Effect of Platelet-Rich Plasma Dosing for Healing after Arthroscopic Cuff Repair Compared with Surgery Alone: A Systematic Review and Meta-Analysis.

INTRODUCTION: Platelet-rich plasma (PRP) has been used for arthroscopic rotator cuff repairs (aRCR), but no studies have addressed the impact of platelet concentration. The primary aim was to evaluate whether the PRP cell concentration has an effect on tendon healing after aRCR compared with surgery alone. The secondary aim was to assess the functional and pain outcomes. MATERIALS AND METHODS: A systematic review was performed with searches in the MEDLINE (PubMed), Scopus, Web of Science, and Cochrane (Central) databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Metanalytic procedures were performed for randomized controlled trials (RCTs), and a subgroup analysis was used for studies with target (approximately 10 6 cells·µL -1 ) or below-target PRP cellular concentrations (app. 5 × 10 5 cells·µL -1 ) regarding the primary outcome of tendon healing. RESULTS: This review included 10 studies (8 RCTs) with 342 patients in the aRCR + PRP group and 344 patients with isolated aRCR. The risk of bias was low to intermediate (6/4, respectively). Meta-analysis of the RCT revealed that the aRCR + high-concentration PRP group had an approximately 3.9-fold higher chance of healing than the non-PRP group (odds ratio, 3.89; 95% confidence interval, 1.78-8.44; P = 0.0007). No significant difference in healing was found between the aRCR + low-concentration PRP and non-PRP groups (odds ratio, 2.21; 95% confidence interval, 0.66-7.45; P = 0.2). The Constant-Murley score and University of California Los Angeles scores were significantly improved in the aRCR + PRP groups with more than 12 months of follow-up, and no significant differences were found consistently for the American Shoulder and Elbow Society and visual analog scale scores. CONCLUSIONS: This study highlights that a PRP cell concentration close to the target (10 6 cells·µL -1 ) of patients with aRCR may improve their healing and functional outcomes and that dosing may be potentially useful in therapy.

Proximal humerus fractures: epidemiology and trends in surgical management of hospital-admitted patients in Portugal.

Background: Proximal humerus fractures (PHFs) are frequent and associated with significant health care burden. National epidemiological data are limited. Our objective is to characterize the Portuguese population admitted with PHFs and analyze therapeutic management, the impact of associated lesions, and mortality rate. Methods: This was a retrospective, observational study of admissions from mainland public hospitals (2000-2015), with primary or secondary diagnosis of PHFs. Incomplete records, pathologic lesions, malunion/nonunion, and hardware removal were excluded. Age, gender, admission date, hospitalization period, associated injuries, treatment, and mortality were recorded. Results: A total of 19,290 patients were included. Through the analyzed period, an increase in the absolute number and incidence of PHFs was observed. The mean age at diagnosis was 62.6 ± 21.0 years old (57% elderly; 63.5% female). The mean length of stay was 10.0 ± 14.1 days, higher in patients submitted to arthroplasty (P < .001) and in those with associated fractures (25%; P < .001). A total of 14,482 patients were operated, most frequently with open reduction and internal fixation (28%). The inpatient mortality rate was 3.2%, significantly higher in patients with associated fractures (odds 2.77 for lower limb vs. upper limb). Conclusion: There is a trend toward an increase in surgical management of PHFs. The relative proportion of open reduction and internal fixation and arthroplasty (particularly reverse arthroplasty) increased, probably reflecting biomechanical implant properties, fracture pattern, and demand for better functionality. Associated fractures are an important comorbidity, associated with increased mortality and length of stay.

Cost effectiveness of outpatient lumbar discectomy.

BACKGROUND: Microdiscectomy is the most commonly performed spine surgery and the first transitioning for outpatient settings. However, this transition was never studied, in what comes to cost-utility assessment. Accordingly, this economic study aims to access the cost-effectiveness of outpatient lumbar microdiscectomy when compared with the inpatient procedure. METHODS: This is a cost utility study, adopting the hospital perspective. Direct medical costs were retrieved from the assessment of 20 patients undergoing outpatient lumbar microdiscectomy and 20 undergoing inpatient lumbar microdiscectomy Quality-adjusted life-years were calculated from Oswestry Disability Index values (ODI). ODI was prospectively assessed in outpatients in pre and 3- and 6-month post-operative evaluations. Inpatient ODI data were estimated from a meta-analysis. A probabilistic sensitivity analysis was performed and incremental cost-effectiveness ratio (ICER) calculated. RESULTS: Outpatient procedure was cost-saving in all models tested. At 3-month assessment ICER ranged from €135,753 to €345,755/QALY, higher than the predefined threshold of €60,000/QALY gained. At 6-month costs were lower and utilities were higher in outpatient, overpowering the inpatient procedure. Probabilistic sensitivity analysis showed that in 65% to 73% of simulations outpatient was the better option. The savings with outpatient were about 55% of inpatient values, with similar utility scores. No 30-day readmissions were recorded in either group. CONCLUSION: This is the first economic study on cost-effectiveness of outpatient lumbar microdiscectomy, showing a significant reduction in costs, with a similar clinical outcome, proving it cost-effective.

Use and Cost of Orthosis in Conservative Treatment of Acute Thoracolumbar Fractures: A Survey of European and North American Experts.

STUDY DESIGN: Survey study. OBJECTIVE: Assess practices and opinions of spine specialists from Europe and North America on orthosis use in adult patients with acute thoracolumbar (TL) fractures. Evaluate cost of the devices. SUMMARY OF BACKGROUND DATA: Although orthosis are traditionally used in conservative treatment of TL fractures, recent systematic reviews showed no benefit in patient's outcomes. METHODS: A search for contact authors with publications on spine fractures from all European and North American countries was performed. An online questionnaire was sent on demographic data, practice setting, mean number of fractures treated, use of orthosis upon choice for conservative treatment, and average orthosis cost. Data was analyzed based in world regions, economic rank of the country, and health expenditure. RESULTS: We received 130 answers, from 28 European and five North American countries. Most responders had more than 9 years of practice and worked at a public hospital. 6.2% did not prescribe a brace in any patient with acute TL fractures conservatively treated and 11.5% brace all patients. In a scale from 1 to 5, 21 considered that there is no/low benefit (1) and 14 that bracing is essential (5), with a mean of 3.18. Europeans use orthosis less commonly than North Americans (P < 0.05). Orthosis mean cost was $611.4 ±â€Š716.0, significantly higher in North America compared with Europe and in high income, when compared with upper middle income countries (both P < 0.05). Although hospital costs were not evaluated, orthosis is costlier when it involves admission of the patient (P < 0.05). An increase in orthosis cost associated with higher gross domestic product (GDP) per capita and higher health expenditure was found. CONCLUSION: More than 90% of spine specialists still use orthosis in conservative treatment of adult patients with acute TL fractures. Orthosis cost vary significantly between continents, and it is influenced by the country's economy.Level of Evidence: 4.

Lateralized versus nonlateralized glenospheres in reverse shoulder arthroplasty: a systematic review with meta-analysis.

HYPOTHESIS/BACKGROUND: Lateralization in reverse shoulder arthroplasty (L-RSA) was proposed to overcome some limitations of the original Grammont-style design (S-RSA). This systematic review aims to compare the clinical and functional outcomes and complications of S-RSA with L-RSA, and to assess the individual results of metallic and bony lateralization implants. METHODS: A systematic search from January 1980 to December 2019 was performed. Studies were selected in 2 phases by 2 independent reviewers; disagreements were solved by discussion. Inclusion criteria were: (1) original studies; (2) written in English or French; (3) adult individuals submitted to RSA surgery; and (4) RSA with a lateralization device in at least one of the groups. Exclusion criteria were: (1) nonoriginal studies or case reports; (2) absence of clinical or radiographic outcomes; and (3) no comparison group using S-RSA. Data were extracted for outcomes of functional status (American Shoulder and Elbow Surgeons, Constant, visual analog scale, Simple Shoulder Test, Subjective Shoulder Value, Activities of Daily Life that require External Rotation, and Disabilities of the Arm, Shoulder, and Hand), range of motion (ROM), complications, revisions, and notching. Meta-analyses were performed when possible. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. RESULTS: Fifteen articles/16 studies were included (865 participants: 440 L-RSA and 425 S-RSA). Most studies found no differences between the L-RSA and S-RSA groups in qualitative and meta-analysis for American Shoulder and Elbow Surgeons, Constant, Simple Shoulder Test, Activities of Daily Life that require External Rotation, and Disabilities of the Arm, Shoulder, and Hand scores. Meta-analysis demonstrated significantly lower visual analog scale (1 point) and higher Subjective Shoulder Value (6 points) in L-RSA than in S-RSA. No significant differences were found in the qualitative analyses of most studies regarding ROM in forward elevation, abduction, and internal/external rotation, but meta-analysis reported a significantly higher external rotation in L-RSA groups and specifically in osseous lateralization. Complication rate was significantly lower in L-RSA (odds ratio = 0.38), but no significant differences were found for revision rates. Notching rate was significantly lower in the L-RSA group (odds ratio = 0.14), both for osseous and metallic lateralization. DISCUSSION/CONCLUSION: This systematic review focused on studies comparing L-RSA and S-RSA and found significantly lower notching and complication rates in L-RSA groups. This review highlighted similar outcomes in clinical scores and a slight advantage for L-RSA in ROM, especially in external rotation. L-RSA was not associated with increased revision rates, while presenting lower complication and notching rates. Inclusion of studies with metallic and osseous lateralization has helped to provide further evidence on this subject, but heterogeneity and low evidence levels of the included studies may limit our conclusions.

Orthosis in Thoracolumbar Fractures: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trial (RCT). OBJECTIVE: The aim of this study was to evaluate radiological and clinical outcomes of acute traumatic thoracolumbar fractures in skeletally mature patients treated with orthosis, versus no immobilization. SUMMARY OF BACKGROUND DATA: Orthosis is traditionally used in conservative treatment of thoracolumbar fractures. However, recent studies suggest no benefit, and a possible negative impact in recovery. METHODS: Databases were searched from inception to June 2019. Studies were selected in two phases by two blinded reviewers; disagreements were solved by consensus. Inclusion criteria were: RCT; only patients with acute traumatic thoracolumbar fractures; primary conservative treatment; comparison between orthosis and no orthosis. Exclusion criteria were inclusion of nonacute fractures, patients with other significant known diseases and comparison of groups different than use of an orthosis. Two independent reviewers performed data extraction and quality assessment. Fixed-effects models were used upon no heterogeneity, and random-effects model in the remaining cases. A previous plan for extraction of radiological (kyphosis progression; loss of anterior height) and clinical (pain; disability; length of stay) outcomes was applied. PRISMA guidelines were followed. RESULTS: Eight articles/five studies were included (267 participants). None reported significant differences in pain, kyphosis progression, and loss of anterior height. One reported a better ODI with orthosis at 12 but not at 24 weeks. No other study reported differences in disability. All authors concluded an equivalence between treatments.Meta-analysis showed a significant increase of 3.47days (95% confidence interval 1.35-5.60) in mean admission time in orthosis group. No differences were found in kyphosis at 6 and 12 months; kyphosis progression between 0 to 6 and 0 to 12 months; loss of anterior height 0 to 6 months; VAS for pain at 6 months; VAS change 0 to 6 months. CONCLUSION: Orthosis seems to add no benefit in conservative treatment of acute thoracolumbar fractures. This should be considered in guidelines and reviews of health care policies. LEVEL OF EVIDENCE: 3.

Results of Total Cervical Disc Replacement with a Minimum Follow-up of 10 Years.

Objective In the present study, we present the results with at least 10 years of follow-up of the cervical disc prosthesis implanted in a single level. Methods Retrospective study of patients undergoing single-level total cervical disc replacement (TCDR). Clinical results included the neck disability index (NDI) and the visual analogue scale (VAS) in the preoperative period, one year postoperatively, and a minimum of 10 years of follow-up. The radiographic parameters included cervical mobility, segmental lordosis, C2-C7 angle, heterotopic ossification (HO), facet and joint degeneration (FJD) and adjacent segment disease (ASD). Results We identified 22 patients, 16 women and 6 men with mean age of 39.7 years old (26-51 years old), of which fifteen completed a minimum follow-up of 10 years. There was a statistically significant improvement of NDI and VAS ( p < 0.001) between the preoperative and the postoperative periods (1 year or > 10 years). At the end of 10 years, HO was observed in 59% of the cases. The mobility of the implant was preserved in 80% of the patients. Radiological evidence of ASD was recorded in 6 patients (40%). There was no correlation between the clinical parameters evaluated and the presence of ASD or the different classes of HO. Conclusion Clinical improvement in all evaluated parameters, which persists over time. Most implants maintained mobility, as has already been demonstrated in other studies with shorter follow-ups. In a significant percentage of cases, ASD was observed, questioning the concept of motion preserving technology. However, we did not have any surgical intervention for this reason, since there was no correlation with worse clinical results.

Results of Total Cervical Disc Replacement with a Minimum Follow-up of 10 Years / Resultados da artroplastia total de disco cervical com acompanhamento mínimo de 10 anos

Abstract Objective In the present study, we present the results with at least 10 years of follow-up of the cervical disc prosthesis implanted in a single level. Methods Retrospective study of patients undergoing single-level total cervical disc replacement (TCDR). Clinical results included the neck disability index (NDI) and the visual analogue scale (VAS) in the preoperative period, one year postoperatively, and a minimum of 10 years of follow-up. The radiographic parameters included cervical mobility, segmental lordosis, C2-C7 angle, heterotopic ossification (HO), facet and joint degeneration (FJD) and adjacent segment disease (ASD). Results We identified 22 patients, 16 women and 6 men with mean age of 39.7 years old (26-51 years old), of which fifteen completed a minimum follow-up of 10 years. There was a statistically significant improvement of NDI and VAS (p < 0.001) between the preoperative and the postoperative periods (1 year or > 10 years). At the end of 10 years, HO was observed in 59% of the cases. The mobility of the implant was preserved in 80% of the patients. Radiological evidence of ASD was recorded in 6 patients (40%). There was no correlation between the clinical parameters evaluated and the presence of ASD or the different classes of HO. Conclusion Clinical improvement in all evaluated parameters, which persists over time. Most implants maintained mobility, as has already been demonstrated in other studies with shorter follow-ups. In a significant percentage of cases, ASD was observed, questioning the concept of motion preserving technology. However, we did not have any surgical intervention for this reason, since there was no correlation with worse clinical results.

Resumo Objetivo No presente estudo, apresentamos os resultados com um acompanhamento mínimo de 10 anos da artroplastia total do disco cervical (ATDC) em um nível. Métodos Estudo retrospectivo de pacientes submetidos a ATDC em um nível. Os resultados clínicos incluíram o índice de incapacidade relacionada ao pescoço (IIRP) e a escala visual analógica (EVA) no período pré-operatório, um ano pós-operatório e um mínimo de 10 anos de acompanhamento. Os parâmetros radiográficos incluíram a mobilidade cervical, lordose segmentar, ângulo C2-C7, ossificação heterotópica (OH), degeneração facetária e articular (DFA) e doença do segmento adjacente (DSA). Resultados Identificados 22 pacientes, 16 mulheres e 6 homens com média de idade de 39,7 anos (26-51 anos), dos quais 15 tiveram um acompanhamento mínimo de 10 anos. Foi verificada melhoria estatisticamente significativa do IIRP e EVA (p < 0,001) entre pré-operatório e pós-operatório. (1 ano ou > 10 anos). Ao final de 10 anos, OH foi observada em 59% dos casos. A mobilidade do implante foi preservada em 80% dos pacientes. Houve evidência radiológica de DSA em 6 pacientes (40%). Não houve correlação entre os parâmetros clínicos avaliados e a presença de DSA ou as diferentes classes de OH. Conclusão Melhoria clínica em todos os parâmetros avaliados, que persiste ao longo do tempo. A maioria dos implantes manteve a mobilidade, como já demonstrado em estudos anteriores com acompanhamentos mais curtos. Numa percentagem significativa, a DSA estava presente, questionando o conceito da tecnologia de preservação de movimento. No entanto, sem nenhuma intervenção cirúrgica por esse motivo, uma vez que não houve correlação com piores resultados clínicos.

Surgical treatment of fractures of the ankylosed spine / Tratamento cirúrgico de fraturas da coluna anquilosada / Tratamiento quirúrgico de las fracturas en la columna anquilosada

ABSTRACT Objective We aim to identify retrospectively surgically treated patients with an ankylosed spine who sustained a vertebral fracture. Our goal is to evaluate the main outcomes and complications. Methods We selected patients through the database of surgical interventions in the setting of fractures of an ankylosed spine segment between January 1st 2008 and June 30th 2018. We collected data from digital medical records. The parameters analyzed include hospital length of stay, Intensive Care Unit (ICU) admission, perioperative and postoperative complications as well as neurological evolution. Results Fractures occurred in 14 patients with ankylosing spondylitis (82%) and 3 patients with diffuse idiopathic skeletal hyperostosis (18%). All patients were male and the mean age was 69 years. Fourteen fractures occurred after minor trauma (83%), of which 11 were due to falls from standing height or lower (65%). The cervical spine represents the majority of the levels involved (65%). Seven patients were admitted to the ICU (41%) and 11 suffered neurological damage. There was improvement of neurological status in less than 50% and there were high percentages of post-operative complications. Conclusion Patients with ankylosed spine diseases are at higher risk for vertebral fracture, even after minor trauma, and these are located predominantly in the cervical spine. The surgical treatment of these conditions is effective as it allows improvement of the patient's neurological status. However, they still present higher morbidity and mortality, as well as increased post-op complications. Prevention of falls may drastically change patients' outcome, neurological function and independence in activities of daily living. Level of evidence IV; A case series therapeutic study.

RESUMO Objetivo Identificar retrospetivamente casos de tratamento cirúrgico de fraturas vertebrais em pacientes com coluna anquilosada. O nosso propósito consiste em avaliar os principais desfechos e respectivas complicações. Métodos Selecionamos pacientes através do banco de dados de intervenções cirúrgicas no quadro de fraturas de um segmento da coluna anquilosada entre 1 de janeiro de 2008 a 30 de junho de 2018. Coletamos os dados a partir dos prontuários médicos digitais. Os parâmetros analisados incluem período de internação hospitalar, admissão na Unidade de Tratamento Intensivo (UTI), complicações pré- e pós-operatórias, assim como evolução neurológica. Resultados As fraturas ocorreram em 14 pacientes com espondilite snquilosante (82%) e em 3 pacientes com hiperostose esquelética difusa idiopática (18%). Todos os pacientes eram do sexo masculino e a idade média era de 69 anos. Quatorze fraturas ocorreram devido a trauma menor (83%), das quais 11 eram devido a quedas da própria altura ou inferiores (65%). A coluna cervical representa a maioria dos níveis envolvidos (65%). Sete pacientes foram admitidos na UTI (41%) e 11 sofreram lesão neurológica. Houve melhoria do estado neurológico em menos de metade dos pacientes e altas porcentagens de complicações pós-operatórias. Conclusão Os pacientes com doenças da coluna anquilosada têm maior risco de fraturas vertebrais, mesmo após trauma menor, localizando-se predominantemente na coluna cervical. O tratamento cirúrgico dessas condições é eficaz, uma vez que permite melhora do estado neurológico do paciente. Entretanto, ainda apresentam altos índices de morbilidade e mortalidade, assim como maior incidência de complicações pós-operatórias. A prevenção de quedas pode alterar drasticamente o desfecho, função neurológica e independência nas atividades diárias do paciente. Nível de evidência IV; Estudo terapêutico de série de casos.

RESUMEN Objetivo Identificar retrospectivamente casos de tratamiento quirúrgico de fracturas vertebrales en pacientes con columna anquilosada. Nuestro propósito consiste en evaluar sus principales resultados y respectivas complicaciones. Métodos Seleccionamos pacientes mediante banco de datos de intervenciones quirúrgicas en el cuadro de fracturas de un segmento de la columna anquilosada entre el 1 de enero de 2008 al 30 de junio de 2018. Recolectamos los datos a partir de los prontuarios médicos digitales. Los parámetros analizados incluyen período de internación hospitalaria, admisión en la Unidad de Tratamiento Intensivo (UTI), complicaciones pre y postoperatorias, así como evolución neurológica. Resultados Las fracturas ocurrieron en 14 pacientes con espondilitis anquilosante (82%) y en 3 pacientes con hiperostosis esquelética difusa idiopática (18%). Todos los pacientes eran del sexo masculino y la edad promedio era de 69 años. Catorce fracturas ocurrieron debido a trauma menor (83%), de las cuales 11 eran debido a caídas de la propia altura o inferiores (65%). La columna cervical representa la mayoría de los niveles implicados (65%). Siete pacientes fueron admitidos en la UTI (41%) y 11 sufrieron lesión neurológica. Hubo mejora del estado neurológico en menos de la mitad de los pacientes y altos porcentajes de complicaciones postoperatorias. Conclusión Los pacientes con enfermedades de la columna anquilosada tienen mayor riesgo de fracturas vertebrales, incluso después de trauma menor, localizándose predominantemente en la columna cervical. El tratamiento quirúrgico de esas condiciones es eficaz, ya que permite mejora del estado neurológico del paciente. Entretanto, aún presentan altos índices de morbilidad y mortalidad, así como mayor incidencia de complicaciones postoperatorias. La prevención de caídas puede alterar drásticamente los resultados, función neurológica e independencia en las actividades diarias del paciente. Nivel de evidencia IV; Estudio terapéutico de serie de casos.

Minimum of 10-year follow-up of V-rod technique in lumbar spondylolysis.

PURPOSE: To describe and analyze the use of the V-rod technique described by Gillet to repair spondylolysis in both early and late postoperative periods. METHODS: Patients submitted to surgical correction of lumbar spondylolysis with a V-rod system were selected upon exclusion of adjacent disk degenerative changes and high-grade spondylolisthesis. A preoperative clinical (ODI and VAS) and radiological evaluation was performed, along with assessments on the early (clinical evaluation-up to 1 year) and late (clinical and radiological-at least 10 years) postoperative periods. RESULTS: Twenty-two patients were included, 21 with L5 spondylolysis. Fifty percent had grade I spondylolisthesis. A significant decrease in ODI and VAS was observed from pre- to early and late post-op evaluation (all p < 0.05) but not during post-op evaluations. Changes from pre- to postoperative of both ODI and VAS were significantly higher than the minimal clinically important difference. Preoperative ODI and VAS were significantly higher in overweight/obese but similar postoperatively. No additional instability was found in late postoperative X-rays. Three patients needed revision surgery, with a survival rate of 81.8% for Gillet instrumentation at a mean follow-up of 687.7 ± 60.0 weeks. CONCLUSIONS: Surgical treatment with V-rod system is associated with a significant improvement in ODI and VAS and radiologic stability, with an equal benefit in obese/overweight patients. This study reports for the first time an improvement that is maintained even 10 years after the initial intervention, associated with a low rate of failure. These slides can be retrieved under Electronic Supplementary Material.

Ozone therapy for low back pain. A systematic review.

BACKGROUND: Low back pain associated with lumbar disc herniation is common in the general population, with evident repercussion in quality of life and a significant economic burden. Patients refractory to conservative treatment seek additional treatment and minimally invasive interventions were proposed as valid options. Ozone therapy has been suggested as an alternative due to its potential analgesic and anti-inflammatory effect. OBJECTIVE: This systematic review aims to investigate the effectiveness and safety of ozone therapy for low back pain in patients with lumbar disc herniation. MATERIAL AND METHODS: A systematic search was performed in Pubmed and Scopus, followed by a three-step selection process. Data was processed by 2 independent reviewers and information was gathered based in pre-defined variables. Only articles performed in humans; original and English written; on treatment with ozone; comparing the result of ozone therapy (experimental group) with another non-ozone intervention (control group); and on patients with lumbar pain and disc hernia, were included. RESULTS: From 439 references retrieved after duplicates removal, inclusion and exclusion criteria were applied, and 7 studies were included in the final revision. One article compared treatment with ozone versus placebo, one ozone and global postural re-education versus global postural re-education alone, two the combination of ozone with steroid versus steroid alone, two ozone versus steroid and one ozone versus micro-discectomy. All but the study comparing ozone application with micro-discectomy, showed similar or better results in the experimental group. Only three studies evaluated the presence of side effects. In two papers no complication was reported, and in the other, a low percentage of adverse effects was observed, not significantly different between the two study groups. CONCLUSIONS: Only a small number of poor quality studies on ozone effect in low back pain and disc herniation were available for inclusion in our review. Nevertheless, these reported an improvement in pain and functional scores with its application. Complications, mostly minor, but potentially serious are underreported. Additional studies with adequate and consistent methodologies are needed before the role of ozone can be established in the management of low back pain.

[Epidemiological Trends of Proximal Femoral Fractures in the Elderly Population in Portugal]. / Tendências Epidemiológicas das Fraturas do Fémur Proximal na População Idosa em Portugal.

INTRODUCTION: Proximal femoral fractures are an important public health problem in industrialized societies. There are few studies that evaluate the incidence of this type of fracture in Portugal. The aim of this study was to analyze and interpret epidemiological trends of proximal femoral fractures in the elderly population in Portugal between 2005 and 2013. MATERIAL AND METHODS: Cross-sectional study including all patients aged 65 years and older admitted due to proximal femoral fractures in Portuguese hospitals belonging to the National Health Service using data from the national registry of the health system central administration. RESULTS: 101,436 patients were included. There was a progressive increase in the number of hospitalizations per year over the period analyzed. The mean age at admission was 79.32 (± 12.33) years presenting a progressive and significant increase over the analyzed period (p < 0.001). 74.5% of the patients were female (p < 0.001). They had a significantly higher average age at admission, both globally and in each study year (p < 0.001). The age-adjusted incidence (≥ 65 years) was 597 fractures / year / 100,000 inhabitants. There was an increase in the incidence of proximal femoral fractures from 508.49 (2005) to 628.39 fractures per 100,000 person-years (2013). In the female sex the increase was from 616.78 to 762.88 and in the male sex from 339.95 to 419.06. DISCUSSION: This is the first study to evaluate and interpret the epidemiological trends of proximal femur fractures in patients admitted to the National Health Service in Portugal including only individuals aged 65 years or over. CONCLUSION: The global number of proximal femoral fractures in Portugal showed a trend of increase between 2005 - 2013, affecting a significant percentage of the Portuguese population over 65 years of age, especially in females and progressively older individuals.

Introdução: As fraturas do fémur proximal representam um problema de saúde pública nas sociedades industrializadas. São escassos os estudos sobre a incidência destas fraturas em Portugal. O objectivo deste estudo foi analisar e interpretar as tendências epidemiológicas das fraturas do fémur proximal, na população idosa em Portugal, no período de 2005 a 2013.Material e Métodos: Estudo transversal incluindo todos os doentes com idade igual ou superior a 65 anos admitidos por fratura do fémur proximal em hospitais portugueses pertencentes ao serviço nacional de saúde com recurso aos dados do registo nacional da administração central do sistema de saúde.Resultados: Foram incluídos 101 436 doentes. Observou-se um aumento progressivo no número de internamentos por ano ao longo do período analisado. A idade média à admissão foi de 79,32 (± 12.33) anos apresentando um aumento progressivo e significativo ao longo do período analisado (p < 0,001). Dos doentes, 74.5% eram do sexo feminino (p < 0,001). Apresentavam idade média à admissão significativamente superior, quer globalmente, quer em cada ano em estudo (p < 0,001). A incidência ajustada à idade (≥ 65 anos) foi de 597 fraturas / ano / 100 000 habitantes. Verificou-se um aumento na incidência de fraturas do fémur proximal de 508,49 (2005) para 628,39 fraturas por 100 000 pessoas / ano (2013). No sexo feminino o aumento foi de 616,78 para 762,88 e no masculino de 339,95 para 419,06.Discussão: Este é o primeiro estudo a avaliar e interpretar as tendências epidemiológicas das fraturas do fémur proximal em doentes admitidos nos hospitais do Serviço Nacional de Saúde em Portugal incluindo apenas indivíduos com idade igual ou superior a 65 anos.Conclusão: O número absoluto de fraturas do fémur proximal em Portugal mostrou uma tendência de aumento entre 2005 - 2013, afetando uma percentagem significativa da população portuguesa com mais de 65 anos de idade. Tendem a ocorrer mais comummente no sexo feminino e em indivíduos progressivamente mais velhos.

Neuroimmune expression in hip osteoarthritis: a systematic review.

BACKGROUND: Neuroimmune axis is central in the physiopathology of hip osteoarthritis (OA), but its specific pathways are still unclear. This systematic review aims to assess the nervous and immune system profile of patients with hip osteoarthritis (OA) when compared to healthy controls. METHODS: A systematic review followed PRISMA guidelines was conducted. A two-step selection process was completed, and from 609 references 17 were included. The inclusion criteria were: original articles on adult patients with hip OA, with assessment of neuroimmune expression. Articles with other interventions prior to analysis and those without a control group were excluded. RESULTS: Thirty-nine relevant neuroimmune markers were identified, with assessments in bone, cartilage, synovial membrane, synovial fluid, whole blood, serum and/or immune cells. GM-CSF, IFN-γ, IL-1α, IL-6, IL-8, IL-1 and TNF-α presented variable expression among tissues studied when compared between hip OA and controls. VEGFs and TGF-ß isoforms showed similar tendencies among tissues and studies. On nervous expression, CGRP, Tuj-1 and SP were increased in synovial membrane. Overall, patients with hip OA presented a higher number of overexpressed markers. CONCLUSIONS: For the first time a systematic review on neuroimmune expression in patients with hip OA found an upregulation of neuroimmune markers, with deregulated balance between pro and anti-inflammatory cytokines. However, no clear systematic pattern was found, and few information is available on nervous expression. This highlights the importance of future research with clear methodologies to guide the management of these patients.

Atypical presentation of a cervical synovial cyst.

INTRODUCTION: Synovial cysts of the cervical spine are rare. These lesions have been associated with other spinal conditions as osteoarthritis, spondylolisthesis, and disc degeneration, with authors postulating a possible link with segmental spinal instability. This study aims to describe an atypically presenting case of a cervical synovial cyst. CASE REPORT: A 65-year-old man presented with complaints of cervical radicular pain (VAS of 7) that evolved with development of paresthesia and muscular weakness, compatible with C8 right compression. This symptomatology had an odd pattern with total regression of symptoms when lying supine or upon extreme efforts, leading to a delayed referral to MRI. A C7-T1 synovial cyst was identified, compressing the C8 nerve root. The patient was submitted to decompression and instrumented fusion of the affected level and showed total regression of symptoms. CONCLUSIONS: Although rare, cervical synovial cysts are associated with a significant impairment in patients' daily activities. The atypical pattern of symptoms described in this case may be associated with the fluid content of the cyst, with postural changes causing different degrees of root compression. Most authors agree on a surgical option, but the need for associated fusion is still under debate.

[Analysis of the Cochrane Review: Pedicle Screw Fixation for Traumatic Fractures of the Thoracic and Lumbar Spine. Cochrane Database Syst Rev. 2013;05:CD009073]. / Análise da Revisão Cochrane: Fixação com Parafusos Pediculares de Fraturas Traumáticas da Coluna Vertebral Torácica e Lombar. Cochrane Database Syst Rev. 2013;05:CD009073.

Traumatic fractures of the thoracic and lumbar spine are common causes of spine surgery. Pedicle screw fixation is usually chosen, using monosegmentar, short or long segment instrumentations, with or without bone graft. This review aims to evaluate the effect of transpedicular fixation in traumatic fractures of the thoracic and lumbar spine. A systematic search on controlled, randomized or quasi-randomized trials comparing different methods of surgical treatment of this fractures was performed, followed by a process of article selection, data extraction and bias assessment by 3 independent authors. Eight articles were included in a total of 5 comparisons, between different transpedicular fixation techniques. No significant differences on function or quality of life, neurologic status or limitation of motion were found. Only instrumentation with fracture level screw incorporation showed significant decrease of pain when compared with instrumentation alone. Several techniques resulted in significant improvements of different radiological parameters. Significantly, surgeries with smaller duration were associated with lesser blood loss. Bone graft use caused a significant raise in post-operative complications, namely donor site pain. So, this paper showed that significative improvements in radiological parameters do not associate with correspondent clinical benefits, and only instrumentation with level screw incorporation is associated with a clear benefit on pain. Moreover, the need for bone graft is questioned, since it leads to no clinic-radiological improvement with a raise of complications. However, a small number of controlled studies is available on this topic.

As fraturas da coluna vertebral torácica e lombar são causa comum de cirurgia da coluna vertebral. A fixação com parafusos pediculares é geralmente escolhida para a sua estabilização, com recurso a instrumentações curtas, longas ou monosegmentares com ou sem enxerto ósseo. O objetivo desta revisão é avaliar o efeito da fixação transpedicular nas fraturas vertebrais torácicas e lombares traumáticas. Foi realizada uma pesquisa sistemática de estudos controlados aleatorizados ou quasi-aleatorizados que comparassem diferentes técnicas de tratamento cirúrgico destas fraturas, seguida de um processo de seleção, extração de dados e avaliação de viéses por três autores independentes. Oito estudos foram incluídos, num total de cinco comparações entre diferentes fixações com parafusos pediculares. Não se encontraram diferenças significativas quanto à melhoria da função e qualidade de vida, dos défices neurológicos ou da mobilidade. Apenas a instrumentação com parafusos pediculares no nível da fratura mostrou melhoria significativa da dor quando comparada com instrumentação posterior sem parafuso no nível. Várias técnicas resultaram em melhoria significativa dos parâmetros imagiológicos, sem melhoria clínica correspondente. De modo significativo tempos cirúrgicos mais curtos associaram-se a menores perdas sanguíneas. O uso de enxerto ósseo causou um aumento significativo das complicações pós-operatórias, nomeadamente dor no local dador. Assim, os resultados mostram que melhorias imagiológicas significativas não se associam a impactos clínicos correspondentes, e que apenas o uso de fixação transpedicular no nível da fratura se associa a melhoria clínica evidente da dor. Adicionalmente, a necessidade de enxerto ósseo é posta em causa, pela ausência de melhoria clínico-imagiológica, com aumento das complicações. Contudo, o número de estudos controlados disponíveis acerca deste tópico é reduzido.

Paediatric cervical spine injures. Nineteen years experience of a single centre.

PURPOSE: This observational study aims to describe pediatric C-spine injuries from a level 1 trauma centre through a period of 19 years. METHODS: Clinical records of pediatric trauma patients admitted to a level 1 trauma centre between 1991 and 2009 were analyzed. Patients were stratified by age into groups A (8 or less) and B (9 to 16), and in lower (C0-C2) and upper (C3-C7) spine injuries. Several variables were studied. RESULTS: Seventy-five cases of C-spine injuries (nine SCIWORA) were identified. Group A included 23 patients and group B 52. In group A, skeletal injuries at the upper C-spine were more common than injuries at the lower C-spine, whereas in group B, injuries of the lower C-spine were more frequent (p = 0.035). Motor vehicle accidents were the main cause of injury (44 %); 25.3 % of patients were surgically treated. Thirty-nine patients presented neurologic deficits, 16 of which improved. The overall mortality rate was 18.7 % and significantly higher in patients with neurological damages (p < 0.001) CONCLUSIONS: This study revealed a low incidence of cervical spine injuries in the paediatric population. As in previous reports younger children mainly sustained injuries at the upper C-spine, higher incidence of spinal injuries, and higher risk of death than older children.

Validation of control of allergic rhinitis and asthma test for children (CARATKids)--a prospective multicenter study.

BACKGROUND: Control of Allergic Rhinitis and Asthma Test for Children (CARATKids) is the first questionnaire that assesses simultaneously allergic rhinitis and asthma control in children. It was recently developed, but redundancy of questions and its psychometric properties were not assessed. This study aimed to (i) establish the final version of the CARATKids questionnaire and (ii) evaluate its reliability, responsiveness, cross-sectional validity, and longitudinal validity. METHODS: A prospective observational study was conducted in 11 Portuguese centers. During two visits separated by 6 wk, CARATKids, visual analog scale scales and childhood asthma control test were completed, and participant's asthma and rhinitis were evaluated by his/her physician without knowing the questionnaires' results. Data-driven item reduction was conducted, and internal consistency, responsiveness analysis, and associations with external measures of disease status were assessed. RESULTS: Of the 113 children included, 101 completed both visits. After item reduction, the final version of the questionnaire has 13 items, eight to be answered by the child and five by the caregiver. Its Cronbach's alpha was 0.80, the Guyatt's responsiveness index was -1.51, and a significant (p < 0.001) within-patient change of CARATKids score in clinical unstable patients was observed. Regarding cross-sectional validity, correlation coefficients of CARATKids with the external measures of control were between 0.45 and -0.69 and met the a priori predictions. In the longitudinal validity assessment, the correlation coefficients between the score changes of CARATKids and those of external measures of control ranged from 0.34 to 0.46. CONCLUSION: CARATKids showed adequate psychometric properties and is ready to be used in clinical practice.

Development process and cognitive testing of CARATkids - Control of Allergic Rhinitis and Asthma Test for children.

BACKGROUND: Allergic rhinitis and asthma (ARA) are chronic inflammatory diseases of the airways that often coexist in children. The only tool to assess the ARA control, the Control of Allergic Rhinitis and Asthma Test (CARAT) is to be used by adults. We aimed to develop the Pediatric version of Control of Allergic Rhinitis and Asthma Test (CARATkids) and to test its comprehensibility in children with 4 to 12 years of age. METHODS: The questionnaire development included a literature review of pediatric questionnaires on asthma and/or rhinitis control and two consensus meetings of a multidisciplinary group. Cognitive testing was carried out in a cross-sectional qualitative study using cognitive interviews. RESULTS: Four questionnaires to assess asthma and none to assess rhinitis control in children were identified. The multidisciplinary group produced a questionnaire version for children with 17 questions with illustrations and dichotomous (yes/no) response format. The version for caregivers had 4-points and dichotomous scales. Twenty-nine children, 4 to 12 years old, and their caregivers were interviewed. Only children over 6 years old could adequately answer the questionnaire. A few words/expressions were not fully understood by children of 6 to 8 years old. The drawings illustrating the questions were considered helpful by children and caregivers. Caregivers considered the questionnaire complete and clear and preferred dichotomous over the 4-points scales. The proportion of agreement between children and their caregivers was 61%. The words/expressions that were difficult to understand were amended. CONCLUSION: CARATkids, the first questionnaire to assess a child's asthma and rhinitis control was developed and its content validity was assured. Cognitive testing showed that CARATKids is well-understood by children 6 to 12 years old. The questionnaire's measurement properties can now be assessed in a validation study.

Limitação do suporte de vida em unidade de terapia intensiva pediátrica / Limitation of life support in the pediatric intensive care unit

O presente estudo resulta de revisão de prontuários de pacientes falecidos no período de quatro anos em UTI pediátrica de hospital universitário, tendo analisado variáveis como tempo de internação, diagnóstico da principal falência orgânica da criança, ocorrência de doenças crônicas prévias, tomada de decisões dos médicos referentes à introdução de medidas de suporte vital de vida, ordens de não reanimação e qualidade da relação dos profissionais com familiares dos pacientes. Os resultados sugerem que as condutas adotadas pelos médicos refletem majoritariamente a preocupação de se protegerem contra eventuais processos judiciais decorrentes da acusação de omissão de socorro. Embora os casos clínicos estudados refiram-se a pacientes portadores de enfermidades terminais, o que por si só envolve complexos conflitos morais, em nenhum momento foi oferecido aos familiares dos pacientes a possibilidade de participarem dos processos de decisões médicas e, tampouco, existem registros de consultas ao comitê de ética do hospital.

The present study has been made through a revision of medical reports during the period of three years at thePediatric Intensive Care Unit of a University Hospital, having analyzed the variables as, hospitalization time,diagnosis of the child’s principle organ failure, presence of chronic disease, the doctor’s decision concerningthe introduction of life support measure, the do-not-resuscitate (DNR) orders additionally the relationshipquality towards doctors and relatives. Most of the obtained results revealed that the procedures adopted bydoctors reflect majorly the professional concerns to protect themselves from lawsuits about neglecting help.Although, the clinic cases studied refers to patients carriers of terminal illness, which only by itself, involves anenormous quantity of moral conflicts, at none of these situations were offered to the patient’s relatives thepossibility to participate at the deliberately procedures about the medical decision therefore there were no consultations with the Ethics Committee from the Hospital.

[Protocol of the animal assisted activity program at a university hospital]. / Protocolo do Programa de Assistência Auxiliada por Animais no Hospital Universitário.

Animal-Assisted Activity (AAA) consists in visitation and recreation through contact with animals, aiming at entertainment and improving the interpersonal relationship between patients and staff. Permission for the animals to visit an Institution requires a protocol with rules and safety routines to avoid accidents and zoonoses. The objective of this study is to describe the important points of the protocol to implement the AAA program. The protocol includes: introduction, objectives, inclusion and exclusion criteria for animals, drivers and patients; recommendations to the handlers and the health team, responsibilities of the Nosocomial Infection Control Committee, zoonoses posters, vaccination schedule for dogs and cats, free-informed consent to take part in the program and records with behavioral analysis of the animals. We believe that disclosing the protocol, based on scientific studies, favors the implementation of new programs in institutions considering the lack of national publications.