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Abordaje transfibular modificado para fracturas del platillo tibial posterolateral. Serie de Casos
Modified transfibular approach for posterolateral tibial plateau fractures. Case Series
Eduardo A. González-Ríosa, Carolina Carvajal-Barrerab,
Autor para correspondencia
carolinacarbar@gmail.com

Autor para correspondencia.
, Diego Fernando Luna-Duzanc
a Ortopedista y traumatólogo, Hospital Pablo Tobón Uribe, Director médico Tissue Bank, Medellín, Antioquia, Colombia
b Ortopedista y traumatóloga, Universidad Militar Nueva Granada-Hospital Militar Central, Fellowship Cirugía de Rodilla Fundación Universitaria Ciencias de la Salud-Hospital de San José. Bogotá D.C., Colombia
c Ortopedista y traumatólogo, Universidad Pontificia Bolivariana, Medellín, Antioquia, Colombia
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          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">T&#233;cnica quir&#250;rgica&#58; paciente en dec&#250;bito lateral &#40;si se requieren otros abordajes puede ubicarse dec&#250;bito prono&#41;&#44; referencias anat&#243;micas&#58; r&#243;tula&#44; tend&#243;n rotuliano&#44; superficie articular tibial&#44; cabeza de f&#237;bula&#44; sitio de la incisi&#243;n cut&#225;nea curvil&#237;nea &#40;en rojo&#41; &#40;A&#41;&#46; Se incide la piel y tejido celular subcut&#225;neo hasta identificar bandeleta iliotibial&#44; tend&#243;n del b&#237;ceps y posterior a este el nervio fibular com&#250;n&#44; el cual se libera con la rodilla en semiflexi&#243;n hacia proximal y distal para relajarlo&#44; y se repara sin traccionarlo&#46; &#40;B&#41;&#46; Se realiza artrotom&#237;a submeniscal y se fija el menisco a la c&#225;psula con puntos de sutura &#40;C&#41;&#46; Posterior a perforaciones con broca de 2&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#44; se realiza osteotom&#237;a en dos planos con cincel&#44; respetando la articulaci&#243;n tibiofibular proximal &#40;D y E&#41;&#46; Se evierte la f&#237;bula osteotomizada &#40;F&#41;&#46;</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se evidencia exposici&#243;n que se logra&#44; con adecuada visualizaci&#243;n de todo el platillo lateral &#40;G&#41; Vs exposici&#243;n insuficiente sin la osteotom&#237;a descrita &#40;C&#41;&#46; Se procede a reconstruir y elevar platillo tibial posterolateral bajo visi&#243;n directa articular&#44; se aplica injerto &#243;seo de soporte a necesidad y se fija material de osteos&#237;ntesis planeado&#46; Posteriormente se fijan suturas capsulomeniscales a orificios de la placa&#44; se reduce la osteotom&#237;a de f&#237;bula y se fija con tornillo canulado de 3&#46;5 o 4&#46;5 paralelo a articulaci&#243;n tibiofibular&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Las fracturas de platillos tibiales son una lesi&#243;n frecuente secundaria a traumas de alta energ&#237;a como accidentes de transito y ca&#237;das de altura&#44; aquellas complejas y que comprometen el platillo tibial posterolateral son m&#225;s exigentes en su abordaje&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Es indispensable para mejorar el pron&#243;stico<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a>&#44; teniendo en cuenta las caracter&#237;sticas biomec&#225;nicas de la rodilla y su importancia como la articulaci&#243;n del cuerpo que m&#225;s soporta carga&#44; realizar un manejo quir&#250;rgico que busque restaurar la superficie articular&#44; la estabilidad de la rodilla&#44; la adecuada alineaci&#243;n del eje de la extremidad y lograr una rehabilitaci&#243;n precoz&#46; La restauraci&#243;n incompleta de la superficie articular y de la altura del platillo de estas fracturas llevar&#225; subluxaci&#243;n posterior&#44; artrosis y dolor&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Hay diversos abordajes reportados en la literatura&#44; los cuales pueden comprometer el f&#233;mur incluyendo osteotom&#237;a del epicondilo femoral lateral<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> o respet&#225;ndolo&#44; centr&#225;ndose en la tibia&#46; El abordaje anteromedial para la elevaci&#243;n de hundimientos posterolaterales que puede ser abierto o artrosc&#243;pico<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a>&#44; s&#243;lo es &#250;til en fracturas en las cuales no hay compromiso asociado de platillo tibial medial y se respeta el anillo de la superficie tibial&#44; los autores reconocen en sus publicaciones que algunas fracturas posterolaterales tratadas por este abordaje no logran la reducci&#243;n anat&#243;mica ni la fijaci&#243;n deseada<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; Por otra parte&#44; desde un abordaje anterolateral&#44; hay cierta dificultad para visualizar y manipular las fracturas posterolaterales<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a>&#59; incluso por un abordaje anterolateral extendido no se logra un manejo suficientemente eficaz en las fracturas cercanas a la l&#237;nea media del platillo posterior<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a>&#46; El abordaje posterior permite una exposici&#243;n del platillo tibial posterior&#44; liberando la cabeza medial del gastrocnemio&#44; pero est&#225; limitado porque no permite una adecuada visualizaci&#243;n del aspecto lateral del platillo lateral&#46; Tambi&#233;n est&#225; descrito un abordaje dual para las fracturas posteriores de ambos platillos<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span> sin embargo permite el apoyo &#40;efecto Buttres&#41; y fijaci&#243;n en direcci&#243;n anterior pero no de lateral hacia medial&#46; El abordaje lateral convencional<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> no proporciona una exposici&#243;n adecuada del sitio de la fractura hacia distal&#44; es decir se queda corto para las fracturas que tienen compromiso amplio metafisiario<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span> aun si el abordaje incluye secci&#243;n del soleo<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a>&#46; En un intento de resolver esta dificultad aparecen los abordajes que incluyen osteotom&#237;a de la f&#237;bula&#44; los cuales conllevan mayor riesgo de lesi&#243;n de nervio peroneal com&#250;n&#59; puede realizarse invadiendo y separando la sindesmosis tibiofibular y flejando el cuello de peron&#233; hacia arriba con el tend&#243;n del b&#237;ceps femoral&#44; o en capa con el ligamento meniscotibial y la banda iliotibial<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a>&#46; Los abordajes ampliados posterolaterales que conservan la f&#237;bula&#44; pueden lograr una buena exposici&#243;n a expensas de grandes disecciones de tejidos blandos&#44; desprendiendo el tend&#243;n del b&#237;ceps femoral y la inserci&#243;n del ligamento colateral lateral<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a>&#46; Por &#250;ltimo&#44; los abordajes con ostectom&#237;a de la cabeza de la f&#237;bula parcial o total<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a>&#44; describen como complicaciones&#44; dolor e inestabilidad lateral de rodilla&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Por estas razones&#44; se desarroll&#243; la nueva t&#233;cnica para osteotom&#237;a de la f&#237;bula que se describe en este estudio&#44; buscando dar soluci&#243;n a las fracturas de platillo tibial posterolateral con pocas complicaciones&#46; Adem&#225;s se reportan los primeros resultados cl&#237;nicos del seguimiento de los pacientes y una discusi&#243;n sobre la utilidad de este procedimiento&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">T&#233;cnica quir&#250;rgica</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Objetivo</span><p id="par0025" class="elsevierStylePara elsevierViewall">Lograr una excelente exposici&#243;n de las fracturas complejas de platillo tibial posterolateral que permita una adecuada reducci&#243;n y fijaci&#243;n acorde con el trazo de fractura&#44; respetando al m&#225;ximo las estructuras estabilizadoras laterales de la rodilla para lograr la adecuada rehabilitaci&#243;n y resultados funcionales&#44; as&#237; como conservar el aporte vascular para la consolidaci&#243;n de la fractura&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ventajas</span><p id="par0030" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">T&#233;cnica mente f&#225;cil&#44; se requiere dominio sobre la anatom&#237;a de la regi&#243;n posterolateral de la rodilla</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Reproducible</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Permite la exposici&#243;n adecuada de todo el platillo lateral</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Facilita la aplicaci&#243;n del material de osteos&#237;ntesis seg&#250;n el requerimiento de la fractura</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se evita el da&#241;o de la articulaci&#243;n tibiofibular proximal</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Mayor &#225;rea de consolidaci&#243;n de la osteotom&#237;a de la f&#237;bula</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Se conservan los tejidos blandos y el aporte vascular de la tibia proximal</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Poca morbilidad y&#47;o complicaciones como dolor&#44; inestabilidad&#44; p&#233;rdida de la reducci&#243;n</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Puede utilizarse solo o en combinaci&#243;n con otros abordajes&#44; como posteromedial o anteromedial</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Indicaciones</span><p id="par0080" class="elsevierStylePara elsevierViewall">El procedimiento esta indicado para pacientes con&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Fracturas simples o complejas de platillo tibial posterolateral</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">Fracturas agudas o cr&#243;nicas en mala uni&#243;n&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Plan quir&#250;rgico</span><p id="par0095" class="elsevierStylePara elsevierViewall">Incluye la toma de tomograf&#237;a computarizada para caracterizar adecuadamente la fractura&#44; definir si requiere abordajes combinados&#44; as&#237; como el m&#233;todo de fijaci&#243;n&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Aspectos t&#233;cnicos operatorios</span><p id="par0100" class="elsevierStylePara elsevierViewall">Paciente en dec&#250;bito lateral&#44; si se requieren otros abordajes puede ubicarse en dec&#250;bito prono&#46; Se identifican referencias anat&#243;micas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#46;A&#41;&#44; se aplica torniquete en el muslo para facilitar la liberaci&#243;n del nervio fibular y la reducci&#243;n de fragmentos articulares&#46; Se incide la piel en forma curvil&#237;nea &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#46;A&#41; y tejido celular subcut&#225;neo&#44; hasta identificar bandeleta iliotibial&#44; tend&#243;n del b&#237;ceps&#44; y justo posterior a este el nervio fibular com&#250;n&#44; el cual se libera con la rodilla en semiflexi&#243;n para relajarlo&#44; hacia proximal y distal y se repara sin traccionarlo&#44; se protege para prevenir su lesi&#243;n durante el abordaje o la correcci&#243;n de la deformidad en valgo secundaria al colapso del platillo lateral<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#46;B&#41;&#46; Se realiza artrotom&#237;a submeniscal y se fija el menisco a la c&#225;psula con puntos de sutura&#44; entre el ligamento cruzado posterior y la bandeleta iliotibial&#44; se drena hematoma fracturario y se lava articulaci&#243;n&#46; En la <a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#46;C&#46; se ilustra la exposici&#243;n que se logra del platillo lateral sin osteotom&#237;a de la f&#237;bula&#44; para compararla con la imagen 1&#46;G&#46; posterior a la misma&#46; Para la osteotom&#237;a fibular &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#46;D&#44; 1&#46;E&#44; <a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#44; se realizan perforaciones con broca de 2&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#44; se realiza corte en dos planos con cincel&#44; respetando la articulaci&#243;n tibiofibular proximal&#44; uno trasverso respecto al eje de la f&#237;bula&#44; y otro con orientaci&#243;n a 45 grados de anterolateral a posteromedial&#44; se evitan los cortes con sierra oscilante por el riesgo de lesi&#243;n de nervio peroneal com&#250;n&#44; se evierte la f&#237;bula osteotomizada &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#46;F&#44; 2&#41; logrando una adecuada exposici&#243;n con visualizaci&#243;n de todo el platillo lateral&#46; Bajo visi&#243;n directa&#44; con la rodilla en extensi&#243;n y valgo&#44; se realiza reducci&#243;n de la superficie articular posterolateral hasta lograr la altura deseada &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#46;H&#41; se aplica injerto &#243;seo de soporte&#44; ya sea auto o aloinjerto&#44; y se fija con el material de osteos&#237;ntesis planeado previamente &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#46;I&#41;&#46; Durante la cirug&#237;a se puede tomar imagen con fluoroscopio anteroposterior y lateral seg&#250;n la necesidad dada por complejidad de la fractura o p&#233;rdida de referencias anat&#243;micas&#44; no siempre es necesaria&#46; Se lava la articulaci&#243;n&#44; se fijan suturas capsulomeniscales a los orificios de material de osteos&#237;ntesis&#44; se reduce la osteotom&#237;a del peron&#233; y se fija con tornillo canulado de 3&#44;5 o 4&#44;5&#44; cierre por planos&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Cuidado postoperatorio</span><p id="par0105" class="elsevierStylePara elsevierViewall">Se inmoviliza con brace articulado en extensi&#243;n durante 3 semanas&#44; luego se inicia terapia f&#237;sica con movilidad progresiva hasta alcanzar 90 grados a las 6 semanas&#44; momento en el cual se retira el brace&#44; y seg&#250;n las caracter&#237;sticas de la fractura&#44; se permite apoyo luego de 6 a 8 semanas&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Se dan instrucciones sobre ejercicio isom&#233;tricos de fortalecimiento de cu&#225;driceps para inicio temprano seg&#250;n control del dolor</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Pacientes y resultados</span><p id="par0115" class="elsevierStylePara elsevierViewall">Se incluyeron 15 pacientes&#44; de los cuales 11 fueron hombres&#44; con edades comprendidas entre 20 y 55 a&#241;os&#44; con un promedio de 33 a&#241;os&#44; 9 rodillas izquierdas&#44; el mecanismo de trauma m&#225;s com&#250;n fue en el contexto de accidente de tr&#225;nsito&#44; motocicleta en 13 de los casos&#44; a 6 de ellos se les realiz&#243; otro abordaje asociado en el mismo tiempo quir&#250;rgico seg&#250;n los requerimientos por las caracter&#237;sticas de la fractura&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Una vez se obtuvo el consentimiento para participar en el estudio&#44; se les realizo escalas funcionales subjetivas para valorar la percepci&#243;n posterior al manejo quir&#250;rgico de las fracturas de platillos tibiales&#44; mediante este abordaje&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La escala funcional de rodilla de Lysholm es una escala subjetiva&#44; ha demostrado ser psicom&#233;tricamente aceptada&#44; y est&#225; dise&#241;ada para evaluar c&#243;mo se percibe funcionalmente el paciente&#46; Eval&#250;a 8 dominios &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#58; Cojera&#44; ayudas para la marcha&#44; sensaci&#243;n de bloqueo&#44; inestabilidad&#44; dolor&#44; edema&#44; subir escalones y agacharse con rodillas flexionadas&#46; Se da un puntaje de forma algor&#237;tmica obteni&#233;ndose un puntaje final donde 100 puntos indican el mayor nivel de funci&#243;n&#44; este puntaje se engloba en excelente de 95-100 puntos&#44; bueno de 84-94 puntos&#44; regular de 65-83 puntos y pobre de menos de 64 puntos&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Los resultados funcionales en escala de Lysholm fueron excelentes en 3 pacientes&#44; buenos en 8 y regulares en 4&#44; no hubo resultados pobres&#46; En todos los pacientes se logr&#243; una reducci&#243;n satisfactoria de la superficie articular de la tibia&#44; sin p&#233;rdida de altura de la misma&#44; con alineaci&#243;n adecuada&#44; sin s&#237;ntomas de inestabilidad&#44; todos con consolidaci&#243;n de la f&#237;bula que no retras&#243; la rehabilitaci&#243;n&#44; no hubo lesiones del nervio peroneal ni problemas con la piel&#59; se present&#243; un caso de infecci&#243;n superficial que se manej&#243; con antibi&#243;ticos orales sin complicaciones&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Pacientes con mejores resultados fueron en quienes el procedimiento se realiz&#243; de 6 a 18 meses antes de la evaluaci&#243;n y los pacientes con resultados menores a 84 puntos ten&#237;an fracturas muy complejas o menos de 3 meses de evoluci&#243;n desde la cirug&#237;a y a&#250;n se encontraban en plan de rehabilitaci&#243;n temprano&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discusi&#243;n</span><p id="par0140" class="elsevierStylePara elsevierViewall">El abordaje mediante nuestra t&#233;cnica modificada de osteotom&#237;a de la f&#237;bula&#44; puede ser considerado para el manejo las fracturas del platillo tibial posterolateral&#46; Permite una adecuada exposici&#243;n de la superficie articular deprimida&#44; con trazo cizallante o conminuto&#44; facilitando su reducci&#243;n y fijaci&#243;n&#46; Nuestros resultados no mostraron ninguna complicaci&#243;n mediante el uso de esta t&#233;cnica&#44; y aunque los resultados funcionales son alentadores&#44; es necesario mayor tiempo de seguimiento para definir adecuadamente los resultados posteriores a la rehabilitaci&#243;n&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">El abordaje descrito facilita una amplia exposici&#243;n de la superficie articular&#44; es t&#233;cnicamente f&#225;cil y reproducible&#44; permite la reducci&#243;n y fijaci&#243;n necesaria&#44; con menor riesgo de complicaciones&#44; favorece conservar el aporte vascular de la tibia proximal&#44; se evita el da&#241;o a la articulaci&#243;n tibiofibular proximal y se propicia una mayor &#225;rea de consolidaci&#243;n de la osteotom&#237;a&#46; &#201;sta t&#233;cnica puede utilizarse sola o en combinaci&#243;n con otros abordajes&#44; para fracturas agudas o cr&#243;nicas con mala uni&#243;n&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Financiaci&#243;n</span><p id="par0150" class="elsevierStylePara elsevierViewall">No se tuvo financiaci&#243;n de ninguna entidad&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicto de intereses</span><p id="par0155" class="elsevierStylePara elsevierViewall">Los autores declaran no tener conflicto de intereses para el desarrollo de este trabajo&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Agradecimiento</span><p id="par0160" class="elsevierStylePara elsevierViewall">Al Hospital Pablo Tob&#243;n Uribe por ser centro de formaci&#243;n acad&#233;mica e investigaci&#243;n</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Las fracturas del platillo tibial posterolateral exigen un abordaje que permita una buena visualizaci&#243;n de la superficie articular para su restituci&#243;n anat&#243;mica&#44; restablecimiento de la altura y un espacio adecuado para la aplicaci&#243;n del material de osteos&#237;ntesis y fijaci&#243;n estable&#46; Hay diversos abordajes descritos en la literatura que no proporcionan la visualizaci&#243;n deseada o conllevan m&#250;ltiples limitaciones y&#47;o complicaciones&#46; El prop&#243;sito de este estudio es describir una modificaci&#243;n a la t&#233;cnica quir&#250;rgica de la osteotom&#237;a de la f&#237;bula para el manejo de las fracturas de platillo tibial posterolateral&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materiales y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se presentan los resultados cl&#237;nicos de una serie de casos retrospectiva de 15 pacientes con fracturas de platillo tibial posterolateral que al momento del estudio ten&#237;an un seguimiento promedio de 6 meses&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Los resultados funcionales en escala de Lysholm fueron excelentes en 3 pacientes&#44; buenos en 8 y regulares en 4&#46; En todos los pacientes se logr&#243; una reducci&#243;n satisfactoria de la superficie articular de la tibia&#44; sin p&#233;rdida de altura de la misma&#44; con alineaci&#243;n adecuada&#44; sin s&#237;ntomas de inestabilidad&#44; todos con consolidaci&#243;n de la f&#237;bula que no retras&#243; la rehabilitaci&#243;n&#44; no hubo lesiones del nervio peroneal ni problemas con la piel&#59; se present&#243; un caso de infecci&#243;n superficial que se manej&#243; con antibi&#243;ticos orales sin complicaciones&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El abordaje descrito facilita una amplia exposici&#243;n de la superficie articular&#44; es t&#233;cnicamente f&#225;cil y reproducible&#44; permite la reducci&#243;n y fijaci&#243;n necesaria&#44; con menor riesgo de complicaciones&#44; con la cual se conserva el aporte vascular de la tibia proximal&#44; se evita el da&#241;o a la articulaci&#243;n tibiofibular proximal y se propicia una mayor &#225;rea de consolidaci&#243;n de la osteotom&#237;a&#46; &#201;sta t&#233;cnica puede utilizarse sola o en combinaci&#243;n con otros abordajes&#44; para fracturas agudas o cr&#243;nicas con mala uni&#243;n&#46; Consideramos que el abordaje con la t&#233;cnica descrita es una alternativa para el manejo de las fracturas posterolaterales&#44; con resultados alentadores&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Nivel de Evidencia&#58; IV</p></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Fractures of the posterolateral tibial plateau require an approach that allows a good visualization of the articular surface for its anatomical restitution&#44; restoration of height and an adequate space for the application of osteosynthesis material and stable fixation&#46; There are several approaches described in the literature that do not provide the desired visualization or involve multiple limitations and &#47; or complications&#46; The purpose of this study is to describe a modification to the surgical technique of the fibula osteotomy for the management of posterolateral tibial plate fractures&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We present the clinical results of a retrospective case series of 15 patients with posterolateral tibial plate fractures that at the time of the study had an average follow-up of 6 months&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Functional results in Lysholm scale were excellent in 3 patients&#44; good in 8 and regular in 4&#46; Good results were obtained in all patients with a reduction of the tibia articular surface&#44; without loss of height of the same&#44; with alignment adequate&#44; without symptoms of instability&#44; all with consolidation of the fibula that did not delay rehabilitation&#44; there were no peroneal nerve injuries or problems with the skin&#59; There was a case of superficial infection that was managed with oral antibiotics without complications&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The described approach facilitates a broad exposure of the articular surface&#44; is technically easy and reproducible&#44; allows the necessary reduction and fixation&#44; with a lower risk of complications&#44; with which the vascular supply of the proximal tibia is conserved&#44; the damage is avoided to the proximal tibiofibular joint and a greater area of consolidation of the osteotomy is favored&#46; This technique can be used alone or in combination with other approaches&#44; for acute or chronic fractures with poor union&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">We consider that the approach with the described technique is an alternative for the management of posterolateral fractures&#44; with encouraging results&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Evidence Level&#58; IV</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Discussion"
          ]
        ]
      ]
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    "multimedia" => array:3 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1809
            "Ancho" => 1505
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        "descripcion" => array:1 [
          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">T&#233;cnica quir&#250;rgica&#58; paciente en dec&#250;bito lateral &#40;si se requieren otros abordajes puede ubicarse dec&#250;bito prono&#41;&#44; referencias anat&#243;micas&#58; r&#243;tula&#44; tend&#243;n rotuliano&#44; superficie articular tibial&#44; cabeza de f&#237;bula&#44; sitio de la incisi&#243;n cut&#225;nea curvil&#237;nea &#40;en rojo&#41; &#40;A&#41;&#46; Se incide la piel y tejido celular subcut&#225;neo hasta identificar bandeleta iliotibial&#44; tend&#243;n del b&#237;ceps y posterior a este el nervio fibular com&#250;n&#44; el cual se libera con la rodilla en semiflexi&#243;n hacia proximal y distal para relajarlo&#44; y se repara sin traccionarlo&#46; &#40;B&#41;&#46; Se realiza artrotom&#237;a submeniscal y se fija el menisco a la c&#225;psula con puntos de sutura &#40;C&#41;&#46; Posterior a perforaciones con broca de 2&#46;4<span class="elsevierStyleHsp" style=""></span>mm&#44; se realiza osteotom&#237;a en dos planos con cincel&#44; respetando la articulaci&#243;n tibiofibular proximal &#40;D y E&#41;&#46; Se evierte la f&#237;bula osteotomizada &#40;F&#41;&#46;</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se evidencia exposici&#243;n que se logra&#44; con adecuada visualizaci&#243;n de todo el platillo lateral &#40;G&#41; Vs exposici&#243;n insuficiente sin la osteotom&#237;a descrita &#40;C&#41;&#46; Se procede a reconstruir y elevar platillo tibial posterolateral bajo visi&#243;n directa articular&#44; se aplica injerto &#243;seo de soporte a necesidad y se fija material de osteos&#237;ntesis planeado&#46; Posteriormente se fijan suturas capsulomeniscales a orificios de la placa&#44; se reduce la osteotom&#237;a de f&#237;bula y se fija con tornillo canulado de 3&#46;5 o 4&#46;5 paralelo a articulaci&#243;n tibiofibular&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 360
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        "descripcion" => array:1 [
          "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Esquema de la osteotom&#237;a modificada de la f&#237;bula&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabla 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="10" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Escala Lysholm&#58; Postoperatorio</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pte&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cojea&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Utiliza soporte para caminar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Se traba la rodilla&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Presenta inestabilidad&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Presenta dolor en rodilla&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Presenta inflamaci&#243;n en la rodilla&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Puede subir escalas&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Puede ponerse en cuclillas&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10 meses POP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 meses POP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5 meses POP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 meses POP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20 dias POP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">8 meses POP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 meses POP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 meses POP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 meses POP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Descripci&#243;n&#44; posibles respuestas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; NO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; NO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; NO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; NO&#44; NUNCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; NO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46; NO&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46; SIN PROBLEMAS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46; SIN PROBLEMAS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46; PERIODICAMENTE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46; BAST&#210;N O MULETA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46; SOLO SIENTE LA SENSACI&#211;N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46; A VECES CON EJERCICIO VIOLENTO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46; INCONSTANTE Y CON LIGERO EJERCICIO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&#46; CON ACTIVIDAD SEVERA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46; EMPEORO LIGERAMENTE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46; EMPEORO LIGERAMENTE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46; CONSTANTEMENTE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46; NO PUEDE APOYAR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46; SE TRABA OCACIONALMENTE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46; FRECUENTEMENTE&#44; NO HACE DEPORTE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46; MARCADO CON LA ACTIVIDAD SEVERA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46; CON ACTIVIDAD HABITUAL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46; UN ESCALON A LA VEZ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46; MAS ALLA DE 90&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">4&#46; SE TRABA FRECUENTEMENTE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#46; OCACIONALMENTE&#44; VIDA COTIDIANA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46; MARCADO DURANTE Y DESPUES DE CAMINAR MAS DE 2KM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#46; CONSTANTEMENTE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#46; IMPOSIBLE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46; IMPOSIBLE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46; ESTA BLOQUEADA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46; MARCADO DURANTE Y DESPUES DE CAMINAR MENOS DE 2KM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Puntajes que asigna la escala&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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