Two-stage bone-and-strut technique in the treatment of septic non-unions in the upper limb.

Aim To report the results of a two-stage reconstruction of septic non-unions of the upper limb using the bone-and-strut technique with a follow-up of more than two years. Methods A total of 19 patients (12 males and seven females; age 27 to 85 years) were included in this cohort study. The evaluation endpoint was set at 24 months. Radiographic union, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores, pain and return to work were assessed. All patients were treated with debridement and antibiotic therapy. At a second stage, the nonunion focus was filled with a cancellous bone allograft. Stability was provided using a locking plate and a bone strut. Results After 24 months, the QuickDASH scores improved from a median of 28 (interquartile range, 13 - 35 points), to a median of 78 (interquartile range, 70 - 89 points). Mean pain scores improved from 8.1 (range, 0.3-10) to 0.6 (range 0-2). Radiographic and clinical union was seen in all patients. The majority of patients returned to work or previous activities when retired. A new neurological deficit, recurrence of infection, or other surgery-related adverse events were not observed. Conclusion The two-stage bone-and-strut technique is a safe and effective technique in the treatment of septic non-unions of the upper limb. The union rate is high, the complication rate is acceptable and return return-to-work is high. Recurrence of infectious sequelae during a follow-up period of at least two years was not seen. The patient-reported outcomes increased significantly.

Tibial diaphyseal fractures in children: indications and limitations of the treatment with monolateral and hybrid external fixator.

Aim To report our indications and limitations about the use of external fixation in children. Methods It was retrospectively reviewed all tibial fractures treated with monolateral and hybrid external fixator, at our three Centres. It was included 32 fractures which did not show an acceptable reduction after an attempt under anaesthesia. The exclusion criteria were: open fractures, children with previous fractures of the lower limbs, with skeletal congenital diseases, fractures involving the physis and with neurovascular involvement. All fractures were classified according to the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification. An outcome was evaluated according to the time needed to obtain radiographic bone healing, the range of motion (ROM) of the ankle, the asymmetry of the lower limbs, the malunion, and complications. Results The average time of consolidation was 10.66 weeks (6-17 weeks). There were no cases of deep infection, but only seven cases of superficial pin infections. No patients reported loss of ROM of the knee or ankle. We had zero cases of residual angle greater than 5°, and in all cases the difference in length between the limbs was <1 cm. Conclusion The external fixation is a viable technique in the treatment of tibial fractures in children. Therefore, the external fixation, both monolateral and hybrid, should be considered a viable treatment for this type of fracture.

Strut graft vs. traditional plating in the management of periprosthetic humeral fractures: a multicentric cohort study.

Aim The gradual increase in shoulder implants in active elderly patients has appeared in a parallel increase in periprosthetic humeral fractures. The aim of this study was to investigate the advantages of using strut grafting with plate fixation during periprosthetic humerus fractures. Methods Thirty patients diagnosed with periprosthetic humeral fracture were divided into two groups. The first group of 15 patients (PS) underwent plate, ring, screws and strut allografts. The second group with resting 15 patients (PWS) was treated with only plate and screws. The criteria to evaluate the groups during followup were the Constant Shoulder Score (CSS) and Oxford Shoulder Score (OSS); the bone healing was measured by X-rays, controls measured by radiographic union score (RUS), and complications. The follow up was terminated at 12nd month in both groups. Results The difference between the two groups in all parameters was not significant. However, all patients gained adequate shoulder motor skills for normal daily living activities. All fractures were healed. Only two complications were registered, and blood loss was minimal. Conclusion We believe a revision to reverse shoulder prosthesis with a long-stem implant with or without cortical strut allograft augmentation to be safe and appropriate in the management of these complex injuries, though technically challenging, and having good results for normal activities daily life.

Expresión tumoral de BRCA1 y resultados clínicos en pacientes uruguayas diagnosticadas de cáncer de mama antes de los 40 años / BRCA1 tumor expression and clinical results in uruguayan patients diagnosed with breast cancer before the age of 40 years old / Expressão tumoral de BRCA1 e resultados clínicos em pacientes uruguaias com diagnóstico de câncer de mama antes dos 40 anos

Resumen: Las mutaciones de BRCA1 son raras en el cáncer de mama (CM) esporádico; sin embargo, su expresión a nivel tumoral se encuentra disminuida o ausente en 30%-50% de los casos. Objetivo: valorar la expresión tumoral de BRCA1 por inmunohistoquímica (IHQ) en mujeres uruguayas diagnosticadas de CM antes de los 40 años. Material y método: se incluyeron pacientes diagnosticadas de CM antes de los 40 años. Se utilizaron los anticuerpos monoclonales anti-BRCA1 MS110 contra el extremo N-terminal y GLK-2 contra el extremo C-terminal. Se calculó la sobrevida global (SVG) y la sobrevida libre de enfermedad (SVLE), para la construcción de las curvas se utilizó el método de Kaplan-Meier y la diferencia de sobrevida se evaluó mediante el test de log rank. Resultados: se incluyeron 40 pacientes, la SVG y la SVLE a cinco años fueron de 73% y 60% respectivamente. La expresión de BRCA1 mediante GLK-2 fue <10% en 16 de las 40 pacientes (40%). La SVG y la SVLE a cinco años para las pacientes con expresión <10% fue de 56% vs 85% para las pacientes con expresión >10% (p=0,015) y de 40% vs 72% (p=0,034) respectivamente. La expresión de BRCA1 mediante MS110 fue <10% en 11 de las 40 pacientes (27,5%). No se encontraron diferencias en la SVG ni en la SVLE a cinco años con este marcador. Conclusión: la pérdida de la expresión tumoral de BRCA1 determinada mediante GLK-2 se encontró en el 40% de las pacientes incluidas y se asoció a una menor SVG y SVLE, por lo que podría tener un valor pronóstico desfavorable en estas pacientes.

Summary: BRCA1 mutations are rare in sporadic breast cancer (CM), however their expression at the tumor level is diminished or absent in 30-50% of cases. Objective: to assess the tumor expression of BRCA1 using immunohistochemistry (IHC) in Uruguayan women diagnosed with BC before the age of 40 years. Material and methods: patients diagnosed with BC before the age of 40 between. The antibodies used were anti BRCA1 MS110 monoclonal antibodies against the N-terminal end and GLK-2 against the C-terminal. Overall survival (OS) and disease free survival (DFS) were calculated; the curves were developed using the Kaplan-Meier method and the difference in survival was evaluated through the log rank test. Results: the average age of the 40 patients included was 36 years. The 5-year OS and DFS were 73% and 60% respectively. The expression of BRCA1 with GLK-2 was <10% in 16 of the 40 patients included (40%). The 5-year OS and DFS for patients with <10% expression was 56% vs. 85% for patients with >10% (p=0.015) and 40% vs. 72% (p = 0.034) respectively. The expression of BRCA1 by MS110 was <10% in 11 of the 40 patients included (27.5%). No differences were found in the 5-year OS or DFS based on the expression of this marker. Conclusion: The loss of BRCA1 expression using GLK-2, which suggests the presence of a truncated protein, was associated with a statistically significantly lower OS and DFS, that the decrease in the BRCA1 protein as determined by GLK2 has an unfavorable prognostic value for young patients with BC.

Resumo: As mutações de BRCA1 são raras no câncer de mama (CM) esporádico; no entanto sua expressão no nível tumoral está diminuída ou ausente em 30-50% dos casos. Objetivo: avaliar a expressão tumoral de BRCA1 por imuno-histoquímica (IHQ) em mulheres uruguaias com diagnóstico de CM antes dos 40 anos. Material e métodos: foram incluídas pacientes com diagnóstico de CM antes dos 40 anos. Foram utilizados anticorpos monoclonais anti BRCA1 MS110 contra o extremo N-terminal e GLK-2 contra o extremo C-terminal. A sobrevida global (SVG) e a sobrevida livre de enfermidade (SVLE) foram calculadas; o método de Kaplan-Meier foi utilizado para a construção das curvas e a diferença de sobrevida foi avaliada usando o teste de log-rank. Resultados: foram incluídas 40 pacientes; a SVG e a SVLE aos 5 anos foram 73% e 60% respectivamente. A expressão de BRCA1 mediante GLK-2 foi <10% em 16 das 40 pacientes (40 %). A SVG e a SVLE aos 5 anos para as pacientes com expressão £10% foi 56% vs. 85% para as pacientes com expressão >10% (p=0,015) e 40% vs. 72% (p=0,034) respectivamente. A expressão de BRCA1 mediante MS110 foi =10% em 11 das 40 pacientes (27,5%). Não foram encontradas diferenças na SVG nem na SVLE aos 5 anos com este marcador. Conclusão: foi encontrada perda da expressão tumoral de BRCA1 determinada por GLK-2 em 40% das pacientes incluídas e foi associada a uma menor SVG e SVLE, o que poderia ter um valor prognóstico desfavorável nestas pacientes.

Tranexamic Acid in Pertrochanteric Femoral Fracture: Is it a Safe Drug or Not?

BACKGROUND: There is a high incidence of blood transfusion following hip fractures in elderly patients. AIM: The aim of this study is to evaluate the effectiveness and complications of use of tranexamic acid in proximal femur nailing surgery. MATERIALS AND METHODS: Our sample group consisted of 90 patients suffering from pertrochanteric fractures surgically treated with osteosynthesis with SupernailGT(LimaCorporate). The classification system AO/OTA was used to divide the fractures into 31A1 (n=45) and 31A2 (n=45). The patients were divided into two groups: 47 patients were administered 15 mg of tranexamic acid per kg (group A) and 43 patients were administered placebo (group B). Blood counts were monitored daily to evaluate the rate of anemia. As a safety criterion, we monitored the possible occurrence of vascular events, symptomatic or not, over the 8 weeks post-surgery. Markers predicting mortality and deep venous thrombosis (DVE) were also monitored (fibrinogen D-dimer). RESULTS: Blood loss occurring post-surgery can be influenced by numerous factors that are not linked to the use or non-use of tranexamic acid. While closely monitoring hemoglobin levels daily, we observed that 42% of the patients in group A required blood transfusion as opposed to 60% in group B. The results of the markers predicting mortality (alpha1-acid glycoprotein; albumin LDL) and those of DVE were not statistically significant between the two groups in this study (p>0.05). CONCLUSION: Based on this study, the use of tranexamic acid was statistically significant in reducing post-surgery blood loss.

Dhs plus anti-rotational screw vs cannulated screws for femoral neck fractures: an analysis of clinical outcome and incidence regarding avn.

The aim of this study was to compare the union time, functional outcome and complications in patients with femoral neck fractures treated with percutaneous cannulated screws or dynamic hip screw (DHS) plus antirotational screw. We selected 117 consecutive patients having a hip fracture at any level within the Garden classification, treated at the Orthopedics and Traumatology Clinic in Perugia from 2010 to 2011. Average patient age was 67.8 years. Patients received either a treatment including cannulated screws (group I) or a DHS plate with anti-rotational screw(group II). All patients were followed up for a minimum of 1 year. The Harris Hip Score at 12 months was used to evaluate functional outcome. Between the two treatment groups, the differences in union time and functional outcome were not statistically significant. Moreover blood loss was significantly lower in group I. The results of our study did not suggest a superiority of one surgical technique over the other, when considering the union time and functional outcome. Regarding complications, the incidence of avascular necrosis was found to be significantly related to the Garden classification but not to synthesis type. Level of evidence: IV, Retrospective case series.

Comparison of Plate, Nail and External Fixation in the Management of Diaphyseal Fractures of the Humerus.

INTRODUCTION: Humeral shaft fractures are quite common in orthopedics and represent 1-3% of adult fractures. The surgical treatment is the a better choice in order to obtain a reduction and stable alignment and to prevent the complications. The goal of this study was to compare the three techniques (IMN, LCP and EF) in the treatment of diaphyseal fractures of the humerus in the adult patient. MATERIALS AND METHODS: We examined 79 patients with diaphyseal fractures of the humerus. 32 were treated with plaque (LCP), 26 with intramedullary nail (IMN) and 21 with eternal fixer (FE) The clinical and radiographic follow-up was done at 1.3, 6 and 12 months. As rating scales we used the ASES and SF-36. We recorded all the complications. RESULTS: The median follow-up was 11.5 months (9-16). The operative time was significantly smaller in the case of FE (47 ') with a statistically significant difference compared with other techniques. Even the blood loss was lower in the case of FE (60ml), compared to nails (160ml) and LCP (330ml) p <0.05. We had no differences in the duration of hospitalization and the ASES SF-36 score. We had 2 cases of non-union in the LCP group, 1 case in the IMN group and no cases in the FE group. In IMN group we had one case of radial transient paralysis. We did not have any deep infection, in the FE group 8 patients we had superficial secretions from pins. CONCLUSION: From the results of our study, it is clear that the treatment of humeral shaft fractures guarantee overlapping results with the use of plates, of intramedullary nails, or with the external fixator. Consequently, the choice of which technique to use should be determined based on the experience of the operator and patient compliance.

Características clínico-patológicas y evolución del cáncer de mama en mujeres uruguayas jóvenes / Clinical and pathological characteristics of breast cancer in young uruguayan women

Introducción: en Uruguay el cáncer de mama (CM) es la principal causa de muerte por esta afección en la mujer. Aproximadamente 5,4% de los casos se diagnostican en menores de 40 años, es decir, en mujeres en edad reproductiva y laboralmente activas. Objetivo: investigar la frecuencia, características clínico-patológicas y evolución de pacientes uruguayas diagnosticadas con CM antes de los 40 años y su sobrevida de acuerdo al subtipo biológico. Material y método: se recolectaron datos relacionados con las características clínico-patológicas y la evolución de pacientes menores de 40 años tratadas por CM en el período comprendido entre el 1º de enero de 2006 y 31 de diciembre de 2012 asistidas en las instituciones participantes. Se calculó la sobrevida global (SVG) y la sobrevida libre de enfermedad (SVLE) para todas las pacientes, globalmente, y según el subtipo biológico. Resultados: se incluyeron 107 pacientes; edad mediana: 35 años (rango 24 a 39 años); las características clínico-patológicas fueron: carcinoma ductal: 89,7%; GH 2-3: 93,5%; estadio: II-III: 75%; metástasis axilares: 57%; HER2- RE/RP+ 53%; HER2+ 24,5%, y triple negativas (TN) 22,5%. El 17% de las pacientes presentaron antecedentes familiares (AF) significativos y la totalidad realizaron los tratamientos según pautas vigentes. La SVG y la SVLE a cinco años para la totalidad de las pacientes fueron 79% y 72%, respectivamente. La SVG y la SVLE fueron 97% y 90%, respectivamente, para las pacientes ER/PR+/HER2-; de 54% y 49% para las HER2+, y de 60% y 20% para las TN. Las curvas de SVLE fueron similares para las pacientes TN y HER2+, mientras que las pacientes ER/PR+/HER2- tuvieron una mayor SVG y SVLE (Log Rank, p < 0,0001). Conclusiones: las pacientes uruguayas diagnosticadas de CM antes de los 40 años incluidas tuvieron una SVG y una SVLE menor a la reportada en pacientes de la población general y de mayor rango etario. Si bien la peor evolución se ha vinculado al retraso en el diagnóstico, la mayoría de nuestras pacientes fueron diagnosticadas en estadios localizados y la totalidad realizó los tratamientos según las pautas vigentes. Por otra parte, la proporción de subtipos desfavorables (TN y HER2+) fue mayor a lo reportado para mujeres de todas las edades con CM, por lo que su peor evolución podría estar relacionada con el perfil biológico.

Introduction: In Uruguay, breast cancer is the main cause of death for this condition. Approximately 5.4% of cases are diagnosed in women younger than 40 years old, in other words, in women in their reproductive age, when they may be part of the labor force. Objective: To investigate the frequency, clinical and pathological characteristics and evolution of Uruguayan patients who are diagnosed with breast cancer before they are 40 years old, and their survival according to the biological sub-type. Method: the data in connection with the clinical and pathological characteristics and the evolution of patients was collected for women younger than 40 years old who had been treated for breast cancer at the participating institutions between January 1, 20016 and December 31, 2012. Global survival and disease-free survival was calculated for all patients, globally and according to the biological sub-type. Results: 107 students were included in the study; median age: 35 years old, range (24 to 39 years old); clinical and pathological characteristics: ductal carcinoma: 89.7%; Grade 2-3: 93.5%; stage II-III: 75% axillary metastasis: 57%; HER2- ER/PR 53%; HER"+ 24.5% and triple negative 22.5%. 17% of patients evidenced significant family history, and all of them were treated according to protocols in force. Global survival and disease free-survival after five years was 79% and 72% respectively. Global survival and disease free-survival was 97% and 90% respectively for patients RE/RP+/HER2-; of 54% and 49% for HER2+, and of 60% and 20% for triple negative. Disease-free survival curves were similar for patients triple negative and HER2+, whereas patients RE/RP+/HER2-evidenced a greater global survival and disease-free survival (Log Rank, p ? 0,0001). Conclusions: Uruguayan patients diagnosed with breast cancer before the age of 40 years old included in the study evidenced a lower global survival and disease free-survival rate than that reported for patients of the general population and older than 40 years old. In spite of the fact that the worse evolution has been associated to delays in diagnostic, most patients were diagnosed in the localized stage and all of them were treated according to protocols in force. Likewise, the proportion of the unfavorable sub-types (triple negative and HER2+) was greater than that reported for women of all ages with breast cancer. Thus, the worse evolution could be associated with the biological profile.

Introdução: no Uruguai o câncer de mama (CM) é a principal causa de morte das mulheres por este tipo de patologia. Aproximadamente 5,4% dos casos são diagnosticados em mulheres com menos de 40 anos, ou seja, mulheres em idade reprodutiva e economicamente ativas. Objetivo: pesquisar a frequência, características clínico-patológicas e evolução de pacientes uruguaias diagnosticadas com CM antes dos 40 anos e sua sobrevida de acordo com o subtipo biológico. Material e método: foram coletados dados relacionados com as características clínico-patológicas e a evolução de pacientes com menos de 40 anos tratadas por CM no período 1º de janeiro de 2006 - 31 de dezembro de 2012 atendidas nas instituições participantes. A sobrevida global (SVG) e a sobrevida livre de doença (SVLE) foi calculada para todas as pacientes, e segundo o subtipo biológico. Resultados: 107 pacientes foram incluídas com idade mediana 35 anos (intervalo 24 a 39 anos); as características clínico-patológicas foram: carcinoma ductal: 89,7%; GH 2-3: 93,5%; estadio: II-III: 75%; comprometimento axilar: 57%; HER2- RE/RP+ 53%; HER2+ 24,5%, e triplo negativo (TN) 22,5%. 17% das pacientes apresentavam antecedentes familiares (AF) significativos e todas foram tratadas observando-se as pautas vigentes. A SVG e a SVLE aos cinco anos para o total de pacientes foram 79% e 72%, respectivamente. A SVG e a SVLE foram 97% e 90%, respectivamente, para as pacientes ER/PR+/HER2-; 54% e 49% para as HER2+, e 60% e 20% para as TN. As curvas de SVLE foram similares para as pacientes TN e HER2+, porém as pacientes ER/PR+/HER2- apresentaram SVG e SVLE maiores (Log Rank, p ? 0,0001). Conclusões: as pacientes uruguaias diagnosticadas com CM antes dos 40 anos incluídas neste estudo apresentaram SVG e SVLE menores às registradas para pacientes da população em geral e com idades superiores. Embora a pior evolução esteja vinculada ao diagnóstico tardio, a maioria das pacientes estudadas foi diagnosticada em estádios localizados e todas receberam tratamento de acordo com as pautas vigentes. Por outra lado, a proporção de subtipos desfavoráveis (TN y HER2+) foi maior ao informado para mulheres de todas as idades com CM, por isso uma pior evolução poderia estar relacionada com o perfil biológico.

Reliability, Feasibility and Value of Ecography in Clinical-functional Results in Patients Affected by Carpal Tunnel Syndrome: is There a Correlation?

BACKGROUND: The aim of this study was to evaluate how the ultrasound examination in the carpal tunnel diagnosis could contribute to the clinical and neurophysiological evaluation. This was done by evaluating the cross-sectional area (CSA) and its correlation with symptoms and functionality data assessed by the BTQC questionnaire. METHODS: 60 patients were subjected to open CTR for idiopathic carpal tunnel syndrome. The median nerve CSA was assessed both pre-operatively and in follow-up at 4 and 12 weeks. The Boston Carpal Tunnel Questionanaire (BCTQ) was proposed at the same time. RESULTS: BCTQ score significantly improved after 4 weeks, but there was a less significant increase at 12 weeks for both the BCTQ-S and the BCTQ-F. The 4-week CSA, however, did not appear to have markedly improvement, where as the 12-week CSA turned out to be statistically significant. The correlation between BCTQ and CSA shows that post-surgery, the reduction of CSA of the median nerve is correlated with the symptomatic and functional reduction in patients. CONCLUSIONS: The study shows that the symptomatology and the functionality of the hand after surgery for the carpal tunnel resolves quickly. Furthermore, the reduction of the CSA proves to show that the use of ultrasound can help in the evaluation of patients with this state.

Cardiotoxicidad inducida por Trastuzumab en pacientes uruguayas portadoras de cáncer de mama HER positivo / Trastuzumab-induced cardiotoxicity in uruguayan patients with HER positive breast cancer

RESUMEN: Objetivo: Valorar la frecuencia y severidad de la cardiotoxicidad inducida por Trastuzumab (TTZ) en pacientes portadoras de cáncer de mama (CM) HER 2 positivo, asistidas en los Servicios de Oncología del Hospital de Clínicas y de la Asociación Española Primera en Salud. Métodos: Estudio observacional retrospectivo, que incluyó pacientes del Hospital de Clínicas y de la Asociación Española diagnosticadas de CM HER 2 positivo, que recibieron tratamiento con TTZ entre enero de 2007 y diciembre de 2013. Resultados: Se incluyeron 69 pacientes, la mayoría de las cuales tuvieron CM localizado, y cuya media de edad fue 50,1 años. 27% de las pacientes presentó cardiotoxicidad, y el 26% de éstas desarrolló insuficiencia cardíaca sintomática; todas recibieron tratamiento médico adecuado, siendo la insuficiencia cardíaca reversible en la mayoría de los casos. Conclusiones: La frecuencia de cardiotoxicidad observada en el estudio fue del 27 % (IC 95 %: 16,27; 38,8). Con las limitaciones propias del estudio, éste permite verificar similitudes con otras poblaciones reportadas, variando la frecuencia entre 3,7 y 34 %. Sin embargo, la proporción de pacientes que presentaron insuficiencia cardíaca sintomática (7%) fue algo superior a la reportada en la literatura, que es del 4%. La cardiotoxicidad fue reversible en la mayoría de las pacientes.

ABSTRACT: Objective: To evaluate the frequency and severity of Trastuzumab-induced cardiotoxicity in HER2 positive breast cancer (BC) patients assisted in Oncologic Services of the Hospital de Clínicas and Asociación Española Primera en Salud. Methods: Retrospective observational study of HER2 positive BC patients from Hospital de Clínicas and Asociación Española under systemic therapy with Trastuzumab (TTZ) from January 2007 to December 2013. Results: The study included 69 patients, most were early BC, mean age was 50,1 years . 27% of the patients developed cardiotoxicity and 26 % of them developed symptomatic heart failure. All patients received adequate medical treatment and the most instances were reversible Conclusions: The frequency of cardiotoxicity observed in the study was 27% (IC 95 %: 16,27; 38,8). With the limitations of the study, it can verify reported similarities with other populations, oscillating frequency between 3.7 and 34%. However, the proportion of patients who had symptomatic heart failure (7%) was higher than that reported in the literatura wich is 4%. Cardiotoxicity was reversible in most patients.