloid tumors accumulate mutations years before disease onset; whether this occurs in B lymphocytes before lymphoma remains uncertain. We sequenced multiple stages of the B lineage in elderly individuals and patients with lymphoplasmacytic lymphoma, a singular disease for studying lymphomagenesis because of the high prevalence of mutated MYD88. We observed similar accumulation of random mutations in B lineages from both cohorts and unexpectedly found MYD88(L265P) in normal precursor and mature B lymphocytes from patients with lymphoma. We uncovered genetic and transcriptional pathways driving malignant transformation and leveraged these to model lymphoplasmacytic lymphoma in mice, based on mutated MYD88 in B cell precursors and BCL2 overexpression. Thus, MYD88(L265P) is a preneoplastic event, which challenges the current understanding of lymphomagenesis and may have implications for early detection of B cell lymphomas

Inferior lateral genicular artery injury during anterior cruciate ligament reconstruction surgery

We report a case of inferior lateral genicular artery (ILG) injury during anterior cruciate ligament (ACL) reconstruction surgery with lateral partial meniscectomy. This is a rare arthroscopy complication. A review of the literature has been made with the aim to define the anatomy of ILG across the lateral articular line and the risk of lesion during knee arthroscopy. We propose embolization as a good treatment option for this type of injurie