Conceptos actuales: ventajas del clavo endomedular para fracturas del húmero proximal / Current concepts: advantages of intramedullary nail for proximal humerus fractures

Las fracturas de húmero proximal (FHP) son una de las fracturas más frecuentes en la población anciana. La reducción abierta y fijación interna (RAFI) generalmente está indicada para pacientes con una FHP desplazada en jóvenes o pacientes mayores con alta demanda funcional y buena calidad ósea. No se ha llegado a un consenso sobre la técnica de fijación ideal. La RAFI con placas ha sido la más utilizada, pero se han reportado altas tasas de reintervenciones y complicaciones globales en la literatura. La necesidad de agregar técnicas de aumentación a la RAFI con placas bloqueadas en fracturas complejas puede resultar en un tiempo quirúrgico más largo, abordajes extensos y mayores costos. Debido a esto, se hace necesario considerar otras opciones para la osteosíntesis de FHP. Con una mayor comprensión de los mecanismos de falla de la osteosíntesis, la fijación intramedular se ha convertido en una opción de tratamiento aceptada para las FHP con ventajas biomecánicas y biológicas. La fijación intramedular para las FHP ha demostrado menor tiempo quirúrgico, sangrado intraoperatorio, tiempo hasta la unión ósea y menores tasas de infecciones, que las placas bloqueadas. La fijación intramedular es una opción válida para que las fracturas complejas se resuelvan con un implante que por sí solo puede satisfacer en gran medida todas las necesidades de aumento requeridas por una placa bloqueada

Proximal humeral fractures are one of the most frequent fractures in the elderly population. Open reduction and internal fixation (ORIF) is generally indicated for young patients and older patients with high functional demands and good bone quality. No consensus has been reached regarding the ideal fixation technique. Although ORIF with plates is the most widely used technique, high re-intervention rates and global complications with locked plate fixation have been reported in the literature. Addition of augmentation techniques to locked plate fixation in complex fractures may result in longer surgical times, extensive approaches, and higher costs. Therefore, considering other options for ORIF is necessary. With a greater understanding of the mechanisms of fixation failure, intramedullary fixation has become the accepted treatment option for proximal humeral fractures considering the specific biomechanical and biological advantages. Compared with ORIF with locked plates, intramedullary fixation for proximal humeral fractures has low surgical time, intraoperative bleeding, time to bone union, and rate of infections. Intramedullary fixation is a valid option to resolve complex fractures with an implant that may largely supply all the augmentation requirements of a locked plate.

Osteotomia valguizante de tibia aditiva medial: analisis de dos tipos de implante / Valgus tibial osteotomy. Two surgical alternatives

La osteotomía valguizante de tibia es un procedimiento comúnmente utilizado para la corrección del deseje en varo con el objetivo de restaurar el eje neutro. Existen dos alternativas quirúrgicas: osteotomía de apertura y de cierre. Los implantes utilizados para la osteotomía de apertura ofrecen ciertas ventajas y también desventajas. El objetivo de esta nota técnica es describir y comparar dos tipos de implante diseñados para las osteotomías valguizantes de tibia proximal: la placa Puddu y la placa TomoFix™. Nivel de Evidencia: V

The valgus tibial osteotomy is a procedure commonly used for the correction of the varus displacement with the objective of restoring the neutral axis. There are two surgical alternatives, opening and closing osteotomy. The implants used for opening osteotomy offer certain advantages and disadvantages. The objective of this technical note is to describe and compare two types of implants designed for valgus osteotomies of the proximal tibia: the Puddu plate and the TomoFix™ plate. Level of Evidence: V

Analysis of Intraoperative Exposure to X-rays and Surgical Time in Different Techniques for Fixation of Transtrochanteric Fractures of the Femur / Análise da exposição intraoperatória ao raio X e do tempo cirúrgico em diferentes técnicas de fixação das fraturas transtrocanterianas do fêmur*

Abstract Objective The present study aimed to evaluate and compare the total surgical procedure time and intraoperative X-ray exposure during different techniques for fixation of transtrochanteric fractures of the femur in elderly patients, using extramedullary and intramedullary methods based on cephalic traction screws. Methods The Orthopedics and Traumatology Service from our hospital evaluated 107 patients with transtrochanteric fractures, including 34 males and 73 females, with age ranging from 61 to 101 years old. Fracture fixation was performed with a dynamic hip system (DHS) in 21 patients, a standard proximal femoral nail (PFN) in 55 subjects, and a standard gamma nail in 31 patients. All procedures were performed by the same surgeon and his team of nursing assistants, along with the same radiology technician using the same image intensifier. Total surgery time (in minutes) and X-ray emission (in centigrays [cGy]) were evaluated. Results Transtrochanteric fracture fixation with PFN provides a significantly shorter surgical time (p = 0.013) in comparison to the 2 other techniques. Intraoperative exposure to X-rays was significantly lower when using DHS (p = 0.015) as a fixation method when compared with gamma nail and PFN. Conclusion Although PFN resulted in the shortest surgical time, DHS was associated with the lowest X-ray exposure levels within the studied sample.

Resumo Objetivo Avaliar e comparar o tempo total do procedimento cirúrgico e a exposição ao raio X no intraoperatório em diferentes técnicas de fixação das fraturas transtrocanterianas do fêmur em pacientes idosos, utilizando técnicas extramedulares e intramedulares baseadas em parafuso de tração cefálico. Métodos Foram avaliados no serviço de ortopedia e traumatologia do nosso hospital 107 pacientes com fraturas transtrocanterianas, sendo 34 do sexo masculino e 73 do sexo feminino, com idade mínima de 61 anos e máxima de 101 anos. As fraturas fixadas, utilizando a técnica com dynamic hip system (DHS, na sigla em inglês) somaram 21 pacientes; em 55 pacientes, foi utilizado o proximal femur nail (PFN, na sigla em inglês) standard; e em 31 idosos, foi optado pelo uso do gama nail standard. Todos os procedimentos foram realizados pelo mesmo cirurgião acompanhado de sua equipe de auxiliares de enfermagem, assim como pelo mesmo técnico de radiologia manuseando o mesmo intensificador de imagens. Foram avaliados o tempo total da cirurgia (em minutos) e a emissão de raios X medida em centigrays. Resultados A fixação das fraturas transtrocanterianas com PFN proporciona um menor tempo cirúrgico com uma diferença estatística significativa (p =0,013), quando comparada com as demais técnicas utilizadas entre os grupos envolvidos. Foi observada, também, uma menor exposição intraoperatória aos raios X (p =0,015), a qual foi estatisticamente relevante quando utilizado o DHS como método de fixação comparado com o gama nail e o PFN. Conclusão Apesar do PFN ter o menor tempo de cirurgia, a técnica do DHS se mostrou com menores níveis de exposição dentro da amostra estudada.

Empleo de osteosíntesis recubierta de cemento con antibiótico en el tratamiento de la osteomielitis. Presentación de dos casos / Osteomyelitis treatment with antibiotic cement-coated plate fixation. Two case reports

El tratamiento de la osteomielitis asociada a la falla de la osteosíntesis representa un verdadero desafío para el cirujano ortopédico. El retiro del implante, la limpieza quirúrgica del área afectada y la fijación externa como métodos de estabilidad transitoria, sumados a la administración de antibióticos por vía sistémica son conductas habituales en el manejo inicial de la infección asociada a la falla del implante. No obstante, la suma de estas medidas puede no ser suficiente para controlar completamente el cuadro. El agregado local de cemento con antibiótico permite la liberación continua y sostenida del agente que alcanza una concentración local significativamente más alta que las concentraciones inhibitorias bacterianas mínimas necesarias, a expensas de una menor toxicidad sistémica. Se presentan dos casos de osteomielitis asociada a la falla de la osteosíntesis tratados mediante una nueva síntesis con placa revestida de cemento con antibiótico. Se logró controlar la infección y la consolidación ósea en ambos casos. El resultado funcional fue excelente con un puntaje QuickDASH de 6,3 y 4,5, respectivamente. Nivel de Evidencia: IV

Treatment of osteomyelitis associated with osteosynthesis failure represents a real challenge for the orthopedic surgeon. Implant removal, surgical debridement of the affected area, and external fixation as a temporary stabilization method coupled with antibiotic therapy administered by the systemic route constitute the basis for the initial management of infections associated with implant failure. However, this combined management may prove inadequate to achieve complete control of the infection. The local use of antibiotic-loaded cement allows for maintaining a sustained agent release that reaches significantly higher concentrations than the minimum required bacterial inhibitory concentrations while reducing the associated systemic toxicity. We present two cases of osteomyelitis associated with osteosynthesis failure treated with a second osteosynthesis procedure with an antibiotic cement-coated plate. Infection control and bone union were achieved in both cases. The functional outcome was excellent with Quick-DASH scores of 6.3 and 4.5 points, respectively. Level of Evidence: IV

Treatment of floating knee injury in children with elastic intramedullary nail / 中国骨伤

OBJECTIVE@#To observe the clinical effect of elastic intramedullary nail in minimally invasive treatment of floating knee injury in children.@*METHODS@#From January 2009 to September 2017, 11 children with floating knee injury were treated with one-off open reduction and elastic intramedullary nail or external fixator fixation, including 7 males and 4 females, aged 5.0 to 11.0 years, with an average age of 8.3 years. The treatment results were evaluated according to karlstrom's standard.@*RESULTS@#Eleven patients were followed up for 8 to 48 months, with an average of 28 months. All the fractures healed at one time, and there were no complications such as nonunion, malunion and serious dysfunction of knee joint. The length of the affected limb in 2 cases was 1.2 to 1.5 cm longer than that in the opposite side without shortening. According to Karlstrom scoring standard, 8 cases were excellent, 1 case was good and 2 cases were middle.@*CONCLUSION@#Elastic intramedullary nail minimally invasive treatment of floating knee injury in children is a safe and effective treatment, which can effectively reduce the fracture and promote bone healing, which is conducive to early functional recovery.

Research progress on finite element analysis of internal fixation for clavicular fracture / 中国骨伤

Clavicular fracture is a common upper limb fracture. Because of its special anatomical structure, it directly affects the function of the shoulder joint. The different injury mechanisms of clavicular fracture affect the mechanical effect of internal fixation, so the selection of internal fixation method has been puzzling orthopedists. As a modern computer based mechanical analysis, finite element analysis application in the internal fixation of clavicular fracture can not only clarify the pathogenesis of fractures, biomechanical properties of internal fixators and complications of fractures, but also provide guidance for preoperative planning. Therefore, it is beneficial to preoperative planning and individualized selection of surgical methods, and is expected to become an indispensable part in preoperative planning for clavicular fracture. In this paper, the pathogenesis, related influencing factors, selection of internal fixation and postoperative complications of clavicular fracture based on finite element analysis and problems during finite element analysis were reviewed.

Comparação biomecânica de CRIF e placa de reconstrução na estabilização de fraturas distais de fêmur em cães / Biomechanical comparison of CRIF and reconstruction plate for stabilization of distal femur fractures in dogs

O presente estudo objetivou comparar, biomecanicamente, por meio do ensaio de compressão excêntrica, a resistência dos implantes Clamp and Rod Internal Fixation (CRIF) 5,0mm e placa de reconstrução 3,5mm na fixação de fraturas distais de fêmur de cão. Foram utilizados 22 fêmures de 11 cadáveres de cão entre 2 e 7 anos de idade e peso corporal entre 20 e 40kg e subdivididos em dois grupos, denominados grupo CRIF (GC - 11 fêmures) e grupo placa (GP - 11 fêmures). Para realização dos testes, foi simulada falha que mimetizasse uma fratura distal nos corpos de prova, por meio de uma osteotomia de até 0,5cm, realizada com auxílio de serra oscilatória, imediatamente proximal ao início da tróclea. Os implantes foram fixados segundo os padrões AOSIF, lateralmente ao fêmur, sendo utilizados três parafusos distais e cinco proximais ao foco de fratura. Foi empregado o programa de computador PMI para calcular o ponto máximo de resistência antes da falha e avaliaram-se as variáveis força máxima, deformação máxima real, rigidez, força intermediária e deformação intermediária real. Não foram encontradas diferenças estatisticamente significativas entre os GC e GP quanto às variáveis avaliadas, sugerindo que ambos os implantes são boas opções de fixações para tais fraturas.(AU)

This study aims to compare the biomechanical properties, through compression eccentric test, of the resistance of the 5.0mm Clamp and Rod Internal Fixation Implants (CRIF) and 3.5mm reconstruction plate in fixing dog femur distal fracture. It was used 22 femurs from 11 dog cadavers with age between 2 and 7 years old and body weight between 20 and 40kg, subdivided into two groups, called CRIF Group (CG - 11 femurs) and plate group (PG - 11 femurs). A distal fracture in the specimens with a gap of 0.5cm osteotomy, was simulated to perform the test, performed by the oscillating saw, just proximal to the beginning of the trochlea. The implants were fixed by the standards AO / SIF, laterally to the femur, using three distal screws and five proximal to the fracture site. PMI computer program was used to calculate the maximum point of resistance before failure and evaluated the variables maximum strength, real maximum deformation, stiffness, intermediate strength and real intermediate deformation. No statistically significant differences were found between the GC and GP as the variables evaluated, suggesting that both implants are good fixation options for such fractures.(AU)

Dispositivos interespinosos en discectomías lumbares primarias: ¿Favorecen la recurrencia de la hernia de discos? / Use of interspinous process devices in primary lumbar discectomy. Does it promote recurrent disc herniation?

Objetivo: Evaluar si la colocación de los dispositivos interespinosos siliconados tipo DIAM favorecen una tasa más alta de recidiva de la hernia discal homolateral clínica y por imágenes comparada con la discectomía pura. Materiales y Métodos: Se realizó un estudio prospectivo, observacional, aleatorizado desde mayo de 2009 hasta mayo de 2013, en nuestro Centro. Se evaluó a 123 pacientes, 3 se perdieron en el seguimiento; la muestra incluyó 120 sujetos. Todos fueron operados por el mismo equipo quirúrgico. Se formaron dos grupos: grupo A: discectomía más colocación de dispositivo interespinoso siliconado, 30 pacientes (16 mujeres y 14 hombres), con mayor frecuencia L4-L5 (27 pacientes, 90%) y grupo B: discectomías puras, 90 pacientes (53 mujeres y 37 hombres) con más frecuencia L4 y L5 (72 pacientes, 80%). Resultados: Seis de los pacientes del grupo A (20%) tuvieron una recidiva clínica y por imágenes, y 3 (10%) fueron operados nuevamente; en el grupo B, hubo 4 recidivas discales (4,4%), uno fue operado nuevamente (1,1%). Se hallaron diferencias significativas en las tasas de recidiva y reintervención entre los grupos (p = 0,0073 y p = 0,0188, respectivamente). Conclusiones: Los beneficios de los dispositivos interespinosos para tratar el canal estrecho lumbar secundario a hernia de disco son controvertidos, pero en nuestro estudio, se halló una diferencia significativa según el grupo. Al mantener el movimiento del segmento y cambiar ligeramente las cargas fisiológicas aumentarían la tasa de recidiva discal; no obstante, son necesarios estudios con mayor evidencia científica para corroborar estas tendencias. Nivel de Evidencia: III

Objective: The objective of this study was to determine if discectomy with placement of an interspinous DIAM silicon spacer is associated with a different rate of clinical and radiological recurrent ipsilateral disc herniation compared to discectomy alone. Methods: A prospective, observational, randomized study was performed from May 2009 to May 2013 at our center. Of the 123 patients included in the study, 3 were lost to follow-up, leaving 120 patients for data analysis. All patients were operated on by the same surgical team. Patients received one of two types of treatment. Group A consisted of 30 patients (16 women and 14 ment) who underwent discectomy with placement of an interspinous DIAM silicone spacer. Group B was comprised of 90 patients (53 women and 37 men) treated by discectomy alone. Results: Discectomy at L4-L5 level was the most common approach, being performed in 90% (27) of Group A patients and 80% (72) of Group B patients. Group A demonstrated clinical and radiological recurrent disc herniation in 6/30 (20%) patients. Recurrent disc herniation developed in 4/90 (4.4%) of Group B patients. One patient underwent surgical revision (1.1%). Both recurrence and surgical revision were significantly higher in Group A (p = 0.007 and p = 0.019, respectively). Conclusions: The benefits of interspinous devices for the treatment of the lumbar spinal stenosis secondary to disc herniation are controversial, and this study showed a significant intergroup difference. In this study, patients that underwent discectomy and interspinous spacer placement had higher revision and recurrence rates than discectomy patients that did not receive an interspinous spacer. Interspinous spacers may increase the rate of disc herniation by preserving movement at the level of the original disc herniation and changing the physiologic load. Further studies are needed to corroborate and evaluate these trends. Level of Evidence: III

Experience with Wang procedure for treatment of pectus excavatum in young children / 南方医科大学学报

OBJECTIVE@#To review the experience with Wang procedure for treatment of pectus excavatum in young children.@*METHODS@#The clinical data of 21 children with a mean age of 3.3 ± 1.1 years (ranging from 1.5-6 years) undergoing Wang procedure for pectus excavatum were analyzed. A longitudinal incision (1 to 2 cm) was made in the front of the xiphoid, and two tunnels were created using steel bars beneath the muscles on two sides of the chest wall. The fibrous tissue between the diaphragm and the sternum was dissociated, and the steel wires were sutured through the deformed chest wall. After the steel bar was placed in the tunnels, the wires were pulled and fixed in the middle of the bar, and the incision was sutured.@*RESULTS@#All the operations were performed using 3 wires and 1 steel bar. The operation time was 25 to 51 (38.1 ± 9.6) min with an intraoperative bleeding volume of 5 to 10 (7.1±1.5) mL. The time of hospitalization of the patients ranged from 6 to 10 days (mean 8.1±1.3 days). In all the patients, the incision healed smoothly without serious pain or obvious complications. All the patients were followed up for 1 to 13 months after the operation. During the follow- up, no recess recurred and no such complications as bar displacement or transposition occurred. According to the evaluation criteria after pectus excavatum operation, 13 cases had a total score of 9, and 8 had a total score of 8. The overall effect was satisfactory, and there were no cases rated as basically satisfactory or unsatisfactory.@*CONCLUSIONS@#Wang procedure is a good option for treatment of pectus excavatum in young children.

Outcomes of Combined Neck and Trochanter Fractures of the Femur Treated with Cephallomedullary Nail in Elderly / 대한고관절학회지

PURPOSE: Proximal femur fractures are classified into intracapsular neck fractures and extracapsular trochanteric fractures, and several related treatment recommendations in elderly patients have already been introduced. Importantly, we have observed cases of combined intra and extracapsular fractures (i.e., ipsilateral neck and trochanter fractures). The purpose of this study is to report the outcomes of combined neck and trochanter fractures of the femur treated with cephalomedullary nail (CMN) in elderly patients. MATERIALS AND METHODS: From January 2010 to December 2014, 410 patients with proximal femoral fractures were fixed using CMN; among this group, 37 patients with combined neck and trochanter fractures were identified. Two of these patients died fewer than three months after injury and another two did not return for follow-up. Thirty-three patients were included and reviewed retrospectively in this study. RESULTS: All patients were injured by simple fall. Bone union was obtained in 28 of 33 patients. Of the five patients who failed treatment, three experienced implant penetration through head (cut-through and cut-out), one had breakage of CMN and the last one had a loosening of internal fixation device with persistent non-union at final follow-up. The former four patients underwent hip replacement surgery and the latter refused surgery because he had low demand in daily life and many medical problems. CONCLUSION: Eighty-five percent of elderly patients with combined neck and trochanter fractures of the femur treated with CMN achieved bone union; these complex fractures require more accurate reduction than usual extra-articular intertrochanteric fractures.

Cobalt chromium-Titanium rods versus Titanium-Titanium rods for treatment of adolescent idiopathic scoliosis; which type of rod has better postoperative outcomes?

SUMMARY OBJECTIVE; Compare the outcome of spinal deformity correction between Ti-Ti and CrCo-Ti rods for the treatment of spinal Adolescent Idiopathic Scoliosis (AIS) using rods mentioned with all pedicle screws and translation technique. METHOD; 59 patients operated for spinal deformity (Lenke 1 or 2) AIS. The patients were divided into two groups by random allocation using Ti-Ti rods (n = 29) and CrCo-Ti rods (n = 30) and the alone difference among them in the surgical procedure was rod material (Ti-Ti or CrCo-Ti rods) and finally, radiological outcomes were compared preoperatively, postoperatively and at last follow-up for 12 months. RESULTS; Patients' main curve correction after surgical procedure regardless type of rod was 48.95±11.04 (13-75) degree. Success rate of spinal deformity correction following surgical procedure regardless of type of administered rod was 86.76 ± 11.30 percent (62.5-100%). Mean of deformity correction rate was 91.49±10.67% using CrCo-Ti rods versus 81.86±9.88% using Ti-Ti rods (P-value=0.01). Angle change was 3.29±6.60 for kyphosis angle and 0.59±7.76 for lordosis angle. Rate of main curve correction was not significantly different considering patients' gender (P-value0.657). Main curve correction success rate was in association with patients' age and type of rod (P-value=0.054, r=-1.863 and P-value=0.001, r=8.865 respectively). CONCLUSION; CrCo-Ti rods have the ability to produce higher correction rates in AIS compared to Ti-Ti rod of the same diameter. CrCo-Ti rods provide significant and stable spinal correction, especially in correction of main curve. This rate was associated with patients' age and type of rod administered but not gender.

RESUMO OBJETIVO: Comparar o resultado da correção da deformidade da coluna vertebral com ligas de Ti-Ti e CrCo-Ti para o tratamento da Escoliose Idiopática do Adolescente (EIA) na coluna usando as ligas mencionadas com todos os parafusos pediculares e técnica de tradução. MÉTODO: 59 pacientes operados por EIA com deformidade da coluna vertebral (Lenke 1 ou 2). Os pacientes foram divididos em dois grupos por alocação aleatória usando ligas de Ti-Ti (n = 29) e ligas de CrCo-Ti (n = 30) e a única diferença entre eles no procedimento cirúrgico foi o material da liga (ligas de Ti-Ti ou CrCo-Ti) e, finalmente, resultados radiológicos foram comparados no pré-operatório, pós-operatório e no último retorno por 12 meses. RESULTADOS: A correção da curva principal do paciente após o procedimento cirúrgico, independentemente do tipo de liga, foi de 48,95±11,04 (13-75) graus. A taxa de sucesso da correção da deformidade da coluna vertebral após o procedimento cirúrgico, independentemente do tipo de liga administrada, foi de 86,76 ± 11,30% (62,5-100%). A média da taxa de correção da deformidade foi de 91,49±10,67% usando ligas de CrCo-Ti e 81,86±9,88% usando ligas de Ti-Ti (valor de P = 0,01). A mudança de ângulo foi de 3,29±6,60 para o ângulo de cifose e de 0,59±7,76 para o ângulo de lordose. A taxa de correção da curva principal não foi significativamente diferente considerando o sexo dos pacientes (Valor de P 0,657). A taxa de sucesso da correção da curva principal foi associada à idade do paciente e ao tipo de liga (valor de P=0,054, r=-1,863 e valor de P=0,001, r=8,865, respectivamente). CONCLUSÃO: As ligas de CrCo-Ti têm a capacidade de produzir taxas de correção mais altas em EIA em comparação com a liga de Ti-Ti do mesmo diâmetro. As ligas de CrCo-Ti fornecem uma correção espinhal significativa e estável, especialmente na correção da curva principal. Essa taxa foi associada à idade e ao tipo de liga administrada, mas não ao sexo.

Percutaneous endoscopic debridement and irrigation for thoracic infections

SUMMARY OBJECTIVE: To investigate the safety and efficacy of percutaneous endoscopic debridement and irrigation for thoracic infections and to make an appropriate choice according to the patient's condition. METHODS. Thirty patients with thoracic infections who received surgical treatment from August 2014 to December2016 were retrospectively analyzed. There were 16 males and 14 females, aged from 41 to 90 years, with an average of 64.4 years. A total of 9 cases were treated with percutaneous endoscopic debridement and irrigation (minimal group), and 21 cases were treated with open debridement in combination with pedicle screw fixation (conventional group). Patients underwent follow-up for 1 month. General condition, operative index, laboratory results, and imaging features were recorded. RESULTS. Compared with the conventional group, there were more comorbidities in patients in the minimal group (8 cases in the minimal group, 10 cases in the conventional group, P=0.049), shorter hospital stay (10.1 + 2.26 days in the minimal group, 16.1 + 6.81 days in the conventional group, P=0.016), less bleeding volume (383.3 + 229.86ml in the minimal group, 90 + 11.18ml in the conventional group, P=0.000), lower VAS score at discharge (2.9 + 0.93 in the minimal group, 3.9 + 0.91 in the conventional group, P=0.013). There was no spinal instability case in the minimal group, 10 cases in the conventional group, P=0.013. There were significant differences. The C reaction protein prior to operation in the minimal group was 28.4±7.50mg/L. Compared with 45.1 + 15.78mg/L in the conventional group, P=0.005, it was lower. CONCLUSIONS. Percutaneous endoscopic debridement and irrigation are an effective surgery for treatment of thoracic infections, especially suitable for patients with comorbidities and poor general condition. However, for severe infection and spinal instability, we tend to choose open surgery in combination with fixation.

RESUMO OBJETIVOS: Investigar a eficácia e segurança de desbridamento endoscópico percutâneo e irrigação torácica para infecções e fazer uma escolha adequada de acordo com a condição do paciente. MÉTODOS: Trinta pacientes com infecção torácica que receberam tratamento cirúrgico de agosto de 2014 a dezembro de 2016 foram analisadosretrospectivamente. Havia 16 homens e 14 mulheres, de 41 a 90 anos, com uma média de 64,4 anos. Nove casos foram tratados com desbridamento endoscópico percutâneo e irrigação (grupo mínimo) e 21 casos foram tratados com desbridamento aberto em combinação com fixação do parafuso pedicular(grupo convencional). Os pacientes foram submetidos a acompanhamento durante um mês. Estado geral, índice operacional, resultados de laboratório e imagem e funcionalidades foram gravados. RESULTADOS: Em comparação com o grupo convencional, há mais comorbidades em pacientes do grupo mínimo (8 casos no grupo mínimo, 10 casos no grupo convencional, P = 0,049), menos tempo no hospital (10,1 + 2,26 dias no grupo mínimo, 16,1 + 6,81 dias no grupo convencional, P = 0,016), menos volume de sangramento (383,3 + 229,86 ml no grupo mínimo, 90 + 11,18 ml no grupo convencional, P = 0,000), menor pontuação no VAS a quitação (2,9 + 0,93 no grupo mínimo, 3,9 + 0,91 no grupo convencional, P = 0,013). Não houve nenhum caso de instabilidade espinhal no grupo mínimo, e 10 casos no grupo convencional, P = 0,013. Houve diferenças significativas. O nível de proteína C-reativa antes da operação no grupo mínimo era de 28,4±7,50mg/L. Em comparação com 45,1 + 15,78 mg/L no grupo convencional, P = 0,005, era mais baixa. CONCLUSÃO: O método de desbridamento endoscópico percutâneo e irrigação é eficaz para o tratamento de infecções em cirurgia torácica, especialmente adequado para pacientes com comorbidades e mau estado geral. Mas, para a infecção grave e instabilidade vertebral, tendemos a escolher a cirurgia aberta em combinação com a fixação.

The Current Concepts in the Management of Open Fractures / 대한정형외과학회잡지

Open fractures require infection prevention, injured soft tissue management, and fracture fixation. Moreover, it should be treated according to the emergency surgery. The main goals of treatment are life preservation, limb preservation, infection prevention, and functional restoration. Treatment procedure is carried out in the following order. Early diagnosis and management in the emergency room, appropriate antibiotic treatment, adequate irrigation and thorough debridement, fracture fixation and wound restoration (temporary stabilization of the fracture and covering of the wound, definite fixation of the fracture and soft tissue coverage). Herein, we discuss the current trends in each treatment phase to be helpful to other clinicians regarding the applicability of these steps in clinical practice.

Mechanical analysis of transversal iliac fracture stabilization using dynamic compression plate or screws and PMM in polyurethane bone model / Avaliação mecânica de estabilização de fratura ilíaca transversa com placa de compressão dinâmica ou polimetilmecatrilato associado à parafusos utilizando modelo de osso sintético de poliuretano

Pelvic fractures correspond to 20 to 30 % of the fractures observed in dogs. Complete fractures, especially with bone axis deviation should be surgically treated. The mechanical study of surgical techniques is of utmost importance to assess the best way of treating these injuries. This study compared, biomechanically, the use of a dynamic compression plate (DCP) and screws (group 1) or screws and polymethylmethacrylate (PMMA) (group 2) to stabilize an iliac fracture using a static test. Sixteen canine synthetic hemi-pelvises (test specimens) with a transverse iliac osteotomy were used. After fixation with implants, a load was applied to the acetabulum until failure. Group 1 maximal compressive load was 133.9±18.60 N, displacement at yield 21.10±3.59mm and stiffness 125.22±12.25N/mm. Group 2 maximal compressive load was 183.50±27.38N, displacement at yield 16.66±5.42mm and stiffness 215.68±33.34N/mm. The stabilization with polymethylmethacrylate was stronger than dynamic compression plate since it resisted a greater load in all test specimens.(AU)

As fraturas da pelve são frequentes em cães, correspondendo a 20-30% das fraturas encontradas na espécie. A grande maioria delas é tratada cirurgicamente, principalmente aquelas que apresentam desvio ósseo. O estudo mecânico das técnicas cirúrgicas é de extrema importância para avaliação da melhor maneira de tratamento destas lesões. O objetivo deste estudo foi comparar, do ponto de vista biomecânico, a fixação das fraturas do ílio utilizando uma placa de compressão dinâmica ou parafusos associados ao polimetilmetacrilato, por meio de um teste estático. Foram utilizadas 16 hemipelves caninas de origem sintética, nas quais uma osteotomia transversa foi realizada no corpo do ílio. As fixações foram divididas em dois grupos: fixação com placa de compressão dinâmica e parafusos (grupo1) ou parafusos associados ao polimetilmetacrilato (grupo 2). Posteriormente à fixação dos implantes foi aplicada uma carga no acetábulo de cada corpo de prova até a falha. O grupo 2 apresentou força máxima de aplicação de carga a média de 133.9±18.60N, deflexão 21.10±3.59mm e rigidez 125.22±12.25N/mm. O grupo 2 apresentou força máxima de aplicação de carga a média de 183.50±27.38N, deflexão 16.66±5.42mm e rigidez 215.68±33.34N/mm. A estabilização com o polimetilmetacrilato mostrou ser mais resistente, pois resistiu a uma maior quantidade de carga em relação à placa de compressão dinâmica, em todos os corpos de prova.(AU)

Secuelas en pacientes con fracturas cigomáticas tratados con osteosíntesis semirrígida / Sequelae in patients with zygomatic fractures treated with semirigid osteosynthesis

Se realizó un estudio descriptivo, transversal y aleatorizado de 102 pacientes con fracturas del complejo cigomático, tratados con osteosíntesis semirrígida en el Servicio de Cirugía Maxilofacial del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba, desde enero de 2005 hasta diciembre de 2011, con vistas a caracterizarles según variables demográficas y terapéuticas en las fases preoperatoria, intraoperatoria y posoperatoria. En la casuística predominaron los accidentes del tránsito como mecanismos causales de las lesiones (55,8 por ciento), la depresión de la eminencia cigomática y la presencia de escalones óseos palpables en el marco orbitario inferior y/o lateral como síntomas principales (92,1 por ciento, respectivamente), y la exposición escleral como complicación posoperatoria (55,2 por ciento), entre otros; asimismo, el valor del tiempo preoperatorio incrementó el riesgo de secuelas y la vía de acceso subciliar se asoció con un mayor riesgo de exposición escleral para el acceso al marco inferior y/o suelo orbitario. Por otra parte, tanto el enoftalmos como el hipoftalmos son de difícil solución y tienen una tendencia significativa de convertirse en secuelas posoperatorias

A descriptive, cross-sectional and randomized study of 102 patients with fractures of the zygomatic complex, treated with semirigid osteosynthesis in the Maxillofacial Surgery Service of Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital was carried out in Santiago de Cuba, from January, 2005 to December, 2011, aimed at characterizing them according to demographic and therapeutic variables in the presurgical, intrasurgical and postsurgical phases. In the case material there was a prevalence of traffic accidents as causal mechanisms of the lesions (55.8 percent), depression of the zygomatic eminence and presence of palpable bony steps in the lower and/or lateral orbitary edge as main symptoms (92.1 percent, respectively), and the scleral exhibition as postsurgical complication (55.2 percent), among others; also, the value of the presurgical time increased the risk of sequelae and the subciliary approach was associated with a higher risk of scleral exhibition for approaching to the lower edge and/or orbitary floor. On the other hand, either enophthalmos or hypophthalmos are of difficult solution and have a significant tendency of becoming postsurgical sequelae

Behavior study of the doped castor bean polymer rod with bioactive glass and hidroxyapatite in mice femur medullary canal

Abstract Purpose To evaluate the polymer doped rods behavior with bioactive glass and hydroxyapatite for possible application as a fracture fixing method. Methods Twenty eight Rattus norvegicus Wistar underwent bone defect for access to the femoral medullary canal and distributed into three experimental groups: group A - doped castor bean polymer with bioactive glass; group B - castor bean polymer and; group C - castor bean polymer doped with bioactive glass and hydroxyapatite. After 15 and 60 evaluation days, the femurs were removed and sent for histology and scanning electron microscopy. Results Initially mild and moderate inflammatory infiltrate is observed that decreases as time goes by, and the presence of connective tissue capsule around the graft in all groups. Regarding the biomaterials resorption little was observed. The implanted rods did not favor the osteoconductive process in the femoral medullary canal which was observed only in the C15 group. Conclusions The association of castor bean polymer, bioactive glass and hydroxyapatite was biocompatible and osteointegrable. The osteoconductive only occurred in the presence of hydroxyapatite and bioactive glass (C15 Group) and little biodegradation was observed.

assessment of mortality and quality of life after intertrochanteric fracture of femur in elderly patients

Objective: To investigate the mortality and disability rates after surgical treatment of intertrochanteric fractures in patients older than 60 years old

Method: In this retrospective study, 385 patients aged 60 or older who were admitted because of intertrochanteric fracture to treatment and teaching center of Emam Khomeini hospital of Ahvaz, Iran between Mar. 2010 to Feb. 2015 and underwent surgery were included. All the patients were treated by open reduction and internal fixation by dynamic hip screw .Two hundred and six patients were men [53.5%] and 179 were women [46.4%]. Age of patients was between 60 to 89 years old with the average of 75.2 years old. Minimum time required after surgery to enter this study was one year. Results were gathered based on examination of patient or calling patients and their families by phone number

Result: Rate of mortality was 36.9%, including 54.9% for men and 41.9% for women. In eleven patients [2.85%], initial reduction was lost because of failure of fixation device. For these patients reoperation was performed, and 7 of them [63.63%] expired within the mean of 10.1 months after reoperation. Time delay for surgery after occurrence of the fracture was in range of 2 to 15 days with an average of 4.8 days.24 patients [6.23%] went under surgery later than one week after fracture had been happened which seven of them [29.16%] expired. Highest mortality rate was in the age group of 80-89 years old with 50 patients [63.01%] and lowest one was in the group of 60-69 years old with three patients [4.67%]. Disability rate and quality of life of the patients was measured by Modified Harris Hip Score and divided in 3 group of good [with a score of 71 to 90], fair [with a score of 51 to 70] and weak [with a score of 0 to 50]. Patients who had good score consisted of 35.54% of patients with the average age of 64.63 years old and majority of male patients, fair group consisted of 30.5% of patients with average age of 73.45 years old and equal percentage of male and female patients and for Weak group it was 34.2% and 73.45 years old and by majority of male patients

Conclusion: Mortality rate of intertrochanteric fracture of femur is high even after treated with surgery and it's highly related to age of patient. Furthermore, quality of life after surgery is still low and follow up of the patients should be improved

Instrumentación cervical en pacientes menores de 10 años / Cervical instrumentation and fusion in children under 10 years old

Introducción: la instrumentación de la columna cervical pediátrica ha ganado terreno en la última década. Las diferencias anatómicas y biomecánicas entre la columna cervical pediátrica y del adulto hacen que la cirugía requiera de una minuciosa preparación toda vez que se utilizan implantes diseñados para adultos. El objetivo de este estudio fue evaluar los resultados posoperatorios en una serie de niños <10 años sometidos a fusión cervical instrumentada, y describir la técnica quirúrgica y las complicaciones. Materiales y Métodos: Se evaluó a 28 pacientes con patología cervical tratados con fusión instrumentada utilizando las técnicas descritas por Roy-Camille y Magerl para masas laterales, de Goel-Harms para C1-C2, y las fusiones occipitocervicales con placas occipitales o rótulas. Los criterios de inclusión fueron: pacientes <10 años, cirugía primaria y un seguimiento mínimo de 2 años. Resultados: La muestra incluyó 17 niñas y 11 niños, con un seguimiento promedio de 3.8 años (rango 2-10). La edad promedio fue de 6.1 años (rango 1.6-10). La tasa promedio de complicaciones generales fue del 32,1%. Los pacientes que tuvieron más complicaciones sufrían: síndromes genéticos [6 casos (21,4%)] y displasias esqueléticas [3 casos (10,7%)]. Trece tenían <6 años, 7 de ellos presentaron complicaciones (53,8%). Conclusiones: La instrumentación cervical en pacientes <10 años demostró ser un procedimiento factible y seguro. Las displasias vertebrales, las anomalías congénitas y los síndromes genéticos, sumados al factor edad <6 años, son las principales variables asociadas a las complicaciones observadas.

Introduction: pediatric cervical spine implants and construction designs had rapidly evolved in the last decade. Anatomic and biomechanical differences between pediatric and adult cervical spine require a thorough preoperative planning, because these implants were originally designed for adults. The objective of this study was to assess the postoperative results of cervical instrumented fusion in children under 10 years old, and to describe the surgical technique and complications. Methods: Twenty-eight children with different cervical pathology treated with instrumented fusion were evaluated. The following procedures were used: Roy-Camille’s and Magerl’s techniques for lateral masses, Goel-Harms’ technique for C1-C2 fusion, and occipital-cervical fusion with occipital plates or screws. Inclusion criteria were: children under 10 years, no prior spine surgery, and minimum follow-up of 2 years. Results: Sample included 17 girls and 11 boys, with a mean follow-up of 3.8 years (range 2-10). Mean age was 6.1 years (range: 1.6-10). Overall complication rate was 32.1%. The highest complication rates were associated with: genetic syndromes [6 cases (21.4%)], skeletal dysplasias [3 cases (10.7%)]. Thirteen patients were <6 years, 7 of them had complications (53.8%). Conclusions: Cervical instrumented fusion in patients <10 years old proved to be a feasible and safe surgical procedure. Vertebral dysplasias, congenital, syndromic anomalies, and being younger than 6 years old are the main factors associated with high complication rates.

Bone healing after biodegradable mini-plate fixation

ABSTRACT PURPOSE: To compare bone healing in mandibular vertical body osteotomies (MVBO) after fixation with a resorbable 2.0mm-profile fixation system in the first and third postoperative months in rabbits. METHODS: Twenty hemimandibles of ten rabbits were divided into two groups according to duration of resorbable fixation-one or three months. The MVBOs were performed and one four-hole, resorbable, 2.0mm mini-plate fixation system was used on each side. The computed tomography (CT) scans, scanning electron microscopy (SEM), and histomorphometric outcomes of groups I and II were compared. RESULTS: Significant differences were found between the one- and three- month assessments in terms of newly formed bone ratio values (p<0.05). There was more new bone formation at the third month on both the CT and histomorphometric examinations. A better adaptation of the bone tissues to the resorbable mini-plate and screws was observed on SEM at three months. CONCLUSION: The resorbable mini-plates provided a fixation stable enough to allow immediate oral alimentation and callus formation in both groups.

The use of nitinol rods in surgical treatment of degenerative scoliosis. 2.5-year follow-up / Uso de hastes de nitinol no tratamento cirúrgico de escoliose degenerativa. Acompanhamento de dois anos e meio / Uso de varillas de nitinol en el tratamiento quirúrgico de escoliosis degenerativa. Acompañamiento de dos años y medio

ABSTRACT Objectives: To compare the outcomes of surgical treatment with lumbar fixation using nitinol rods without fusion and with standard lumbar fixation with titanium rods and interbody fusion. Methods: Treatment results of 70 patients with degenerative lumbar scoliosis aged 40 to 82 were analyzed. In all cases pedicle screws and nitinol rods with a diameter of 5.5 mm were used. Thirty patients underwent fixation at L1-S1 and 40 patients underwent fixation at L1-L5. Spinal fusion was not performed. All patients had radiography, CT and MRI performed. The results were assessed according to the Oswestry scale, SRS 22, SF 36 and VAS. The minimum follow-up period for all patients was 2.5 years. For the control group, consisting of 72 patients, pedicle fixation with titanium rods and interbody fusion in the lumbosacral region were performed. Results: The average level of deformity correction equaled 25° (10° - 38°). The analysis of X-ray and CT-scans revealed a single patient with implant instability, two patients with bone resorption around the screws and one patient with rod fractures. Functional radiography 2.5 years after surgery showed an average mobility of the lumbar spine of 21° (15° - 30°). There were no problems at the adjacent levels. Conclusions: The use of nitinol rods in spinal deformity surgery is promising. This technology is an alternative to rigid fixation. Continued gathering of clinical data and its further evaluation is necessary.

RESUMO Objetivos: Comparar os resultados de tratamento cirúrgico com fixação lombar usando hastes de nitinol sem artrodese e com fixação lombar padrão com hastes de titânio e fusão intersomática. Métodos: Foram analisados os resultados do tratamento em 70 pacientes com escoliose lombar degenerativa com idades entre 40 e 82 anos. Em todos os casos, foram usados parafusos pediculares e hastes de nitinol com diâmetro de 5,5 mm. Trinta pacientes foram submetidos à fixação em L1-S1 e 40 pacientes tiveram fixação em L1-L5. Não foi realizada artrodese da coluna. Todos os pacientes fizeram radiografias, TC e RM. Os resultados foram avaliados de acordo com a escala de Oswestry, com o SRS 22, o SF 36 e EVA. O período mínimo de acompanhamento para todos os pacientes foi de 2,5 anos. No grupo controle, com 72 pacientes, realizou-se a fixação do pedículo com hastes de titânio e fusão intersomática na região lombossacral. Resultados: O nível médio de correção da deformidade correspondeu a 25° (10°-38°). A análise das radiografias e das TC revelou um único paciente com instabilidade, dois pacientes com reabsorção óssea ao redor dos parafusos e um paciente apresentou fraturas da haste. A radiografia funcional 2,5 anos após a cirurgia mostrou mobilidade média da coluna lombar de 21° (15°-30°). Não foram encontrados problemas nos níveis adjacentes. Conclusões: O uso de hastes de nitinol na cirurgia de deformidades da coluna é promissor. Essa tecnologia é uma alternativa à fixação rígida. É preciso manter a coleta continuada de dados clínicos e sua posterior avaliação.

RESUMEN Objetivos: Comparar los resultados de tratamiento quirúrgico con fijación lumbar usando varillas de nitinol sin artrodesis y con fijación lumbar estándar con varillas de titanio y fusión intersomática. Métodos: Fueron analizados los resultados del tratamiento en 70 pacientes con escoliosis lumbar degenerativa con edades entre 40 y 82 años. En todos los casos, fueron usados tornillos pediculares y varillas de nitinol con diámetro de 5,5 mm. Treinta pacientes fueron sometidos a fijación en L1-S1 y 40 pacientes tuvieron fijación en L1-L5. No fue realizada artrodesis de la columna. Todos los pacientes hicieron radiografías, TC y RM. Los resultados fueron evaluados de acuerdo con la escala de Oswestry, con SRS 22, SF 36 y EVA. El período mínimo de acompañamiento para todos los pacientes fue de 2,5 años. En el grupo control, con 72 pacientes, se realizó la fijación del pedículo con varillas de titanio y fusión intersomática en la región lumbosacra. Resultados: El nivel medio de corrección de la deformidad correspondió a 25° (10°-38°). El análisis de las radiografías y de las TC reveló un único paciente con inestabilidad, dos pacientes con reabsorción ósea alrededor de los tornillos y un paciente presentó fracturas de la varilla. La radiografía funcional 2,5 años después de la cirugía mostró movilidad media de la columna lumbar de 21° (15°-30°). No fueron encontrados problemas en los niveles adyacentes. Conclusiones: El uso de varillas de nitinol en la cirugía de deformidades de la columna es promisor. Esa tecnología es una alternativa para la fijación rígida. Es preciso mantener la colecta continuada de datos clínicos y su posterior evaluación.