Navigated versus conventional total knee arthroplasty: A prospective study at three years follow-up. / Artroplastia total de rodilla navegada versus convencional; estudio prospectivo a 3 años de seguimiento.

OBJECTIVE: Computer-assisted surgery application in total knee arthroplasty (TKA) has shown more accurate implant alignment compared with conventional instrumentation and is associated with more homogeneous alignment results. Although longer implant survival and superior clinical outcomes should be expected from navigated TKA, currently available evidence does not support this hypothesis. The aim of this study was to compare navigated TKA with conventional TKA regarding clinical and radiological outcomes after a 3-year follow-up under the hypothesis that navigated TKA would provide better outcomes than conventional TKA. MATERIAL AND METHOD: In a prospective multicentre study, 119 patients underwent navigated TKA and 80 patients received conventional instrumentation. Patients were evaluated at the baseline and at postoperative months 3, 12, 24, and 36. Analysis included the American Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-12 (SF12) Health Survey, and radiographic assessment. RESULTS: All clinical scores improved significantly for all patients during the follow-up but were significantly better in the navigation group. The percentage of patients showing a mechanical axis between 3° of varus and 3° of valgus was significantly higher in the ATR group (93%) than in the conventional TKA group (71%) (P<.01). CONCLUSIONS: The use of computer-assisted surgery in TKA provides more accurate mechanical alignment and superior short-term functional outcomes compared to conventional TKA.

Frontal alignment in total knee arthroplasty. Comparative study between radiographic measurement and surgical navigation. / Alineación frontal en la artroplastia total de rodilla. Estudio comparativo entre medición radiográfica y con navegación quirúrgica.

OBJECTIVE: To establish the concordance between angulation of the femoro-tibial mechanical axis measured with x-rays and surgical navigation in both the pre and postoperative period after a total knee arthroplasty (TKA) was implanted. MATERIAL AND METHOD: Pre and postoperative measurements were analyzed in 88 TKA of the same model and all performed with the same surgical navigation system. The mechanical frontal angle (MFA) and femoro-tibial anatomic angle were measured before and after the TKA. The angulation was digitally measured with a teleradiography. In the navigation, the femoro-tibial angle at rest, forced varus and valgus were registered and the average of these three measurements was calculated. RESULTS: The mean preoperative MFA measured on the radiograph was 4.55°. The mean of the same angle measured on the postoperative radiograph was 1.72°, (p=0.05). The mean of the MFA measured with navigation before TKA was 3.12° and after the implant with navigation was 0.53 (P=.013). The concordance coefficient between the MFA in teleradiography and in navigation was 0.869 (P<.001) preoperatively and 0.709 postoperatively (P=.017). CONCLUSIONS: We found a strong concordance between radiographic and surgical navigation measurements of the MFA. This may imply that teleradiography is not necessary when using surgical navigation in TKA.

[Detection of metal ions in hair after metal-metal hip arthroplasty]. / Detección de iones metálicos en cabello tras artroplastia de cadera metal-metal.

OBJECTIVE: There is an increase in the levels of metals in the serum and urine after the implantation of some models of metal-metal hip prosthesis. It has recently been demonstrated that there is an association between these levels and the levels found in hair. The aim of this study is to determine the presence of metals in hair, and to find out whether these change over time or with the removal of the implant. MATERIAL AND METHOD: The levels of chromium, cobalt and molybdenum were determined in the hair of 45 patients at 3, 4, 5, and 6 years after a hip surface replacement. The mean age was 57.5 years, and two were female. Further surgery was required to remove the replacement and implant a new model with metal-polyethylene friction in 11 patients, 5 of them due to metallosis and a periarticular cyst. RESULTS: The mean levels of metals in hair were chromium 163.27 ppm, cobalt 61.98 ppm, and molybdenum 31.36 ppm, much higher than the levels found in the general population. A decrease in the levels of chromium (43.8%), molybdenum (51.1%), and cobalt (91.1%) was observed at one year in the patients who had further surgery to remove the prosthesis. CONCLUSIONS: High concentrations of metals in the hair are observed in hip replacements with metal-metal friction, which decrease when that implant is removed. The determination of metal ions in hair could be a good marker of the metal poisoning that occurs in these arthroplasty models.

Timeliness of care and prognosis in patients with lung cancer.

BACKGROUND: Timeliness of care is an important dimension of health care quality. The determining factors of less timely care and their influence on the survival of patients with lung cancer (LC) remain uncertain. AIMS: To analyse the delays in the diagnosis and treatment of LC in our health area, the factors associated with the timeliness of care and their possible relationship with the survival of these patients. METHODS: A retrospective study was conducted on all patients with a cytohistologically confirmed diagnosis of LC between 1 June 2005 and 31 May 2008. The time delays for consultation (specialist delay), diagnosis (diagnosis delay), and treatment (treatment delay), were analysed, as well as the factors associated with these delays and the influence of the timeliness of care on survival. RESULTS: A total of 307 cases were included (87 % males). The mean specialist delay was 53.6 days (median 35 days), diagnosis delay 31.5 days (median 18 days), treatment delay 23.5 days (median 14 days). The greater age of the patient and a more advanced stage were associated with a shorter specialist delay. Male sex, a more advanced stage, and poor general status were associated with a shorter treatment delay. The survival is longer in patients with a longer treatment delay. CONCLUSIONS: The delay in the diagnosis in our population seems to be excessively long. The greater the age, a more advanced tumour stage, male sex, and poor general health status are associated with shorter delays. A longer treatment delay is associated with a longer survival.

[Lung cancer in the Pontevedra health area: incidence, clinical presentation and survival]. / Cancer de pulmon en el area sanitaria de Pontevedra: incidencia, presentación clinica y supervivencia.

BACKGROUND: To describe the clinical and epidemiological characteristics, and survival of patients with lung cancer (LC) in the Pontevedra Health Area. METHODS: A retrospective observational study was conducted on all patients with a diagnosis of LC in the Pontevedra Hospital Complex (CHOP) health area over a three-year period. The data recorded included, age, gender, smoking history, comorbidity, functional status, diagnostic method, histology type, stage, treatment received, and survival. The patients were followed up for 3 years. RESULTS: A total of 358 cases of LC were included in the study, which gave a crude incidence rate adjusted to the standard European population of 37.33/100,000 inhabitants/year in males and 4.88/100,000 inhabitants/year in females. The large majority were males (87%). The mean age was 68.7 years, and 82% were smokers or ex-smokers. The most common histology type was epidermoid, with 35.2% of the cases. The diagnosis was made in stages III-B or IV in 79% of cases. Chemotherapy was the first treatment in 53% of the cases. Survival after the first year was 25%, which decreased to 4% at the third year. CONCLUSIONS: The incidence of LC in our health area continues to be mainly in male smokers, although the incidence in females and in people who never smoked is higher than in other populations in our country. It is diagnosed in the advance stages of the disease, and survival is poor.

Truck traffic related air pollution associated with asthma symptoms in young boys: a cross-sectional study.

OBJECTIVES: The aim of this study was to evaluate the influence of intensity of truck traffic on asthma symptomatology, and its relationship with age and gender. STUDY DESIGN: A cross-sectional study was conducted on children and adolescents from Galicia (North-West Spain). METHODS: Following the methodology of the International Study of Asthma and Allergies in Childhood (ISAAC): children from schools randomly selected, answered a self-administered questionnaire included questions on asthma symptoms and some risk factors. The association between self-reported truck traffic on the street of residence and symptoms of asthma were investigated by logistic regression adjusted for body mass index, maternal education and parental smoking. RESULTS: Almost 40% of children in Galicia are exposed to the frequent and constant passing of heavy goods vehicles. The odds of 6-7 year-old boys having severe or exercise induced asthma is tripled when they live in streets with the constant passing of heavy goods vehicles, compared with those living in streets where these vehicles never pass. In adolescents and 6-7 year-old girls, no relationship was observed between truck traffic and asthma symptoms. CONCLUSIONS: The results of this study appear to support a distinct effect of truck traffic on asthma symptoms depending on the age and sex of the exposed population, being more harmful for young males.

Obesity and asthma: an association modified by age.

BACKGROUND: Some studies indicate some causal relationship between obesity and asthma, while others show inconsistent results. Our objective was to evaluate the prevalence of asthma according to obesity in children. METHODS: A cross-sectional study, following the ISAAC study methodology, was conducted on two randomly selected groups consisting of 6-7 year-old children (n=7485) and 13-14 year-old adolescents (n=8496). The asthma symptoms and potential risk factors were determined from the questionnaire. Overweight and obesity were defined based on the body mass index. Multiple logistic regression was used to obtain adjusted prevalence odds ratios (OR) and 95% confidence intervals. RESULTS: Obesity was associated with an increase in wheezing ever (OR: 1.35) and exercise-induced asthma (OR: 1.62) in the 6-7 year-old group. No significant relationship was observed in the adolescent population. CONCLUSION: Obesity was associated with a higher prevalence of asthma in young children, but not in adolescents.

Endovascular treatment for pseudoaneurysms after surgical correction of aortic coarctation.

Late complications after surgical repair of aortic coarctation are not uncommon. Among these complications pseudoaneurysms are the most frequent complications, occurring between 3 and 38%. Reoperation in these patients is associated with high morbidity and mortality. In the last decade, endovascular techniques emerged as an alternative to conventional surgery with excellent results. We report the case of two patients who presented with pseudoaneurysms after surgical correction for aortic coarctation, which were treated by endovascular means.

Treatment of innominate arterial stenosis with self-expanding stent: long-term follow-up.

We report our experience with the use of a self-expanding stent in the treatment of a severe innominate artery stenosis resulting in right upper limb ischemia. A 45-year-old woman was admitted for right upper limb ischemia, asymmetry of the carotid pulse and the lack of pulse in the right upper extremity. The patient had a history of chain smoking, hypertension, hypercholesterolemia, and acute myocardial infarction one year ago. She was diagnosed of the innominate artery stenosis by angiography one year ago at another hospital. At the time of admission her blood pressure was normal in the left arm and absent in the right upper limb. Arteriography showed a severe stenosis subocclusion of the innominate artery with an inverse flow of the ipsilateral vertebral artery. As the patient was not considered to be a surgical candidate due to instable angina, stent placement was indicated. After placement through an axillary approach an angiogram showed a patent right subclavian artery without residual stenosis. Angiographic follow-up showed a patent innominate arterial lumen two years after the procedure. The patient continued to be asymptomatic during six years follow-up. Blood pressure remained normal in both upper extremities, without any ischemic signs. Our experience indicates that placement of an endovascular stent is an effective therapeutic option in selected patients with symptomatic stenosis in the innominate artery when a surgical treatment is contraindicated.

[Spinal cord infarction and recurrent venous thrombosis in association with estrogens and the 20210A allele of the prothrombin gene]. / Mielopatía aguda isquémica y trombosis venosa recurrente asociada a estrógenos y alelo 20210A del gen de la protrombina.

The acute spinal cord infarction is a rare cause of acute-onset paraplegia. Furthermore, it is specially uncommon that the infarction occurs in patients with apparent low predisposition to vascular disease. The 20210A allele of the prothrombin gene (causing a threefold-increased risk in venous thromboembolism) was recently associated with unexplained spinal cord infarction in young women under treatment with estrogens (contraceptive pill). We report a case of anterior spinal artery syndrome resulting from an ischaemic infarction at the anterior aspect of the spinal cord in a healthy 50-year-old woman, carrying this mutation, being the first published case under treatment with transdermal estradiol. She referred the typical sudden-onset back pain associated to clinical anterior spinal artery syndrome with sphincter dysfunction and nontraumatic paraplegia. A possible multiple sclerosis was ruled out and the steroids or immunoglobulin therapy induced no clinical improvement. Cerebrospinal fluid and other investigations were all negative. Sequential MRI scans revealed development of spinal cord infarction from T10 to T11, with increased signal in T2-weighted image (T2). Because she referred a previous thrombophlebitis and suffered a deep-vein thrombosis one month after paraplegia, a complete coagulation study was performed. Antithrombin, proteins C and S, homocysteine, factor V Leiden, lupus anticoagulant and anticardiolipin antibodies were all normal or negatives. In opposite, the 20210A variation was positive (heterozygous) and the factor VIIIc level was very high (280 U/dl eight months later). We argue the relative importance of both findings. The patient had no a substantial recovery over a period of 20 months.Certainly, the prothrombin 20210A seems to be associated with unexplained ischemic myelopathy among the young women with estrogens.

Normal frequencies of the C677T genotypes on the methylenetetrahydrofolate reductase (MTHFR) gene among lymphoproliferative disorders but not in multiple myeloma.

The folate availability seems to be critical for the DNA integrity since it is required for the transfer of methyl groups in the biosynthesis of thymidilate. Although the excessive incorporation of uracils to the DNA can be efficiently removed, this mechanism of reparation produces many double-strand breaks from two opposing nicks. Several chromosomal abnormalities (mainly translocations and deletions perhaps not well understood) are involved in the origin of lymphoproliferative disorders. The TT homozygosity at nucleotide 677 in the gene of methylene tetrahydrofolatereductase (MTHFR), a key enzyme in folate metabolism, was recently linked to a significant protection against colon carcinoma and acute lymphoblastic leukaemia in adults. We analysed the genotype frequencies of C677T-MTHFR in a group of 143 patients with lymphoproliferative disorders (REAL classification) and 200 controls. Overally, the frequencies of the polymorphic allele were similar (35.3% and 32.0% respectively)(P=0.6). We did not find differences between patients and controls except for myeloma/plasmacytoma group (n=26) which showed a CC genotype less than expected (19% vs 46%) (p=0.01) with a frequency ratio of 0.28 (0.10-0.77). Even among the IgG myeloma cases only one patient showed a common genotype (CC) (1/15, 7%) (P=0.003). If these preliminary data are validated with prospective studies, the 677C allele of MTHFR gene could be confirmed as an effective multiple myeloma protective factor (specially for the IgG cases).

Diagnosis and percutaneous treatment of gastrointestinal hemorrhage. Long-term experience.

OBJECTIVE: to report our experience in the diagnosis and treatment of gastrointestinal hemorrhage. METHOD: from April 1987 to April 1997, 196 patients with gastrointestinal hemorrhage (134 men and 62 women) were studied. 165 (84%) were diagnosed as presenting upper gastrointestinal hemorrhage, and 31 (16%) presented lower gastrointestinal hemorrhage. The patients were studied with endoscopy and arteriography, and embolization was prescribed in 131 (67%). Patients with bleeding from esophageal varices were excluded from this study. RESULTS: a bleeding point was identified angiographically in 33% (n = 65) patients. 131 (67%) patients were treated with therapeutic embolization, which was successful in 89% (n = 116) patients. The bleeding was resolved in 80% (n = 93) of the patients. Complications included arterial spasm (n = 12), pain (n = 24), coil migration (n = 8), allergic reaction (n = 2) and celiac trunk dissection (n = 2). During follow-up 16 patients presented rebleeding that stopped after reembolization in 9 cases, whereas in 7 cases surgery was needed. CONCLUSIONS: in our experience, diagnostic angiography and percutaneous therapeutic embolization are effective, less aggressive methods that lead to few complications. Both methods have become indispensable tools in managing patients with gastrointestinal hemorrhage that does not respond to conservative therapy. Even in patients with no evidence of angiographic bleeding, embolization in selected patients is successful.

Superior and inferior limb ischaemia in giant cell arteritis: angiography follow-up.

Giant cell arteritis most often affects the superficial temporal artery. Arterial territories such as the facial, carotid, myometrial and upper and lower limb arteries may be affected. In this paper we describe the case of a 52-year-old patient with upper and lower limb ischaemia who presented with grade III ischaemia in the left lower limb. Giant cell arteritis was diagnosed as responsible for the symptoms. After treatment with corticoids, an angiographic improvement was evidence after 2-year period. The low number of reported cases, the diverse symptoms and varied course make diagnosis of GCA difficult. Therefore, GCA must be taken into consideration in the ischaemia of inferior and superior limbs whether isolated or simultaneous.

Transcatheter embolization of symptomatic hepatic venous malformations.

The aim of this study was to evaluate our results in treatment and management of symptomatic hepatic venous malformations using transcatheter embolization therapy. From 1991 to 1997 five venous malformations were embolized in one man and four women ranging in age from 31 to 50 years. All patients presented nonspecific abdominal pain and were assessed in the general surgery unit. Percutaneous embolization was recommended. In all cases polyvinyl alcohol was used to embolize the afferent arterioles. Clinical and echographic control follow-up was carried out on an outpatient basis in our Vascular and Interventional Radiology Unit. Embolization was possible in all cases. No complications developed during the procedure, except in one case where the subject suffered a spasm of the hepatic artery. Mean follow-up time was 42 months (6-73 months). Four patients remained asymptomatic during the entire follow-up period, whereas one patient required reembolization. In our experience, transcatheter embolization of hepatic venous malformations is a noninvasive technique which requires few admissions and presents few complications. With further use, it could become the treatment of choice in symptomatic hepatic venous malformations as an alternative to surgery.

[Treatment of dysphagia of malignant origin with the endoprosthesis of Strecker]. / Tratamiento de la disfagia de origen maligno con endoprótesis de Strecker.

OBJECTIVE: To evaluate the effectiveness of metallic Strecker stents for palliation of malignant dysphagia. PATIENTS AND METHODS: From June 1992 to August 1995, 66 Strecker stents were inserted in 55 consecutive patients, 50 male and 5 female, with a mean age of 62 years (range 25-83). The cause of dysphagia was incurable malignant obstruction of the esophagus. Three patients presented with dysphagia grade I, 8 grade II, 27 grade III and 17 grade IV. All the procedures were performed under fluoroscopic control. RESULTS: Exact positioning of the stent was technically feasible in all patients. No procedure-related mortalities or major complications occurred. Immediate complications were transient chest pain (n = 11), blood stain sputum (n = 8) and gastroesophageal reflux (n = 8). During follow-up, 7 patients (12.7%) had recurrent dysphagia due to tumor ingrowth or overgrowth. In these patients an additional overlapping stent was successfully placed in six cases and balloon dilatation in one. Latest evaluation revealed dysphagia grade O in five patients (9%), 10 dysphagia grade I (18%), 14 grade II (25%), 13 grade III (23.6%) and seven grade IV. CONCLUSIONS: Implantation of Strecker stents is an effective and safe method of palliating severe malignant dysphagia. Placement of the stents was feasible without major procedure complications.