Granzyme-A deficiency attenuates experimental osteoarthritis in mice, but perforin deficiency does not.

OBJECTIVES: This study aims to assess the development of osteoarthritis (OA) in granzyme A- (gzmA) and B- (gzmB) and perforin- (perf) knockout mice. MATERIALS AND METHODS: A total of 75 male and female C57BL/6 (eight to nine-week-old) mice were allocated to: gzmA-deficient (gzmA-/-) (11 females, 8 males), gzmB-deficient (gzmB-/-) (9 females, 8 males), perf-deficient (perf-/-) (10 females, 9 males), and control group (10 females, 10 males). Osteoarthritis was induced in the right knee by instability of the meniscus medial ligament. Sham surgery was practiced in the left knee. Knee samples obtained eight weeks after surgery were stained (Safranin-O) and blindly scored in lateral and medial femur and tibia using the Osteoarthritis Research Society International scale (OARSI) (from Grade 0, cartilage intact to 6, deformation), (five stages from 0, no OA to 4, >50% surface involvement); OARSI score (Grade x Stage); and a semi-quantitative scale from Grade 0 (normal) to 6 (cartilage erosion >80%). RESULTS: Significantly higher values in all scales in the right knees compared to the left knees in male and female mice were observed (p<0.05). Males of all strains showed in the right knee higher values than females on all scales. Deficiency of perforin did not modify OA severity in any sex. The gzmA-/- females presented less degenerative changes than the other groups. CONCLUSION: Our study results show that sex plays an important role in the development of experimental OA in mice. Deficiency of gzmA can protect from the development of OA in female mice.

Three-Dimensional Computational Model Simulating the Initial Callus Growth during Fracture Healing in Long Bones: Application to Different Fracture Types.

Bone fractures are among the most common and potentially serious injuries to the skeleton, femoral shaft fractures being especially severe. Thanks to recent advances in the area of in silico analysis, several approximations of the bone healing process have been achieved. In this context, the objective of this work was to simulate the initial phase of callus formation in long bones, without a pre-meshed domain in the 3D space. A finite element approach was computationally implemented to obtain the values of the cell concentrations along the whole domain and evaluate the areas where the biological quantities reached the thresholds necessary to trigger callus growth. A voxel model was used to obtain the 3D domain of the bone fragments and callus. A mesh growth algorithm controlled the addition of new elements to the domain at each step of the iterative procedure until complete callus formation. The implemented approach is able to reproduce the generation of the primary callus, which corresponds to the initial phase of fracture healing, independently of the fracture type and complexity, even in the case of several bone fragments. The proposed approach can be applied to the most complex bone fractures such as oblique, severely comminuted or spiral-type fractures, whose simulation remains hardly possible by means of the different existing approaches available to date.

Non-vertebral hydatidosis in bone: Difficulties in management.

OBJECTIVES: This study presents our experience in surgical treatment of extravertebral bone hydatidosis and aims to investigate the utility of specific immunoglobulin E (IgE) in diagnosis and prognosis of the disease. PATIENTS AND METHODS: Between January 1990 and December 2019, a total of 10 patients (6 males, 4 females; mean age: 47.2±14.7 years; range, 27 to 71 years) with non-vertebral bone hydatidosis surgically treated in our hospital were retrospectively included. Curettage or wide resection was performed in all cases, followed by medical antihelminthic therapy. Specific IgE p2 was studied in seven patients during and at final follow-up. RESULTS: At the time of diagnosis, secondary infection of the cyst was observed as the initial symptom in two patients mimicking an abscess and, in both cases, more surgeries were required without final healing. In two cases, over five specific IgE presented a false negative at the time of diagnosis and it was not correlated with clinical evolution in three cases over seven. In six cases, diagnosis was obtained before surgery. In treatment, pelvic disease had the worst prognosis (none healed) and bacterial overinfection was a common complication after surgery. At the final follow-up, only two femoral cases (20%) were free of disease. Other four cases (three in iliac bone, one in proximal femur) needed several surgeries without healing. The other four patients showed no progression or refused a new surgical treatment. CONCLUSION: Location, bone defect, when it is possible to perform a radical surgery, and associated bacterial overinfection after surgery make cystic hydatidosis in bone an infection very difficult to treat definitively in humans. Negative specific IgE does not exclude bone hydatidosis.

Orthopedic Surgeons' Accuracy When Orienting an Acetabular Cup. A Comparison with Untrained Individuals.

Background and Objectives: Previous studies demonstrated a huge variability among surgeons when it comes to reproducing the position of an acetabular cup in total hip arthroplasty. Our main objective is to determine if orthopedic surgeons can replicate a given orientation on a pelvic model better than untrained individuals. Our secondary objective is to determine if experience has any influence on their ability for this task. Materials and Methods: A group of specialist orthopedic hip surgeons and a group of volunteers with no medical training were asked to reproduce three given (randomly generated) acetabular cup orientations (inclination and anteversion) on a pelvic model. Error was measured by means of a hip navigation system and comparisons between groups were made using the appropriate statistical methods. Results: The study included 107 individuals, 36 orthopedic surgeons and 71 untrained volunteers. The mean error among surgeons was slightly greater as regards both inclination (7.84 ± 5.53 vs. 6.70 ± 4.03) and anteversion (5.85 ± 4.52 vs. 5.48 ± 3.44), although statistical significance was not reached (p = 0.226 and p = 0.639, respectively). Similarly, although surgeons with more than 100 procedures a year obtained better results than those with less surgical experience (8.01 vs. 7.67 degrees of error in inclination and 5.83 vs. 5.87 in anteversion), this difference was not statistically significant, either (p = 0.852 and p = 0.981). Conclusions: No differences were found in the average error made by orthopedic surgeons and untrained individuals. Furthermore, the surgeons' cup orientation accuracy was not seen to improve significantly with experience.

Biomechanical Behavior of an Hydroxyapatite-Coated Traditional Hip Stem and a Short One of Similar Design: Comparative Study Using Finite Element Analysis.

BACKGROUND: The objective is to compare, by the means of finite elements analysis, the biomechanical behavior of a conventional stem of proven performance with a short stem based on the same fixation principles. METHODS: A 3D femur was modeled from CT scan data, and real bone density measures were incorporated into it. Load stresses were applied to that bone in 3 different scenarios: without prosthesis, with the conventional stem, and with the short stem. Different bone loading patterns were compared by Gruen's zones both visually and statistically using Welch's test. RESULTS: The implantation of a stem generates a certain degree of stress shielding in the surrounding bone, but the pattern of the change is very similar in the compared stem models. Although there is statistical significance (P < 0.01) in the mean stress variation in most of the Gruen's zones, the magnitude of the difference is always under 2 MPa (range: 0.01 - 1.74 MPa). CONCLUSIONS: The bone loading patterns of the traditional stem and the short stem are very similar. Although there is no evidence of a link between biomechanics and clinical outcomes, our results may suggest that theoretical advantages of short stems can be exploited without the fear of altering bone loading patterns.

Revision total knee arthroplasty: hybrid vs standard cemented fixation.

INTRODUCTION: Modular systems with stems are necessary for the stability of revision total knee arthroplasty (rTKA), but controversy remains as to the best fixation method: cemented or hybrid (noncemented stem). The aim of this study was to assess the clinical, X-ray, life-quality and survival results obtained with each fixation method. MATERIALS AND METHODS: During the period 2000-2013, rTKA was performed on 67 patients (29 cemented arthroplasty and 38 hybrid fixation). The average follow-up was 7 years (range 2-15). All patients were evaluated clinically and radiographically using the American Knee Society Score (AKSS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and the Short Form Health Survey (SF-36). A survival study was performed via Kaplan-Meier analysis. RESULTS: There were no differences between the cemented and hybrid fixation groups in the preoperative and postoperative AKSS clinical evaluation indices and the SF-36 health index. However, the WOMAC assessment scale did reveal statistically significant differences between the groups, with a global classification of 64.9 points weighted at 100 (SD 16.8) for cemented fixation versus 78.9 (SD 9.0) for hybrid fixation (p = 0.001). The corresponding values for stiffness were 61.6 (SD 12.9) and 80.5 (SD 14.7) (p = 0.001), and those for function were 61.3 (SD 19.4) and 78.1 (SD 10.5) (p = 0.001). No significant differences between the groups were recorded with respect to the pain score (p = 0.4) or the results of the Kaplan-Meier survival analysis. CONCLUSION: Although the results were similar for the two groups, hybrid fixation tended to produce better results than cemented fixation. In view of the risk of further loosening, we prefer the more conservative approach, i.e. hybrid fixation. LEVEL EVIDENCE: Level III.

Assessment of effectiveness and safety of repeat administration of proinflammatory primed allogeneic mesenchymal stem cells in an equine model of chemically induced osteoarthritis.

BACKGROUND: This study aimed at assessing the effectiveness and safety of repeated administrations of allogeneic bone marrow-derived mesenchymal stem cells (BM-MSCs) primed with tumor necrosis factor (TNF)-α and interferon-γ in an equine model of chemically-induced osteoarthritis. Arthritis was induced in both radio-carpal (RC)-joints by amphotericin-B in 18 ponies, divided into three groups depending on the treatment injected: MSC-naïve (n = 7), MSC-primed (n = 7) and control (n = 4). The study consisted of two phases and used one RC-joint of each animal in each phase, with four months time-lapse, in order to assess two end-points. Clinical, synovial, radiological and ultrasonographic follow-up was performed. At six months, animals were euthanized and both carpi were assessed by magnetic resonance imaging (MRI), gross anatomy, histopathology, histochemistry and gene expression. RESULTS: Clinical and synovial inflammatory signs were quicker reduced in MSC-treated groups and repeated allogeneic administration did not produce adverse reactions, but MSC-primed group showed slight and transient local inflammation after second injection. Radiology and MRI did not show significant differences between treated and control groups, whereas ultrasonography suggested reduced synovial effusion in MSC-treated groups. Both MSC-treated groups showed enhanced cartilage gross appearance at two compared to six months (MSC-naïve, p < 0.05). Cartilage histopathology did not reveal differences but histochemistry suggested delayed progression of proteoglycan loss in MSC-treated groups. Synovium histopathology indicated decreased inflammation (p < 0.01) in MSC-primed and MSC-naïve at two and six months, respectively. At two months, cartilage from MSC-primed group significantly (p < 0.05) upregulated collagen type II (COL2A1) and transforming growth factor (TGF)-ß1 and downregulated cyclooxygenase-2 and interleukin (IL)-1ß. At six months, MSC-treatments significantly downregulated TNFα (p < 0.05), plus MSC-primed upregulated (p < 0.05) COL2A1, aggrecan, cartilage oligomeric protein, tissue inhibitor of metalloproteinases-2 and TGF-ß1. In synovium, both MSC-treatments decreased (p < 0.01) matrix metalloproteinase-13 expression at two months and MSC-primed also downregulated TNFα (p < 0.05) and IL-1ß (p < 0.01). CONCLUSIONS: Both MSC-treatments provided beneficial effects, mostly observed at short-term. Despite no huge differences between MSC-treatments, the findings suggested enhanced anti-inflammatory and regulatory potential of MSC-primed. While further research is needed to better understand these effects and clarify immunogenicity implications, these findings contribute to enlarge the knowledge about MSC therapeutics and how they could be influenced.

Influence of gap size, screw configuration, and nail materials in the stability of anterograde reamed intramedullary nail in femoral transverse fractures.

Femoral shaft fractures are among the most severe injuries of the skeleton. They are associated with high morbidity and mortality. The most appropriate treatment depending on the type of fracture and location level should be chosen. A finite element model of the femur has been developed, analyzing various types of fractures in the subtrochanteric and diaphyseal supracondylar area, with several gap sizes, being stabilized with a single combination of screws for the intramedullary nail. The mechanical strength of the nail against bending and compression efforts was studied comparing two materials for the nail: stainless steel and titanium alloy. Beside the finite elements (FE) simulations, a clinical follow-up was carried out, considering a sample of 55 patients, 24 males, and 31 females, with mean age of 52.5 years. Localizations of fractures were 22 in the right femur and 33 in the left one, respectively. A good agreement between clinical results and the simulated fractures in terms of gap size was found. Non-comminuted fractures have a mean consolidation time of 4.1 months, which coincides with the appropriate mobility at fracture site obtained in the FE simulations, whereas comminuted fractures have a higher mean consolidation period estimated in 7.1 months, corresponding to the excessive mobility at fracture site obtained by means of FE simulations. The obtained results between both nail materials (stainless steel and titanium alloy) show a higher mobility when using titanium nails, which produce a higher rate of strains at the fracture site, amplitude of micromotions and bigger global movements compared to stainless-steel nails. Steel nails provide stiffer osteosyntheses than the titanium nails. In conclusion, anterograde locked nail is particularly useful in the treatment of a wide range of supracondylar fractures with proximal extension into the femoral diaphysis.

Influence of screw combination and nail materials in the stability of anterograde reamed intramedullary nail in distal femoral fractures.

Intramedullary nailing (IM) is a technique universally accepted to treat femoral diaphyseal fractures. The treatment of fractures located in the distal third remains a controversial issue though. A finite element model of the femur has been developed, analyzing distal fractures with several gap sizes combined with different interlocking combinations of distal screws with one oblique screw proximally to stabilize the intramedullary nail. The mechanical strength of the nail against bending and compression efforts was also studied. Beside the FE simulations, a clinical follow-up of 15 patients, 6 males and 9 females, with mean age of 53.2 years was carried out. Localizations of fractures were 10 in the right femur and 5 in the left femur, respectively. A fairly good correspondence agreement between clinical results and the simulated fractures in terms of gap size was found. Non-comminuted fractures had a mean consolidation time of 20.5 weeks (4.8 months), a tendency corresponding well to the mobility obtained in the FE simulations; Comminuted fractures on the other hand exhibited a higher mean consolidation period of 22.2 weeks (5.2 months) secondary to the excessive mobility at fracture site obtained by means of FE simulations. The best stability at fracture site was found for the system with three distal screws and the system with two distal screws placed medial lateral. The highest leverage of distal screws was obtained maximizing the distance between them and choosing the coronal plane for their orientation. The results obtained with both nail materials (stainless steel and titanium alloy) show a higher mobility when using titanium nails. Steel nails provide stiffer osteosyntheses than the titanium nails. In conclusion, the best screw combination in terms of stability to produce fracture healing and the least difficulties during treatment is the one which had one oblique proximal screw with two distal lateral screw implanted in the coronal plane.

Range of Movement for Impingement and Dislocation Avoidance in Total Hip Replacement Predicted by Finite Element Model.

Dislocation is a serious complication in total hip replacement (THR). An inadequate range of movement (ROM) can lead to impingement of the prosthesis neck on the acetabular cup; furthermore, the initiation of subluxation and dislocation may occur. The objective of this study was to generate a parametric three-dimensional finite element (FE) model capable of predicting the dislocation stability for various positions of the prosthetic head, neck, and cup under various activities. Three femoral head sizes (28, 32, and 36 mm) were simulated. Nine acetabular placement positions (abduction angles of 25°, 40° and 60° combined with anteversion angles of 0°, 15° and 25°) were analyzed. The ROM and maximum resisting moment (RM) until dislocation were evaluated based on the stress distribution in the acetabulum component. The analysis allowed for the definition of a "safe zone" of movement for impingement and dislocation avoidance in THR: an abduction angle of 40°-60° and anteversion angle of 15°-25°. It is especially critical that the anteversion angle does not fall to 10°-15°. The sequence of the RM is a valid parameter for describing dislocation stability in FE studies.

Inflammation affects the viability and plasticity of equine mesenchymal stem cells: possible implications in intra-articular treatments.

Mesenchymal stem cells (MSCs) are gaining relevance for treating equine joint injuries because of their ability to limit inflammation and stimulate regeneration. Because inflammation activates MSC immunoregulatory function, proinflammatory priming could improve MSC efficacy. However, inflammatory molecules present in synovial fluid or added to the culture medium might have deleterious effects on MSCs. Therefore, this study was conducted to investigate the effects of inflammatory synovial fluid and proinflammatory cytokines priming on viability and plasticity of equine MSCs. Equine bone marrow derived MSCs (eBM-MSCs) from three animals were cultured for 72 h in media supplemented with: 20% inflammatory synovial fluid (SF); 50 ng/mL IFN-γ and TNF-α (CK50); and 20 ng/mL IFN-γ and TNF-α (CK20). Proliferation assay and expression of proliferation and apoptosis-related genes showed that SF exposed-eBM-MSCs maintained their viability, whereas the viability of CK primed-eBM-MSCs was significantly impaired. Tri-lineage differentiation assay revealed that exposure to inflammatory synovial fluid did not alter eBM-MSCs differentiation potential; however, eBM-MSCs primed with cytokines did not display osteogenic, adipogenic or chondrogenic phenotype. The inflammatory synovial environment is well tolerated by eBM-MSCs, whereas cytokine priming negatively affects the viability and differentiation abilities of eBM-MSCs, which might limit their in vivo efficacy.

Priming Equine Bone Marrow-Derived Mesenchymal Stem Cells with Proinflammatory Cytokines: Implications in Immunomodulation-Immunogenicity Balance, Cell Viability, and Differentiation Potential.

Mesenchymal stem cells (MSCs) have a great potential for treating equine musculoskeletal injuries. Although their mechanisms of action are not completely known, their immunomodulatory properties appear to be key in their functions. The expression of immunoregulatory molecules by MSCs is regulated by proinflammatory cytokines; so inflammatory priming of MSCs might improve their therapeutic potential. However, inflammatory environment could also increase MSC immunogenicity and decrease MSC viability and differentiation capacity. The aim of this study was to assess the effect of cytokine priming on equine bone marrow-derived MSC (eBM-MSC) immunoregulation, immunogenicity, viability, and differentiation potential, to enhance MSC immunoregulatory properties, without impairing their immune-evasive status, viability, and plasticity. Equine BM-MSCs (n = 4) were exposed to 5 ng/mL of TNFα and IFNγ for 12 h (CK5-priming). Subsequently, expression of genes coding for immunomodulatory, immunogenic, and apoptosis-related molecules was analyzed by real-time quantitative polymerase chain reaction. Chromatin integrity and proliferation assays were assessed to evaluate cell viability. Trilineage differentiation was evaluated by specific staining and gene expression. Cells were reseeded in a basal medium for additional 7 days post-CK5 to elucidate if priming-induced changes were maintained along the time. CK5-priming led to an upregulation of immunoregulatory genes IDO, iNOS, IL-6, COX-2, and VCAM-1. MHC-II and CD40 were also upregulated, but no change in other costimulatory molecules was observed. These changes were not maintained 7 days after CK5-priming. Viability and differentiation potential were maintained after CK5-priming. These findings suggest that CK5-priming of eBM-MSCs could improve their in vivo effectiveness without affecting other eBM-MSC properties.

Rotura distal del tendón de la porción larga del bíceps braquial. ¿Por qué está aumentado su incidencia? ¿Cuándo se debe reparar? / Rupture of the distal biceps tendon. Why is increasing its incidence? When it should be repaired?

Introducción y objetivos: La rotura del tendón distal del bíceps braquial es poco frecuente y representa sólo el 3% de todas las roturas de este tendón, aunque en la última década ha aumentado hasta un 10%. Son características en varones de edad media con predominio del brazo dominante. Se asocian factores de riesgo locales (alta demanda funcional) y sistémicos (tabaco, dislipemia, corticoides, anabolizantes, obesidad). Nuestro objetivo es analizar los factores de riesgos asociados a esta patología y evaluar los resultados tras la reparación quirúrgica de dicho tendón. Material y métodos: Estudio retrospectivo de 13 pacientes diagnosticados de rotura de bíceps distal en nuestro servicio desde mayo de 2012 hasta enero de 2014. Todos fueron tratados quirúrgicamente con reinserción anatómica con vía única (69,23% con técnica Endobutton y 30,77% con reanclaje mediante arpones. Se ha valorado los posibles factores de riego, movilidad articular, complicaciones precoces y tardías y satisfacción del paciente (escala de Karunakar). Su seguimiento clínico ha sido de al menos 6 meses. Resultados: Todos fueron varones con edad media de 42,69 años en brazo dominante en el 92,3%. El 76,92% realizaban deportes para ejercitar el bíceps y el 53,84% tomaba medicación por dislipemia. El resultado obtenido tras el tratamiento fue excelente estando satisfechos la totalidad de los pacientes Conclusiones y discusión: Los factores de riesgo conocidos hasta la fecha son el tabaco, dislipemia, corticoides, anabolizantes y obesidad que no justifican el aumento de la incidencia actual. La práctica deportiva habitual que implique tonificar y muscular el músculo braquial en pacientes con factores de riesgo aumenta la probabilidad de rotura del tendón distal de bíceps y su reinserción anatómica por vía anterior es una correcta opción terapéutica

Introduction and objectives: The breaking of the distal biceps tendon is rare and represents only 3% of all breakings of this tendon. However, for the last decade this percentage has increased up to 10%. They are characteristic of middle-aged men with a predominance of the dominant arm. Local risk factor (high functional demand) and systemic ones (smoking, dyslipidemia, steroids, analogies, obesity) are associated with this pathology. Our goal is to analyze the risk factors which are associated with this condition and evaluate the results after surgical repair of the tendon. Materials and methods: Retrospective study of 13 patients diagnosed with distal biceps tendon breaking in our hospital from May 2012 to January 2014. All patients were treated surgically with anatomic reattachment single trak (69,23 % with Endobutton’s technique and 30,77 % remembering using harpoons). There have been assessed factors such us potential risk factors, joint mobility, early and late complications and the patient’s degree of satisfaction (scale Karunakar). Their clinical follow-up was carried out for at least 6 months after the surgery. Result: All patients were male, with an average age of 42,69 years, the 92,3 % were in the dominant arm, 76,92 % of the patients usually exercised the biceps while training and 53,84 % were taking medication for dyslipidemia. The results obtained after the treatment were excellent, shawing that all patients were satisfied with it. Conclusion: The risk factors that are known so far such us smoking, dyslipidemia, steroids, anabolics and obesity do not justify the increase in the currents incidence rate. Regular exercise involving the biceps brachial muscle in patients with risk factors increases the probability of breaking the distal biceps tendon and anatomic reattachment anterior approach is a correct treatment option

Revisión del tratamiento del pie plano adquirido del adulto en el estadio II / Treatment of adult acquired flatfoot stage II: a literature review

El pie plano adquirido del adulto es una patología compleja resultado de la insuficiencia del tendón tibial posterior y del fallo de las estructuras capsulares y ligamentosas del pié. En el estadio II existe una gran controversia respecto al tratamiento a elegir. Se ha realizado una revisión bibliográfica narrativa mediante el motor de búsqueda de Pubmed. La búsqueda se ha acotado a las publicaciones realizadas durante los últimos cinco años. Se han seleccionado 30 artículos que incluyen el pie plano adquirido en su conjunto y el estadio II. Los autores coinciden que el tratamiento conservador debe ser siempre la primera opción. En caso de cirugía debemos de valorar de manera independiente la corrección del valgo del retropié, siendo la osteotomía de medialización de calcáneo el tratamiento más extendido; el alargamiento de la columna externa; la inestabilidad de la columna medial; la supinación del antepié; y la presencia de equinismo. Cada paciente presenta una deformidad característica por lo que el tratamiento debe ser individualizado

Adult acquired flatfoot deformity is a complex pathology consisting both of posterior tibial tendon insufficiency and failure of the capsular and ligamentous structures of the foot. In stage II there is much controversy when it comes to treatment. We performed a narrative literature review using the PubMed search engine. The search was limited to publications over the past five years. We have selected 30 articles including acquired flatfoot a whole and stage II. The authors agree that conservative treatment should always be the first choice. When we decide surgical treatment independently assess the correction of the hindfoot valgus, medializing calcaneal osteotomy is the most accepted treatment; lengthening the lateral column; the instability of the medial column; supination of the forefoot; and the presence of equinus. Each patient has a characteristic deformity so the treatment must be individualized

Hierro intravenoso preoperatorio como estrategia de ahorro de sangre en cirugía de fractura de cadera / Preoperative intravenous iron as a strategy for blood saving in surgery for hip fracture

Fundamento y objetivo: El propósito del estudio ha sido comprobar si la administración de hierro intravenoso en un paciente diagnosticado de fractura de cadera disminuye la necesidad de transfundir sangre. Pacientes y método: Se ha realizado un estudio observacional de casos y controles comparando un grupo control de 63 pacientes intervenidos de fractura de cadera y sin la administración de hierro intravenoso, frente a otro grupo de 57 pacientes en el que se administraron dosis de hierro sacarosa. Se describieron las diferencias demográficas, clínicas y hematométricas entre los casos y controles. Se valoraron la aparición de complicaciones de carácter infeccioso y la mortalidad. Se utilizó el programa SPSS® para el estudio estadístico. Resultados: Existe una correlación estadísticamente significativa entre una menor necesidad de transfusión y la administración de hierro sacarosa intravenoso, siendo necesario un menor número de concentrados en el grupo de casos (1,37 frente a 0,6). En dicho grupo se observa una tendencia decreciente estadísticamente significativa en la tasa de mortalidad hospitalaria (grupo caso: 0,8%/grupo control: 8,3%). No se ha demostrado una disminución de la infección intrahospitalaria con la administración del hierro intravenoso. Se observa una mayor necesidad de transfusión (80%) cuando los valores de hemoglobina son iguales o inferiores a 11 g/dl (p < 0,05). Conclusiones: La administración de hierro sacarosa intravenoso en pacientes diagnosticados de fractura de cadera antes de ser operados podría ser una medida efectiva de ahorro de sangre en esta cirugía traumática. Además, su utilización ha sido segura, sin presentar ningún efecto secundario (AU)

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[Amputation level after frostbite: role of bone scan. A case report]. / Nivel de amputación tras lesiones por congelación: papel de la gammagrafía ósea. Reporte de un caso.

BACKGROUND: frostbite is defined as the damage sustained by tissues while subject to temperatures below their freezing point. The severity of tissue damage is variable, but frequently can result in amputation. Early surgical debridement is contraindicated in almost all patients because it can take weeks for definitive demarcation of non-viable tissues to occur. Bone scan is indicted in the evaluation of frostbite injuries and helps to establish the prognosis early. CLINICAL CASE: a 42 year old man suffered frostbite injury in the fingers and toes after more than 24 hours at 8,000 meters of altitude. The patient was treated with anticoagulant therapy and topical cures for six weeks. During this period, we performed two consecutive bone scan studies showing no changes in the level of vascularization. However, clinical improvement was important, devitalized tissues delimited to the level marked by the bone scan study, so amputation was performed. CONCLUSION: Because the bone scan remained invariable, we believe that could help us to determine the amputation level early without delaying surgery.

Antecedentes: la congelación es el daño sufrido por los tejidos cuando se someten a temperaturas inferiores a su punto de congelación. La gravedad de las lesiones es variable, pero con frecuencia termina en amputación. El desbridamiento quirúrgico temprano está contraindicado en la mayoría de los casos porque la demarcación de los tejidos viables tarda en producirse. La gammagrafía ósea está indicada para la evaluación de las lesiones por congelación y ayuda a establecer el pronóstico temprano. Caso clínico: paciente varón de 42 años, con lesiones por congelación en los dedos de las manos y los pies, tras permanecer más de 24 horas a 8,000 metros de altitud. Durante seis semanas se administró tratamiento anticoagulante y se realizaron curas tópicas. En este periodo se practicaron dos estudios gammagráficos consecutivos, sin apreciarse cambios en la vascularización. Sin embargo, la mejoría clínica fue importante, delimitándose el tejido desvitalizado hasta el nivel marcado por el estudio gammagráfico, por lo que se realizó la amputación. Conclusión: puesto que la gammagrafía ósea permaneció invariable, consideramos que puede ayudar a determinar de forma temprana el nivel de amputación, sin tener que demorar la cirugía.

[Preoperative intravenous iron as a strategy for blood saving in surgery for hip fracture]. / Hierro intravenoso preoperatorio como estrategia de ahorro de sangre en cirugía de fractura de cadera.

BACKGROUND AND OBJECTIVE: To determine whether administration of intravenous iron in a patient diagnosed with hip fracture reduces the need for blood transfusion. PATIENTS AND METHODS: A retrospective observational case-control study was performed comparing a control group of 63 patients diagnosed with hip fracture with another group of 57 patients treated with parenteral iron. Demographic, clinical condition/clinical record and hematometric differences of the case-control patients were described. We analyzed the morbidity (post-surgical infection) and mortality rate. SPSS(®) was used for statistical studies. RESULTS: Being statistically significant, after the administration of intravenous iron sucrose, the need of blood transfusion was reduced in the case group, as well as the quantity of concentrates required (1.37 vs 0.6). In the case group, there was a statistically significant decreasing trend in hospital mortality rate (case group: 0.8%/control group: 8.3%). It was not been proven the relation between the decrease in nosocomial infection and the administration of intravenous iron CONCLUSIONS: The administration of intravenous iron sucrose in patients diagnosed with hip fracture before surgery could be effective blood saving measure in this type of trauma surgery. Furthermore, its use has been reliable without causing any side effects.

Infección de prótesis de rodilla tratada mediante desbridamiento e irrigación artroscópica / Infected knee arthrplasty treated by arthroscopic debridement and irrigation

Varios métodos han sido descritos para el tratamiento de la prótesis de rodilla infectada. Entre estos destacan la antibioterapia prolongada, el desbridamiento de la prótesis de forma abierta mediante artrotomía, el recambio protésico en uno o dos tiempos, la artrodesis e incluso la amputación de la extremidad. Un método no frecuentemente utilizado es el desbridamiento y la irrigación artroscópica de la prótesis. Presentamos un caso tratado mediante este procedimiento con buenos resultados por lo que creemos que el tratamiento artroscópido de la prótesis de rodilla infectada es totalmente válido en pacientes debidamente seleccionados

Various methods have been described for the treatment of the infected total knee arthroplasty. These include prolonged antibiotic suppression, open debridement and irrigation, exchange arthroplastry is one or two stages, the arthrodesis and even the amputation of the extremity. A method done not frequently utilize is the arthroscopic irrigation and debridement of the arthroplasty. We present a case treated by this procedure with good results for which we believe that this method of treatment is totally valid in patients properly selected

Osteonecrosis como causante de fracado de artroplastia total de rodilla / Osteonecrosis as the cause of failure of total knee arthroplasty

Exponemos el caso de una paciente en la que coexistían dos procesos articulares: artritis reumatoide y una intensa osteoporosis. Padecía deformidad en valgo de rodilla derecha con dolor incapacitante por afectación inflamatoria reumatoidea. Se procedió a su tratamiento mediante artroplastia total de rodilla, la cual fracasó por osteonecrosis en cóndilo femoral medial e intensa osteoporosis. La corticoterapia administrada como tratamiento de su patología inflamatoria resultó el factor determinante en este fracaso. Se recurrió a cirugía de rescate puesto que, una vez aparecida la osteonecrosis, el único tratamiento que procede actualmente es tratar sus secuelas y reducir sus factores favorecedores. Terapias con alendronato, vitamina D y suplementos de calcio están demostrando su eficacia en la prevención de osteonecrosis tras artroplastia, instaurándose ya su uso profiláctico en algunos centros con óptimos resultados

We expose the case of a patient in which two joint proceses coexisted reheumatoid artritis and an intense osteoporosis. She suffered deformity in valgus of right knee with incapacitating pain for rheumatic inflammatory affectation. We proceeded to their treatment by means of total knee arthroplasty, which failed for the presence of osteonecrosis in medial femoral condile and intense osteoporosis. The esteroids administered treatment of its inflammatory pathology were the decisive factor in this failure. We practised rescue surgery since, once appeared the osteonecrosis, the only treatment that proceeds at the moment is to treat its sequels and to reduce its favouring factors. Therapies with alendronate, vitamin D and supplements of calcium are demonstrating their effectiveness in the osteonecrosis prevention after artroplastia, being already established their use for profilaxis in some centers with good results

Artroplastia de rodilla dolorosa. Diagnóstico diferencial / Painful total knee arthroplasty. Differential diagnosis

La artroplastia de rodilla es una intervención habitual en los Servicios de Cirugía Ortopédica. La evolución normal de una artroplastia de rodilla, si el paciente sobrevive lo suficiente, es el fracaso, que se manifiesta siempre por la aparición del dolor. Las causas que originan dolor en la artroplastica de rodilla son múltiples y en ocasiones de difícil y complejo diagnóstico. En este trabajo se realiza el diagnóstico diferencial clínico y mediante pruebas complementarias de las diferentes causas que pueden producir dolo en la artroplastia de rodilla tanto precozmente como evolutivamente a largo plazo

The total knee arthroplasty is an habitual surgery in the orthopedic´s Departments. Thenormal evolution of total knee arthroplasty, if the patient survive enough, is the failure, always manifested by pain. Causes of pain intotal knee arthroplasty are many different and sometimes they´re difficult diagnosis. In this issue we study the differential diagnosis clinic and by complementary proofs of the differents causes that produce pain in the total knee arthroplasty as early as large periods of time