Local Antibiotic Delivery Ceramic Bone Substitutes for the Treatment of Infected Bone Cavities and Bone Regeneration: A Systematic Review on What We Have Learned from Animal Models.

AIMS: the focus of this study is to evaluate if the combination of an antibiotic with a ceramic biomaterial is effective in treating osteomyelitis in an infected animal model and to define which model and protocol are best suited for in vivo experiments of local bone infection treatment. METHODS: a systematic review was carried out based on PRISMA statement guidelines. A PubMed search was conducted to find original papers on animal models of bone infections using local antibiotic delivery systems with the characteristics of bone substitutes. Articles without a control group, differing from the experimental group only by the addition of antibiotics to the bone substitute, were excluded. RESULTS: a total of 1185 records were retrieved, and after a three-step selection, 34 papers were included. Six manuscripts studied the effect of antibiotic-loaded biomaterials on bone infection prevention. Five articles studied infection in the presence of foreign bodies. In all but one, the combination of an antibiotic with bioceramic bone substitutes tended to prevent or cure bone infection while promoting biomaterial osteointegration. CONCLUSIONS: this systematic review shows that the combination of antibiotics with bioceramic bone substitutes may be appropriate to treat bone infection when applied locally. The variability of the animal models, time to develop an infection, antibiotic used, way of carrying and releasing antibiotics, type of ceramic material, and endpoints limits the conclusions on the ideal therapy, enhancing the need for consistent models and guidelines to develop an adequate combination of material and antimicrobial agent leading to an effective human application.

Ankyloglossia, Syndactyly and Polydactyly in the Pediatric Patient.

Ankyloglossia is a congenital alteration in the development of the tongue characterized by the presence of a short or thick lingual frenulum, which leads to a limitation in its movements. There is an associative inconsistency between ankyloglossia and complications with breastfeeding, speech, swallowing, breathing, and the development of orofacial structures, and it is urgent to make more scientific research in this area. In the presence of polydactyly and syndactyly may be also present ankyloglossia. The purpose of this paper is to present two ankyloglossia cases with finger alterations, without a syndromic disease, and lead the medical team to research this topic and make an improved treatment plan for these cases.

Vancomycin-Loaded, Nanohydroxyapatite-Based Scaffold for Osteomyelitis Treatment: In Vivo Rabbit Toxicological Tests and In Vivo Efficacy Tests in a Sheep Model.

The treatment for osteomyelitis consists of surgical debridement, filling of the dead space, soft tissue coverage, and intravenous administration of antimicrobial (AM) agents for long periods. Biomaterials for local delivery of AM agents, while providing controllable antibiotic release rates and simultaneously acting as a bone scaffold, may be a valuable alternative; thus, avoiding systemic AM side effects. V-HEPHAPC is a heparinized nanohydroxyapatite (nHA)/collagen biocomposite loaded with vancomycin that has been previously studied and tested in vitro. It enables a vancomycin-releasing profile with an intense initial burst, followed by a sustained release with concentrations above the Minimum Inhibitory Concentration (MIC) for MRSA. In vitro results have also shown that cellular viability is not compromised, suggesting that V-HEPHAPC granules may be a promising alternative device for the treatment of osteomyelitis. In the present study, V-HEPHAPC (HEPHAPC with vancomycin) granules were used as a vancomycin carrier to treat MRSA osteomyelitis. First, in vivo Good Laboratory Practice (GLP) toxicological tests were performed in a rabbit model, assuring that HEPHAPC and V-HEPHAPC have no relevant side effects. Second, V-HEPHAPC proved to be an efficient drug carrier and bone substitute to control MRSA infection and simultaneously reconstruct the bone cavity in a sheep model.

[How to Resume Elective Orthopaedic Surgical Procedures during the COVID-19 Pandemic?] / Como Retomar a Atividade Cirúrgica Eletiva em Ortopedia durante a Pandemia COVID-19?

This document was prepared by the College of Orthopedics of the Portuguese Medical Association with the aim of developing the guidelines on the resumption of elective surgical activity in Orthopedics during the COVID-19 pandemic. It sets the criteria that allow the prioritization of surgeries according to the severity of the clinical situation, based on existing and published classifications. Moreover, it provides an organizational model for patient preparation and describes the patient pathways in the preoperative, intraoperative and postoperative periods. It also describes safety rules for elective surgery and a model for monitoring patients after discharge according to scientific evidence.

Este documento foi elaborado pelo Colégio de Ortopedia da Ordem dos Médicos com o objetivo de estabelecer as orientações sobre a retoma da atividade cirúrgica programada em Ortopedia durante a pandemia COVID-19. As presentes normas de orientação: a) definem os critérios que permitem a priorização das cirurgias de acordo com a gravidade da situação clínica, com base em classificações existentes e publicadas; b) fornecem um modelo de organização para a preparação dos doentes, descrevendo os circuitos do doente nos períodos pré-operatório, intraoperatório e pós-operatório; c) realçam as regras de segurança para a realização de cirurgias e desenham um modelo de acompanhamento após a alta de acordo com a evidência científica.

Combining local antibiotic delivery with heparinized nanohydroxyapatite/collagen bone substitute: A novel strategy for osteomyelitis treatment.

Osteomyelitis is a major challenge in bone surgery and conventional treatment is frequently ineffective to control the infection, with an alternative approach being required. In the present work, a heparinized nanohydroxyapatite/collagen biocomposite was produced in granular form, and loaded with vancomycin, to work as a local drug delivery system for osteomyelitis and as a bone substitute. This strategy involves the local delivery of high concentrations of vancomycin, to eradicate the infection. Additionally, these granules work as a scaffold with regenerative properties, to induce bone regeneration after antibiotic release. The heparinized nanohydroxyapatite/collagen granular bone substitute was produced using two different sintering temperatures to study their effect on granules properties and on vancomycin release profile. Morphological, topographic, chemical and mechanical characterization were carried out for granules sintered at both temperatures and some relevant differences were found. The mechanical strength was increased by several orders of magnitude with increasing sintering temperature, being able to maintain their porous macrostructure and withstand important processes for their commercialization such as packaging, shipping and surgical manipulation. The nanohydroxyapatite/collagen granules were able to release high concentrations of vancomycin, always above MIC, for 19 days. The released antibiotic was able to eradicate both planktonic and sessile methicillin-resistant Staphylococcus aureus. The cytotoxicity was assessed according to ISO 10993-5:2009 and the granules sintered at higher temperature showed no cytotoxic effect. Considering these results nanohydroxyapatite/collagen biocomposite loaded with vancomycin is a promising solution for osteomyelitis treatment.

Sagittal standing posture and relationships with anthropometrics and body composition during childhood.

BACKGROUND: Anthropometry and body composition are plausible influences on pediatric sagittal standing posture. Despite that, the relationship of anthropometrics since birth and body composition with individual postural parameters in children has never been assessed. RESEARCH QUESTION: To assess the associations between anthropometrics since birth and body composition parameters, and angles of sagittal standing posture in children. METHODS: The sample included 1021 girls and 1096 boys, evaluated in the population-based birth cohort Generation XXI, Portugal. Weight and height were obtained at birth, 4 and 7 years of age. At age 7, total body less head fat/fat-free mass and bone properties were estimated from whole body dual energy X-ray absorptiometry scans and posture was assessed through right-side photographs during habitual standing with retro-reflective markers placed on body landmarks. RESULTS: Girls showed increased values of lumbar angle, head and neck flexion, and craniocervical angle with the largest mean (standard deviation) difference in lumbar angle [281.7° (7.4) vs. 276.8° (7.1) in boys, p < 0.001]. In both genders, weight and body mass index were weakly associated with lumbar angle: 0.24 ≥ r ≤ 0.31 in girls and 0.16 ≥ r ≤ 0.26 in boys, all p < 0.001. Fat and fat-free mass and bone mineral density were weakly associated with lumbar angle in both genders. SIGNIFICANCE: Our study showed clear postural heterogeneity between girls and boys in early ages. Lumbar angle is likely to be the single most relevant proxy of overall posture based on the associations with the exposures reported in this study.

Pyogenic Sacroiliitis in a Pediatric Patient: A Rare Case of Infection by Streptococcus intermedius.

This is a case report of pyogenic sacroiliitis in a pediatric patient caused by Streptococcus intermedius. The patient is a 16-year-old boy who presented to an emergency department with sudden onset of back pain radiating to the left lower extremity. The diagnosis was confounded by the presence of isthmic spondylolisthesis. Plain radiography demonstrated mild isthmic spondylolisthesis but no radiographic signs of tumor, trauma, infection, arthritis, or other developmental problems. The C-reactive protein level was 23 mg/L. Over the next 24 hours, the patient developed fever, and the C-reactive protein level increased to 233 mg/L. Sacroiliitis and an iliopsoas abscess were identified on MRI. Blood cultures grew S intermedius. The patient responded to antibiotic treatment and needle aspiration under CT guidance. Sacroiliitis is an uncommon condition and, to our knowledge, there is only one other case report of its being caused by S intermedius. The previous report was in an adult.

Two consecutive limb lengthenings with the same PRECICE nail: a technical note.

PURPOSE: The most significant advance in our time about limb lengthening is the magnetic lengthening nail, as the first reports appeared to show good results with accurate lengthening rates and good regenerate bone formation. The described complication rate is generally low. They avoid external fixation elements, and are activated transcutaneously, so the patient's pain and discomfort are reduced and the rehabilitation is faster and more effective. The aim of authors is to describe a special technical issue of the PRECICE system: the nail can be extended inside the patient limb (after the osteotomy), but it also can be retracted inside the limb after achieving the bone union. METHODS: The authors present a case in which the limb lengthening has been performed in consecutive lengthening periods using the same nail. The nail was extended and retracted by altering the settings on the external remote control as well as accurately setting the rate of distraction. RESULTS: After two consecutive femoral lengthening with the same PRECICE nail, the patient no longer has a significant lower limb length discrepancy and patient satisfaction was high. During this clinical case, we were not confronted with any type of complications. CONCLUSION: This technique utilizes the principles and advantages of lengthening over an magnetic lengthening nail, avoids the necessity of nail removal and minimizes the complication rates and the overall time for complete recovery. LEVEL OF EVIDENCE: Level IV.

Associations of anthropometry since birth with sagittal posture at age 7 in a prospective birth cohort: the Generation XXI Study.

OBJECTIVES: Adult sagittal posture is established during childhood and adolescence. A flattened or hypercurved spine is associated with poorer musculoskeletal health in adulthood. Although anthropometry from birth onwards is expected to be a key influence on sagittal posture design, this has never been assessed during childhood. Our aim was to estimate the association between body size throughout childhood with sagittal postural patterns at age 7. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: A subsample of 1029 girls and 1101 boys taking part in the 7-year-old follow-up of the birth cohort Generation XXI (Porto, Portugal) was included. We assessed the associations between anthropometric measurements (weight, height and body mass index) at birth, 4 and 7 years of age and postural patterns at age 7. Postural patterns were defined using latent profile analysis, a probabilistic model-based technique which allows for simultaneously including anthropometrics as predictors of latent profiles by means of logistic regression. RESULTS: Postural patterns identified were sway, flat and "neutral to hyperlordotic"in girls, and "sway to neutral", flat and hyperlordotic in boys; with flat and hyperlordotic postures representing a straightened and a rounded spine, respectively. In both girls and boys, higher weight was associated with lower odds of a flat pattern compared with a sway/"sway to neutral"pattern, with stronger associations at older ages: for example, ORs were 0.68 (95% CI 0.53 to 0.88) per SD increase in birth weight and 0.36 (95% CI 0.19 to 0.68) per SD increase in weight at age 7 in girls, with similar findings in boys. Boys with higher ponderal index at birth were more frequently assigned to the hyperlordotic pattern (OR=1.44 per SD; p=0.043). CONCLUSIONS: Our findings support a prospective sculpting role of body size and therefore of load on musculoskeletal spinopelvic structures, with stronger associations as children get older.

A shared biomechanical environment for bone and posture development in children.

BACKGROUND CONTEXT: In each specific habitual standing posture, gravitational forces determine the mechanical setting provided to skeletal structures. Bone quality and resistance to physical stress is highly determined by habitual mechanical stimulation. However, the relationship between bone properties and sagittal posture has never been studied in children. PURPOSE: This study aimed to investigate the association between bone physical properties and sagittal standing postural patterns in 7-year-old children. We also analyzed the relationship between fat or fat-free mass and postural patterns. STUDY DESIGN: Cross-sectional evaluation. PATIENT SAMPLE: This study was performed in a sample of 1,138 girls and 1,260 boys at 7 years of age participating in the Generation XXI study, a population-based cohort of children followed since birth (2005-2006) and recruited in Porto, Portugal. OUTCOME MEASURES: Sagittal standing posture was measured through photographs of the sagittal right view of children in the standing position. Three angles were considered to quantify the magnitude of major curves of the spine and an overall balance measure (trunk, lumbar, and sway angles). Postural patterns were identified using latent profile analysis in Mplus. METHODS: Weight and height were measured. Total body less head fat or fat-free mass and bone properties were estimated from whole-body dual-energy X-ray absorptiometry scans. The associations of fat or fat-free mass and bone physical properties with postural patterns were jointly estimated in latent profile analysis using multinomial logistic regressions. RESULTS: The identified patterns were labeled as Sway, Flat, and "Neutral to Hyperlordotic" (in girls), and "Sway to Neutral," Flat, and Hyperlordotic (in boys). In both genders, children in the Flat pattern showed the lowest body mass index, and children with a rounded posture presented the highest: mean differences varying from -0.86 kg/m2 to 0.60 kg/m2 in girls and from -0.70 kg/m2 to 0.62 kg/m2 in boys (vs. Sway or "Sway to Neutral"). Fat and fat-free mass were inversely associated with a Flat pattern and positively associated with a rounded posture: odds ratio (OR) of 0.23 per standard deviation (SD) fat and 0.70 per SD fat-free mass for the Flat pattern, and 1.85 (fat) and 1.43 (fat-free) for the Hyperlordotic pattern in boys, with similar findings in girls. The same direction of relationships was observed between bone physical properties and postural patterns. A positive association between bone (especially bone mineral density) and a rounded posture was robust to adjustment for age, height, and body composition (girls: OR=1.79, p=.006 fat-adjusted, OR=2.00, p=.014 fat-free mass adjusted; boys: OR=2.02, p=.002 fat-adjusted, OR=2.42, p<.001 fat-free mass adjusted). CONCLUSIONS: In this population-based pediatric setting, there was an inverse association between bone physical properties and a Flat posture. Bone and posture were more strongly positively linked in a rounded posture. Our results support that both bone properties and posture mature in a shared and interrelated mechanical environment, probably modulated by pattern-specific anthropometrics and body composition.

Congenital dislocation of the patella - clinical case.

Congenital patellar dislocation is a rare condition in which the patella is permanently dislocated and cannot be reduced manually. The patella develops normally as a sesamoid bone of the femur. This congenital dislocation results from failure of the internal rotation of the myotome that forms the femur, quadriceps muscle and extensor apparatus. It usually manifests immediately after birth, although in some rare cases, the diagnosis may be delayed until adolescence or adulthood. Early diagnosis is important, thereby allowing surgical correction and avoiding late sequelae, including early degenerative changes in the knee. A case of permanent dislocation of the patella is presented here, in a female child aged seven years.

A luxação congênita da patela é uma patologia rara, em que a patela se encontra permanentemente luxada e manualmente irredutível. A patela desenvolve-se normalmente como um osso sesamoide do fêmur. A luxação congênita da patela resulta da falência da rotação interna do miótomo que forma o fêmur, músculo quadricípite e o aparelho extensor. Usualmente manifesta-se imediatamente após o nascimento, embora em alguns casos raros o diagnóstico possa ser adiado até a adolescência/idade adulta. O diagnóstico precoce é importante, permite a correção cirúrgica, evita as sequelas tardias, notadamente alterações degenerativas precoces do joelho. É apresentado um caso de luxação permanente da patela, numa criança de sexo feminino, com sete anos.

Congenital dislocation of the patella - clinical case / Luxação congênita da patela - Caso clínico

Congenital patellar dislocation is a rare condition in which the patella is permanently dislocated and cannot be reduced manually. The patella develops normally as a sesamoid bone of the femur. This congenital dislocation results from failure of the internal rotation of the myotome that forms the femur, quadriceps muscle and extensor apparatus. It usually manifests immediately after birth, although in some rare cases, the diagnosis may be delayed until adolescence or adulthood. Early diagnosis is important, thereby allowing surgical correction and avoiding late sequelae, including early degenerative changes in the knee. A case of permanent dislocation of the patella is presented here, in a female child aged seven years.

A luxação congênita da patela é uma patologia rara, em que a patela se encontra permanentemente luxada e manualmente irredutível. A patela desenvolve-se normalmente como um osso sesamoide do fêmur. A luxação congênita da patela resulta da falência da rotação interna do miótomo que forma o fêmur, músculo quadricípite e o aparelho extensor. Usualmente manifesta-se imediatamente após o nascimento, embora em alguns casos raros o diagnóstico possa ser adiado até a adolescência/idade adulta. O diagnóstico precoce é importante, permite a correção cirúrgica, evita as sequelas tardias, notadamente alterações degenerativas precoces do joelho. É apresentado um caso de luxação permanente da patela, numa criança de sexo feminino, com sete anos.

The role of pharmacotherapy in modifying the neurological status of patients with spinal and spinal cord injuries / O papel da farmacoterapia na modificação do estado neurológico de traumatizados vértebro-medulares

The aim here was to conduct a review of the literature on pharmacological therapies for modifying the neurological status of patients with spinal cord injuries. The PubMed database was searched for articles with the terms "spinal cord injury AND methylprednisolone/GM1/apoptosis inhibitor/calpain inhibitor/naloxone/tempol/tirilazad", in Portuguese or in English, published over the last five years. Older studies were included because of their historical importance. The pharmacological groups were divided according to their capacity to interfere with the physiopathological mechanisms of secondary injuries. Use of methylprednisolone needs to be carefully weighed up: other anti-inflammatory agents have shown benefits in humans or in animals. GM1 does not seem to have greater efficacy than methylprednisolone, but longer-term studies are needed. Many inhibitors of apoptosis have shown benefits inin vitro studies or in animals. Naloxone has not shown benefits. Tempol inhibits the main consequences of oxidation at the level of the spinal cord and other antioxidant drugs seem to have an effect superior to that of methylprednisolone. There is an urgent need to find new treatments that improve the neurological status of patients with spinal cord injuries. The benefits from treatment with methylprednisolone have been questioned, with concerns regarding its safety. Other drugs have been studied, and some of these may provide promising alternatives. Additional studies are needed in order to reach conclusions regarding the benefits of these agents in clinical practice.

O objetivo deste trabalho foi fazer uma revisão da literatura sobre a terapia farmacológica para a modificação do estado neurológico de traumatizados vértebro-medulares. Foi feita uma na base de dados Pubmed por artigos com os termos "spinal cord injury AND methylprednisolone/GM1/apoptosis inhibitor/calpain inhibitor/naloxone/tempol/tirilazad", em português ou em inglês, publicados nos últimos cinco anos. Trabalhos mais antigos foram incluídos pela sua importância histórica. Os grupos farmacológicos foram divididos em função da sua capacidade para interferir nos mecanismos fisiopatológicos da lesão secundária. O uso de metilprednisolona deve ser cuidadosamente ponderado. Outros anti-inflamatórios mostraram benefícios em humanos ou em animais. O GM1 não aparenta ter maior eficácia do que a MP, mas estudos em mais longo prazo são necessários. Muitos inibidores da apoptose têm mostrado benefício em estudos in vitro ou em animais. A naloxona não deu mostras de benefício. O tempol inibe as principais consequências da oxidação no nível da medula e outros fármacos antioxidantes aparentam ter um efeito superior ao da metilprednisolona. É urgente encontrar novos tratamentos que melhorem o estado neurológico dos traumatizados vértebro-medulares. Os benefícios do tratamento com metilprednisolona têm sido questionados, há preocupações em relação à sua segurança. Outros fármacos têm sido estudados, podem alguns deles ser opções promissoras. Estudos adicionais são necessários para tirar conclusões sobre o benefício desses agentes na prática clínica.

[Bone Fractures in a Neonatal Intensive Care Unit]. / Fraturas Ãìsseas em uma Unidade de Cuidados Intensivos Neonatais.

INTRODUCTION: Fractures during the neonatal period are rare. Some fractures, especially long bones, may occur during birth. Moreover, neonates hospitalized in the Neonatal Intensive Care Unit have an increased risk of fractures for several reasons. OBJECTIVE: To evaluate the incidence and characterize fractures in newborns admitted in a tertiary Neonatal Intensive Care Unit. MATERIAL AND METHODS: A retrospective analysis of the newborns admitted to the Neonatal Intensive Care Unit with a diagnosis at discharge of one or more bone fractures from January 1996 to June 2013. RESULTS: Eighty neonates had one or more fractures. In 76 (95%) infants the fractures were attributed to birth injury. The most common fracture was the clavicle fracture in 60 (79%) neonates, followed by skull fracture in 6 (8%). In two (2.5%) neonates, extremely low birth weight infants, fractures were interpreted as resulting from osteopenia of prematurity. Both had multiple fractures, and one of them with several ribs. CONCLUSION: A change in obstetric practices allied to improvement premature neonateâÄôs care contributed to the decreased incidence of fractures in neonatal period. But in premature infants the diagnosis may be underestimated, given the high risk of fracture that these infants present.

Introdução: As fraturas ósseas são raras durante o período neonatal. Algumas das fraturas, sobretudo as de ossos longos, podem ocorrer durante o parto. Por outro lado, os recém-nascidos internados em Unidades de Cuidados Intensivos Neonatais têm um risco aumentado de fraturas ósseas por várias razões.Objetivo: Avaliar a incidência e caracterizar as fraturas ósseas nos recém-nascidos internados numa Unidade de Cuidados Intensivos Neonatais nível III.Material e Métodos: Análise retrospetiva dos recém-nascidos internados na Unidade de Cuidados Intensivos Neonatais com o diagnóstico na alta de uma ou mais fraturas ósseas, entre janeiro de 1996 a junho de 2013.Resultados: Oitenta recém-nascidos apresentaram uma ou mais fraturas ósseas. Em 76 (95%) recém-nascidos, as fraturas foram atribuídas a traumatismo do parto. A fratura mais comum foi da clavícula em 60 (79%) recém-nascidos, seguida da fratura craniana em 6 (8%) recém-nascidos. Em dois (2,5%) recém-nascidos, prematuros de extremo baixo peso, as fraturas foram interpretadas como decorrentes de osteopenia da prematuridade. Ambos apresentaram fraturas múltiplas, um dos quais de várias costelas.Conclusão: Uma mudança das práticas obstétricas, aliada à melhoria dos cuidados prestados ao recém-nascido prematuro contribuíram para a diminuição da incidência de fraturas ósseas no período neonatal. Contudo nos recém-nascidos prematuros o seu diagnóstico pode estar subestimado, dado o elevado risco de desenvolvimento de fratura que estes recém-nascidos apresentam.

The role of pharmacotherapy in modifying the neurological status of patients with spinal and spinal cord injuries.

The aim here was to conduct a review of the literature on pharmacological therapies for modifying the neurological status of patients with spinal cord injuries. The PubMed database was searched for articles with the terms "spinal cord injury AND methylprednisolone/GM1/apoptosis inhibitor/calpain inhibitor/naloxone/tempol/tirilazad", in Portuguese or in English, published over the last five years. Older studies were included because of their historical importance. The pharmacological groups were divided according to their capacity to interfere with the physiopathological mechanisms of secondary injuries. Use of methylprednisolone needs to be carefully weighed up: other anti-inflammatory agents have shown benefits in humans or in animals. GM1 does not seem to have greater efficacy than methylprednisolone, but longer-term studies are needed. Many inhibitors of apoptosis have shown benefits in in vitro studies or in animals. Naloxone has not shown benefits. Tempol inhibits the main consequences of oxidation at the level of the spinal cord and other antioxidant drugs seem to have an effect superior to that of methylprednisolone. There is an urgent need to find new treatments that improve the neurological status of patients with spinal cord injuries. The benefits from treatment with methylprednisolone have been questioned, with concerns regarding its safety. Other drugs have been studied, and some of these may provide promising alternatives. Additional studies are needed in order to reach conclusions regarding the benefits of these agents in clinical practice.

O objetivo deste trabalho foi fazer uma revisão da literatura sobre a terapia farmacológica para a modificação do estado neurológico de traumatizados vértebro-medulares. Foi feita uma na base de dados Pubmed por artigos com os termos "spinal cord injury AND methylprednisolone/GM1/apoptosis inhibitor/calpain inhibitor/naloxone/tempol/tirilazad", em português ou em inglês, publicados nos últimos cinco anos. Trabalhos mais antigos foram incluídos pela sua importância histórica. Os grupos farmacológicos foram divididos em função da sua capacidade para interferir nos mecanismos fisiopatológicos da lesão secundária. O uso de metilprednisolona deve ser cuidadosamente ponderado. Outros anti-inflamatórios mostraram benefícios em humanos ou em animais. O GM1 não aparenta ter maior eficácia do que a MP, mas estudos em mais longo prazo são necessários. Muitos inibidores da apoptose têm mostrado benefício em estudos in vitro ou em animais. A naloxona não deu mostras de benefício. O tempol inibe as principais consequências da oxidação no nível da medula e outros fármacos antioxidantes aparentam ter um efeito superior ao da metilprednisolona. É urgente encontrar novos tratamentos que melhorem o estado neurológico dos traumatizados vértebro-medulares. Os benefícios do tratamento com metilprednisolona têm sido questionados, há preocupações em relação à sua segurança. Outros fármacos têm sido estudados, podem alguns deles ser opções promissoras. Estudos adicionais são necessários para tirar conclusões sobre o benefício desses agentes na prática clínica.

Sagittal standing posture, back pain, and quality of life among adults from the general population: a sex-specific association.

STUDY DESIGN: A prospective radiographical study of sagittal standing posture among adults consecutively recruited from the general population. OBJECTIVE: To analyze the relation of suboptimal sagittal standing posture with back pain and health-related quality of life in general adult males and females. SUMMARY OF BACKGROUND DATA: Clinical studies have shown the association of sagittal standing posture with pain and reduced quality of life, but this relation has not been assessed in the general adult population. METHODS: As part of the EPIPorto population-based study of adults, 178 males and 311 females were evaluated. Age, education, and body mass index were recorded. Radiographical data collection consisted of 36-in. standing sagittal radiographs. Creation of 3 groups for individual spinopelvic parameters was performed (low, intermediate, or high), and 1 of 4 sagittal types of postural patterns attributed to each participant (Roussouly classification). Back pain prevalence and severity were assessed on the basis of self-reported data and health-related quality of life using 2 main components of the 36-Item Short Form Health Survey. RESULTS: In males, differences in back pain severity were observed only among pelvic tilt/pelvic incidence ratio groups. Females presenting high pelvic incidence and sacral slope exhibited higher odds of severe back pain than those with intermediate values (adjusted odds ratios = 2.21 and 2.15; 95% confidence interval, 1.24-3.97 and 1.21-3.86; respectively). Sagittal vertical axis showed the largest differences in physical quality of life of females: high group had 8.8 lower score than the low group (P < 0.001), but this result lost statistical significance after adjustment for age, education, and body mass index. CONCLUSION: Sagittal standing posture was not consistently associated with quality of life measures in males. Increased pelvic incidence and sacral slope may be involved in causing severe back pain among females. Monitoring sagittal postural parameters has limited usefulness as a screening tool for causes of unspecific musculoskeletal symptoms in the general adult population. LEVEL OF EVIDENCE: 3.

Individual and contextual characteristics as determinants of sagittal standing posture: a population-based study of adults.

BACKGROUND CONTEXT: Sagittal standing posture is associated with musculoskeletal symptoms and quality of life. However, the frequency and determinants of suboptimal sagittal alignment outside the clinical context remain to be clarified. PURPOSE: To estimate the association of sociodemographic, anthropometric, and behavioral characteristics with sagittal standing posture among adults from the general population. STUDY DESIGN: Cross-sectional evaluation of a population-based sample. PATIENT SAMPLE: As part of the EPIPorto study, 489 adults were assessed during 2005 to 2008. OUTCOME MEASURES: Individual spinopelvic parameters were measured. Additionally, participants were classified into one of four types of sagittal postural patterns (Roussouly classification: Types 1, 2, and 4 corresponding to nonneutral postures and Type 3 to a neutral posture). METHODS: Spinopelvic parameters were recorded from 36-inch sagittal radiographs obtained in free-standing posture. Age, sex, education, occupation, body mass index (BMI), waist circumference, total physical activity, leisure time physical activity, time spent in sitting position, smoking status, and tobacco cumulative exposure were collected. Individual parameters and patterns of sagittal posture were compared across categories of participants' characteristics. RESULTS: Older age, lower educational level, blue collar occupation, and overall and central obesity were associated with increased sagittal vertical axis and pelvic tilt/pelvic incidence ratio. Taking the neutral postural pattern (Type 3) as reference for the outcome in a multinomial regression model, independently of age, sex, education, total physical activity, and smoking status, overweight adults had higher odds of Type 2 (odds ratio [OR]=1.92; 95% confidence interval [CI]: 1.13-3.27) and Type 4 (OR=2.13; 95% CI: 1.16-3.91) postural patterns in comparison with normal weight subjects. Overall and central obesity were positively related with Type 1 postural pattern (OR=6.10, 95% CI: 1.52-24.57 and OR=3.54, 95% CI: 1.13-11.11, respectively). There was also a weak direct association between female sex and Type 1 postural pattern. Regarding behavioral factors, subjects with total physical activity above the first third exhibited all nonneutral postural patterns less frequently, and current smokers were more likely to present a Type 4 postural pattern. CONCLUSIONS: Higher BMI and central obesity were important potential determinants of nonneutral posture among adults from the general population. Future research should investigate the potential effectiveness of overweight prevention and management in avoiding sagittal misalignment conditions.

Medial epiphyseal fracture-detachment of the sternoclavicular joint with posterior displacement in a judo athlete - equivalent of posterior sternoclavicular dislocation

Posterior sternoclavicular dislocation is a rare traumatic injury that presents a potential risk of injury to mediastinal structures. The diagnosis is fundamentally clinical and treatment is done on an emergency basis. The authors report the clinical case of a young judo athlete with post-traumatic medial epiphyseal fracture-detachment, with posterior displacement (lesion equivalent to posterior sternoclavicular dislocation at pediatric ages). He underwent open reduction and ligament repair by means of a mini-anchor.The radiological and clinical outcome was excellent, and the athlete returned to his sports activity without limitations. We discuss the particular features of this pathological condition, along with the different therapeutic approaches and their complications.