Manejo no quirúrgico de la artrosis de rodilla: ¿Son efectivos los medicamentos orales complementarios? / Non-surgical management of knee osteoarthritis: are complementary oral medications effective?

La artrosis es una enfermedad progresiva de las articulaciones sinoviales que causa dolor, impotencia funcional, discapacidad, y degeneración progresiva de la articulación. En sus tratamientos, sobre todo en etapas tempranas, existen distintas intervenciones para evitar tanto su desarrollo y progresión como también para lograr un adecuado manejo de los síntomas, y hay tratamientos médicos orales no convencionales con evidencia controvertida. El objetivo de este trabajo es proporcionar una actualización, dirigida a especialistas en Ortopedia y Traumatología, respecto a la evidencia actual sobre las terapias complementarias orales en el tratamiento de la artrosis de rodilla. Se hace referencia a los métodos fármacológicos complementarios más usados y estudiados, mencionando el método de acción y las consecuencias estudiadas sobre la artrosis de rodilla. Se finaliza con una tabla de recomendaciones basada en evidencia actual.

Osteoarthritis (OA) is a progressive disease of the synovial joints that causes pain, functional impairment, disability, and progressive degeneration of the joint. Regarding its treatments, especially in early stages, there are different interventions to avoid its development and progression and also to achieve an adequate management of symptoms, and there are unconventional oral medical treatments with controversial evidence. The objective of the present paper is to provide an update, to specialists in Orthopedics and Traumatology, regarding the current evidence on complementary oral therapies in the treatment of knee osteoarthritis. References are made to the most widely used and studied complementary pharmacological methods, mentioning the method of action and the consequences studied on knee osteoarthritis. The article ends with a table of recommendations based on current evidence.

[Limited external fixation of plastic cardboard for the treatment of senile comminuted humeral fracture].

OBJECTIVE: To explore clinical efficacy of limited external fixation with plastic paperboard in treating senile proximal comminuted humeral fracture. METHODS: From June 2015 to December 2017, 32 senile patients with proximal comminuted fracture of humerus were treated with plasticized cardboard after manual external fixation. Among them, including 13 males and 19 females aged from 55 to 85 years old with an average of(68.22±8.36) years old; 18 patients on the left side and 14 patients on the right side; all patients were regularly review shoulder X-rays and performed appropriate functional exercises. Constant-Murley shoulder joint scoring was used to evaluate clinical effects. RESULTS: Thirty-two patients were followed up for 3 to 12 months with an average of (4.97±2.39) months. All patients were underwent functional exercise under guidance of physicians. Nine patients were treated with topical Chinese herbal moist heat compresses to promote shoulder function recovery. Thirty-one patients were obtained fracture healing, the time ranged from 5 to 12 weeks with an average of(7.44±1.72)weeks. One patient was not healed due to comminuted fracture of fracture end and the separation was large, the blood supply to humeral head was insufficient for necrosis absorption. Postoperative Constant-Murley shoulder score at 3 months was 87.56±6.93; 15 patients got excellent results, 14 good, 2 fair and 1 poor. CONCLUSIONS: Limited external fixation with plastic paperboard for the treatment of senile proximal comminuted humeral fracture could ensure biomechanical stability of fracture, promote early recovery of shoulder joint function and shorten recovery time.

Limited external fixation of plastic cardboard for the treatment of senile comminuted humeral fracture / 中国骨伤

OBJECTIVE@#To explore clinical efficacy of limited external fixation with plastic paperboard in treating senile proximal comminuted humeral fracture.@*METHODS@#From June 2015 to December 2017, 32 senile patients with proximal comminuted fracture of humerus were treated with plasticized cardboard after manual external fixation. Among them, including 13 males and 19 females aged from 55 to 85 years old with an average of(68.22±8.36) years old; 18 patients on the left side and 14 patients on the right side; all patients were regularly review shoulder X-rays and performed appropriate functional exercises. Constant-Murley shoulder joint scoring was used to evaluate clinical effects.@*RESULTS@#Thirty-two patients were followed up for 3 to 12 months with an average of (4.97±2.39) months. All patients were underwent functional exercise under guidance of physicians. Nine patients were treated with topical Chinese herbal moist heat compresses to promote shoulder function recovery. Thirty-one patients were obtained fracture healing, the time ranged from 5 to 12 weeks with an average of(7.44±1.72)weeks. One patient was not healed due to comminuted fracture of fracture end and the separation was large, the blood supply to humeral head was insufficient for necrosis absorption. Postoperative Constant-Murley shoulder score at 3 months was 87.56±6.93; 15 patients got excellent results, 14 good, 2 fair and 1 poor.@*CONCLUSIONS@#Limited external fixation with plastic paperboard for the treatment of senile proximal comminuted humeral fracture could ensure biomechanical stability of fracture, promote early recovery of shoulder joint function and shorten recovery time.

Biomechanical Assessment of Locking Plate Fixation of Comminuted Proximal Olecranon Fractures.

OBJECTIVES: To determine if mean ultimate strength or failure mechanism differed between comminuted olecranon fractures created at the proximal 25% or 50% of the trochlear notch and fixed with precontoured posterior locking plates (PLPs). METHODS: Comminuted osteotomies were created in 10 matched pairs of cadaveric upper extremities at either the proximal 25% or 50% of the trochlear notch after quantitative computed tomography scans were performed to evaluate bone mineral density. Variable-angle olecranon PLPs were fixed to the specimens. The triceps tendon of each specimen was loaded cyclically and then to failure. Comparison of mean force at failure (displacement >2 mm) was performed using the 2-tailed t test. RESULTS: There were no significant differences in specimen bone mineral density within matched pairs. Nineteen specimens failed by olecranon bisection fracture in the sagittal plane. Specimens in the 25% osteotomy group failed at lower ultimate forces of 808 N (SD ± 474 N) versus 1058 N (SD ± 480 N) in the 50% osteotomy group (P = 0.044). CONCLUSIONS: The ultimate strength of comminuted olecranon fracture fixation with a PLP decreases significantly if the fracture is proximal to the midpoint of the trochlear notch. Fractures proximal to the midpoint of the trochlear notch may benefit from supplemental fixation or suture augmentation to prevent failure, particularly at force ranges higher than those experienced during active elbow range of motion.

An Alternative Method of Intermaxillary Fixation for Simple Pediatric Mandible Fractures.

PURPOSE: Mandibular fractures represent a substantial portion of facial fractures in the pediatric population. Pediatric mandibles differ from their adult counterparts in the presence of mixed dentition. Avoidance of injury to developing tooth follicles is critical. Simple mandibular fractures can be treated with intermaxillary fixation (IMF) using arch bars or bone screws. This report describes an alternative to these methods using silk sutures and an algorithm to assist in treating simple mandibular fractures in the pediatric population. PATIENTS AND METHODS: A retrospective chart review was performed and the records of 1 surgeon were examined. Pediatric patients who underwent treatment for a mandibular fracture in the operating room from 2011 to 2015 were identified using Common Procedural Terminology codes. Data collected included age, gender, type of fracture, type of treatment used, duration of fixation, and presence of complications. RESULTS: Five patients with a mean age of 6.8 years at presentation were identified. Fracture types were unilateral fractures of the condylar neck (n = 3), bilateral fractures of the condylar head (n = 1), and a unilateral fracture of the condylar head with an associated parasymphyseal fracture (n = 1). IMF was performed in 4 patients using silk sutures, and bone screw fixation was performed in the other patient. No post-treatment complications or malocclusion were reported. Average duration of IMF was 18.5 days. CONCLUSIONS: An algorithm is presented to assist in the treatment of pediatric mandibular fractures. Silk suture fixation is a viable and safe alternative to arch bars or bone screws for routine mandibular fractures.

Virtual reality hypnosis pain control in the treatment of multiple fractures: a case series.

This case series evaluated the use of virtual reality hypnosis (VRH) for the treatment of pain associated with multiple fractures from traumatic injuries. VRH treatment was administered on 2 consecutive days, and pain and anxiety were assessed each day before and after VRH treatment as well as on Day 3, which was 24 hours after the second treatment session. Pain reduction from baseline to Day 3 was from 70% to 30%, despite opioid analgesic use remaining stable. The subjective pain reduction reported by patients was encouraging, and the results of this case series suggest the importance of further study of VRH with larger samples using randomized controlled trials.

Early Comminuted Fracture of an Alumina Liner in a Ceramic on Ceramic Total Hip Arthroplasty / 대한정형외과학회잡지

The authors experienced a case of early fracture of an alumina ceramic liner after ceramic-on-ceramic total hip arthroplasty, without any history of trauma. A 47-year-old male visited our center, due to a sudden crunching sound from the right hip at three weeks, after a ceramic-on-ceramic total hip arthroplasty for the osteonecrosis of right femoral head. Plain radiographs revealed multiple radio-opaque fragments around the displaced neck of the femoral stem. There were severely comminuted fracture of the ceramic liner with slight black staining of the surrounding tissue, and even damaged the surface of the ceramic head, on the operative field. The fractured liner and a damaged head were replaced with a new ceramic liner and head, after the removal of the fractured ceramic fragments, as completely as possible. Careful follow up with a caution for early ceramic liner fracture should be required in ceramic-on-ceramic total hip arthroplasty.

Bone graft substitutes for articular support and metaphyseal comminution: what are the options?

Subchondral and metaphyseal bone defects pose a great challenge for the Orthopaedic surgeon not only because the support for the articular surface has been lost but also because the mechanism for the nourishment of articular cartilage through the subchondral plate is distorted. A number of options are available to the surgeons, none of them perfect. Autografting has an appreciable high rate of harvest site morbidity, allograft is associated with infection transmission and host immunologic response. These realities have stimulated interest in supplying bone replacement materials (demineralised bone matrix, synthetic bone substitutes, bone morphogenic proteins). This paper presents the indications and applications of bone substitutes for metaphyseal defects and subchondral support in orthopaedic trauma.

Use of noninvasive interactive neurostimulation to improve short-term recovery in patients with surgically repaired bimalleolar ankle fractures: a prospective, randomized clinical trial.

We undertook a trial with 60 patients who had undergone operative reduction and internal fixation of bimalleolar, AO type B2 ankle fractures with comminution. Patients were randomized into 2 groups, one of which received postoperative treatment using a noninvasive interactive neurostimulation device (InterX) and the other with a sham device. The trial was designed to test the hypothesis that incorporation of noninvasive interactive neurostimulation into the rehabilitation protocol would result in reduced pain, increased range of motion, reduced edema, and reduced consumption of pain medication, in comparison with the sham therapy group. Outcome measurements included the patient's subjective assessment of level of pain, range of motion, and the extent of edema in the involved ankle, and the use of ketorolac for postoperative control of pain. The results showed significantly better results in the patients receiving treatment with active neurostimulation (repeated measures analysis of variance, P < .001).

Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing.

INTRODUCTION: Treatment of lower extremity segmental bone loss is difficult. Masquelet et al. proposed a two-stage technique: first, debridement and filling of bone loss with an acrylic spacer; second, bone reconstruction by filling with cancellous bone in the space left free (following cement removal) inside the so-called self-induced periosteal membrane. In the originally described technique, the fracture site is stabilized by an external fixator, which remains in place throughout the bone healing process, i.e., often longer than 9 months with all the known disadvantages of this type of assembly. Following the principle of two-stage reconstruction, we modified the technique by reconstructing around an intramedullary-locking nail placed in the first stage. HYPOTHESIS: This technique prevents the mechanical complications related to external fixator use and provides faster resumption of weight-bearing. PATIENTS AND METHODS: Twelve patients were operated for segmental tibial bone loss greater than 6cm resulting from injury (four cases) or aseptic necrosis (one case) or septic necrosis (seven cases). All the patients were operated on in an emergency setting and the first stage was performed before the 2nd week. A free muscle flap (ten patients) or a pediculated fasciocutaneous flap (two patients) was necessary during this first step to cover the site and provide good conditions for secondary bone growth. The follow-up was 39.5 months (range, 12-94 months). RESULTS: Complete weight-bearing was resumed at a mean 4 months. After the second step, all the patients except one had apparently healed (complete weight-bearing with no pain). Five septic complications occurred after the second step, in one case leading to reconstruction failure. Four other patients had infectious complications successfully treated (as of the last follow-up) either by changing the nail in two cases or by prolonged antibiotic therapy in two other cases, with no graft loss. DISCUSSION: The use of the intramedullary nail facilitates the Masquelet technique by allowing the patient to resume weight-bearing more quickly and avoiding secondary fractures. However, the risk of sepsis remains high but can be controlled without compromising the final bone union in four cases out of five. LEVEL OF EVIDENCE: Level IV. Retrospective study.

[Central-medullary nailing of proximal humerus fractures using T2 nails. A retrospective study of 38 cases]. / Enclouage centromédullaire des fractures de l'extrémité proximale de l'humérus par clou T2. Etude rétrospective de 38 cas.

The intramedullary nailing of humerus has emerged as one of the treatments of reference for proximal fractures. We have reviewed 38 patients aged 64.2 on average with a mean follow of 18 months. The functional scores used were the Constant and Murley's score as well as the DASH self-administered quality of life questionnaire. Radiological criteria have been analyzed, namely the cephalic angle noted alphaF and the presence of any osteolysis of the major tuberosity. Patients were grouped by type of fracture, according to Neer's classification, with nine cases in Neer 2 group, 19 in Neer 3 group, and ten in Neer 4 group. The unrefined Constant score was 53.4 points on average, balanced to 71.6%. The joint mobilities were an average forward elevation of 108 degrees, an average abduction of 100 degrees and an external rotation of 27 degrees. These scores were even worse than the fracture was comminuted. It was not found a radioclinical correlation between value of the angle alphaF and clinical outcome, but the presence of osteolysis of the major tuberosity was significantly associated with poor late functional results. Five cases of osteonecrosis have been counted, divided with 10.5% in the Neer stage 3, and 30% in the Neer stage 4. The average unrefined Constant score from these patients was 38.5 points on average, balanced to 57.7%. Intramedullary nailing allows fixation of comminuted fractures with three or four fragments, but control of fixing and strength of assembly were not always practiced. In young patients, where tuberosities consolidation is essential, screwed plates seem to be a favorable alternative. Moreover, total reverse prosthesis seems to have more and more arguments to impose itself like the preferred treatment towards fractures in four fragments in people aged over 75 years.

Management of a mandibular fracture accompanying a gunshot wound.

Gunshot injuries of the mandible can result in high rates of complications, especially in cases of bone loss. A fractured mandible accompanying a gunshot wound almost always has an external wound; the fracture is always compound and comminuted. Sometimes management of these injuries may require multiple surgical interventions. In this clinical report, treatment of a patient, who had a mandibular fracture due to a gunshot wound, is presented.A 52-year-old man with a mandibular fracture in the right mandibular body accompanying a gunshot wound was operated on. Owing to a nonunion, a second surgery was performed using reconstruction plates after hyperbaric oxygen treatment. Healing was uneventful after the second surgical intervention.

Treatment of distal radius fractures with a wrist-bridging external fixation: the value of alternating electric current stimulation.

The radiological and functional outcomes of two groups of comminuted intraarticular fractures of the distal radius that were treated with wrist-bridging external fixation, with or without an alternating electric current stimulation (EF + ES or EF group, respectively), were compared. The radial length, radial inclination and palmar tilt were measured on radiographs taken immediately after removal of wrist external fixator and also after bone union had occurred. Furthermore, active range of motion was compared at the final consultation. Bridging callus was observed earlier postoperatively in the EF + ES group than in the EF group. The radial length and palmar tilt were significantly larger, and the loss of radial length and radial inclination significantly smaller, in the EF + ES group. We believe that callus maturation is enhanced by alternating electric current stimulation, which enables the early removal of external fixator.

Use of external fixation and primary wound closure in an open comminuted first metatarsal fracture: a case report.

Management of open, comminuted fractures presents a challenge for the foot and ankle surgeon. Reconstructive surgery for such injuries has a high potential for the development of serious complications, and factors such as the extent of soft tissue injury, neurovascular status to the foot, and fracture stability must be taken into consideration before determining a surgical plan. This article describes the case of a patient who presented with an open, comminuted first metatarsal fracture as a result of a chainsaw injury. The patient was treated with a uniplanar mini-external fixator, demineralized bone matrix, primary wound closure, and external bone growth stimulation. At 1-year follow-up, the interview and examination revealed the patient to be pain free with a functional first ray. ACFAS Level of Clinical Evidence: 4.

Fracture of the coronoid and pterygoid processes by firearms: case report.

A rare case of fracture of the coronoid and the pterygoid process caused by firearms is described. A 28-year-old male was hit by a bullet in the face, resulting in restricted mouth opening, difficulty in chewing and pain when opening the mouth. Clinical examination revealed a perforating wound in the right parotid region and a similar wound on the left side of the same region. A CT scan showed comminuted fracture of the left coronoid process and bilateral comminuted fracture of the pterygoid processes. Treatment was conservative, speech therapy was conducted and it was successful. Details of the clinical signs, radiology (3D-CT scan), treatment and follow-up are presented.

Alumina femoral head fracture in uncemented total hip arthroplasty with a ceramic sandwich cup.

In total hip arthroplasty, insertion of a UHMWPE-coated ceramic sandwich liner dramatically reduces any risk related to the stiffness of the ceramic-ceramic coupling. We present a case of an alumina ceramic head fracture with a ceramic sandwich cup. The fracture occurred 16 months after the initial operation, without trauma. Impingement between the neck and posteroinferior portion of the liner rim had occurred. This was related to the traditional cross-legged sitting position of Koreans, which caused impingement between the neck and liner rim. Consequently, the taper became loose, and the resulting force bent the taper and fractured the head. We examined a peculiar case of ceramic femoral head fracture after implantation of an uncemented total hip arthroplasty with a ceramic sandwich cup and investigated the underlying cause.

Fracture of the coronoid and pterygoid processes by firearms: case report

A rare case of fracture of the coronoid and the pterygoid process caused by firearms is described. A 28-year-old male was hit by a bullet in the face, resulting in restricted mouth opening, difficulty in chewing and pain when opening the mouth. Clinical examination revealed a perforating wound in the right parotid region and a similar wound on the left side of the same region. A CT scan showed comminuted fracture of the left coronoid process and bilateral comminuted fracture of the pterygoid processes. Treatment was conservative, speech therapy was conducted and it was successful. Details of the clinical signs, radiology (3D-CT scan), treatment and follow-up are presented.

Um caso raro de fratura dos processos coronóide e pterigóide por arma de fogo é descrito. Paciente do sexo masculino, 28 anos de idade, foi atingido por projétil de arma de fogo na face, resultando em limitação na abertura da boca, dificuldade para mastigar e dor ao abrir a boca. Exame clínico revelou ferimento perfurante em região parotídea direita e ferida similar do lado esquerdo na mesma região. Tomografia computadorizada (TC) mostrou fratura cominutiva do processo coronóide esquerdo e fratura cominutiva bilateral dos processo pterigóides. O tratamento foi conservador, através de fonoterapia, obtendo-se sucesso. Uma descrição detalhada das características clínicas, radiológicas (TC com reconstrução 3D), tratamento e proservação do caso é apresentada.

Muti killing: a case report.

Muti killings are a form of murder committed by certain African tribes in South Africa and other African countries. Body parts for medicinal and ritualistic purposes are removed whilst the victims, mostly women and children, are still alive. The authors report the case of a 10-year-old boy who was found in an unconscious state in the undergrowth near a rural village in Limpopo, South Africa. He had several injuries which included the removal of his private parts and severe head injuries. The incidence, etiological and cultural factors, predisposing conditions and legal questions arising from such deaths are discussed.

Treatment of infected wounds with maggot therapy after replantation.

Postoperative wound infection is a rare, but major, complication of replantation. Failure to control infection can lead directly to vascular thrombosis and, in turn, to loss of the replanted extremity. The use of maggots for wound debridement has a long history and has been lately re-introduced for treatment of intractable wounds. In this report, the authors present the experience of successful debridement of a severely infected wound after forearm replantation, using maggot therapy. The results and mechanism of maggot therapy are discussed.

Graft-supplemented, augmented external fixation in the treatment of intra-articular distal radial fractures.

This article compares the functional and radiographic outcomes of intraarticular distal radial fractures treated with augmented external fixation in which autologous cancellous bone grafting or Norian SRS (Norian Corp, Cupertino, Calif) was used for filling the metaphyseal void. Thirty non-randomized patients, 15 in each group, with AO type C distal radius fractures (20 men and 10 women; average age: 48 years) were operatively treated between 1998-2000 and retrospectively evaluated. Radial inclination, radial length, volar tilt, and Modified Mayo Wrist Score were assessed at the most recent follow-up evaluation (average: 33.3 months). Overall, 12 (80%) patients in the Norian group had an excellent or good result, 2 had fair, and 1 had poor. In the autologous iliac bone graft group, the results were excellent or good in 11 (73.3%) patients, fair in 1, and poor in 2. No statistical difference between the two types of grafting was noted. Norian SRS is equally effective to cancellous bone as supplementary graft in comminuted distal radial fractures treated by external and Kirschner-wire fixation.