Tratamiento quirúrgico de las fracturas periprotésicas de húmero y algoritmo de actuación / Surgical treatment of periprosthetic humerus fractures and algorithm

INTRODUCCIÓN: Las fracturas periprotésicas de húmero son infrecuentes y su manejo, difícil. La bibliografía es limitada y no existe consenso sobre su tratamiento. MATERIAL Y MÉTODO: Hemos realizado un estudio observacional retrospectivo de 10pacientes con fractura periprotésica de húmero con un seguimiento de 25,1 meses (6-87). Valoramos los resultados clínicos, radiológicos y funcionales, como las complicaciones. Utilizamos el cuestionario Quick-DASH y UCLA Shoulder Score (UCLASS). Realizamos una búsqueda sistemática para comparar la serie presentada y los protocolos de tratamiento publicados. RESULTADOS: Diez pacientes con una media de edad de 69,4 años (37-91) fueron intervenidos quirúrgicamente: 8 mediante reducción abierta y fijación interna (RAFI), en otro se realizó un recambio protésico colocando una nueva prótesis con un vástago más largo, y en el último se retiró la prótesis y se realizó una osteosíntesis con un clavo endomedular. Nueve de 10 pacientes consolidaron en un tiempo de 6,2 meses (rango 5-12); el restante sufrió una nueva fractura 5 meses después, siendo reintervenido, realizándole una nueva osteosíntesis, con aporte de aloinjerto óseo, que consolidó a los 8meses de la última fractura. En relación con la situación previa a la fractura, los pacientes tenían como promedio un descenso notable de la función, que era de 10,66 puntos en el test de UCLASS y un ascenso de 27,3 puntos en el cuestionario Quick-DASH. CONCLUSIONES: Nuestra serie tiene similitudes con las publicadas en relación con los aspectos demográficos, las complicaciones y el tiempo de consolidación. Sin embargo, en otros aspectos, como el dolor y los resultados funcionales, encontramos gran variabilidad

INTRODUCTION: Periprosthetic humerus fractures are infrequent and sometimes difficult to treat. There is limited literature and no consensus on the handling of these fractures. The objective of this study was to compare our results with those published in the literature, in order to improve our care and propose a management algorithm. MATERIAL AND METHOD: Observational study of 10 cases of periprosthetic humerus fractures with a mean follow-up of the patients of 23 months. An analysis of sociodemographic, radiological and surgical variables was performed. They were reviewed clinically and by telephone using the UCLA Shoulder Score and Quick-DASH scales. A systematic search was made in Pubmed for periprosthetic humerus fractures, for a literature review with which to compare our series. RESULTS: We analysed 10 patients with an average age of 69.4 years (37-91). Of the patients, 90% underwent surgery through open reduction and internal fixation. Nine of the ten patients consolidated in a mean time of 6.2months (range 5-12), the remaining suffered a new fracture 5 months after the intervention, who were reoperated and a new osteosynthesis performed with bone allograft. In the UCLA scale there was a decrease of 10.66 points, and an increase of 27.3 points in the Quick-DASH, at the end of the follow-up. CONCLUSIONS: In our series of cases we found similarities in the literature, in relation to demographic aspects and obtaining good radiographic results, which do not correspond to the functional outcome of patients

Análisis de la mortalidad tras el tratamiento quirúrgico de las fracturas periprotésicas de fémur distal / Analysis of mortality after surgical treatment of periprosthetic distal femur fractures

INTRODUCCIÓN: Está aumentando la incidencia de las fracturas periprotésicas de rodilla debido al incremento en el número de artroplastias totales de rodilla realizadas, junto al envejecimiento poblacional. Encontramos escasos estudios que analicen en nuestro medio la mortalidad a largo plazo tras la intervención quirúrgica. Nuestro objetivo fue evaluar la mortalidad y la supervivencia tras el tratamiento quirúrgico de las fracturas periprotésicas de fémur distal en nuestro medio. MATERIAL Y MÉTODOS: Realizamos un estudio observacional retrospectivo de una serie consecutiva de 97 pacientes intervenidos quirúrgicamente en nuestro centro por fractura periprotésica de rodilla entre los años 2007 y 2015, con un seguimiento mínimo de 12 meses. Se analizaron estadísticamente diversas variables sociodemográficas, clínicas y quirúrgicas. Se realizó una consulta al índice nacional de defunciones del Ministerio de Sanidad para el análisis de mortalidad y se analizó la supervivencia utilizando el método Kaplan-Meier. RESULTADOS: Revisamos un total de 97 pacientes con edad media de 75años, de los cuales 86 fueron mujeres y 11 fueron hombres. El 50,5% de los pacientes presentaban alguna comorbilidad. La demora media hasta la intervención fue de 3,1 días. Respecto al tratamiento, 45 pacientes fueron intervenidos mediante osteosíntesis con placa (49,5%), 40 de ellos con clavo intramedular (41,2%) y en 9 se realizó una revisión de la artroplastia (9,3%). Se registraron un total de 30 defunciones durante el seguimiento, con una mortalidad acumulada al año, a los 3años y a los 10 años del 7,2, del 17,5 y del 30,9%, respectivamente, aumentando progresivamente en mayores de 75 años. No hubo diferencias significativas en las tasas de mortalidad respecto al método de osteosíntesis. La principal complicación fue la seudoartrosis (6,2%). CONCLUSIONES: Las fracturas periprotésicas de rodilla se asocian a altas tasas de complicaciones y de mortalidad, siendo la edad del paciente y la propia lesión factores no modificables que pueden influir en la mortalidad tras la cirugía, mientras que otras variables, como el tipo de intervención o la demora quirúrgica, no mostraron diferencias en las tasas de mortalidad en nuestro estudio

INTRODUCTION: The incidence of periprosthetic fractures of the knee is increasing due to the increase in the number of total knee arthroplasties performed, together with population aging. We found few studies that analyze mortality in our setting after surgery. Our objective was to evaluate mortality and survival after surgical treatment of periprosthetic fractures of the distal femur in our environment. MATERIAL AND METHOD: We conducted a retrospective observational study of a consecutive series of 97 patients surgically treated in our centre for periprosthetic knee fracture between 2007-2015, with a minimum follow-up of 12 months. Diverse sociodemographic, clinical and surgical variables were analyzed. A consultation was made to the National Death Index of the Ministry of Health for the analysis of mortality and survival was analyzed using the Kaplan-Meier method. RESULTS: We reviewed a total of 97 patients with an average age of 75 years, of which 86 were women and 11 were men. Of the patients, 50.5% of patients had some comorbidity. The average delay until the intervention was 3.1 days. With respect to the treatment, 45 patients were operated by osteosynthesis with plate (49.5%), 40 with intramedullary nail (41.2%) and 9 with revision of the arthroplasty (9.3%). A total of 30 deaths were recorded during the follow-up, with cumulative mortality in the first year, at 3 and at 10 years of 7.2%, 17.5% and 30.9%, respectively, progressively increasing in people over 75 years. There was no significant difference in mortality rates with the osteosynthesis method. The main complication was pseudoarthrosis (6.2%). CONCLUSIONS: Periprosthetic knee fractures are associated with high rates of complications and mortality. The patient's age and the lesion itself are non-modifiable factors that can influence mortality after surgery, while other variables such as the type of intervention or surgical delay did not show differences in mortality rates in our study

Analysis of mortality after surgical treatment of periprosthetic distal femur fractures. / Análisis de la mortalidad tras el tratamiento quirúrgico de las fracturas periprotésicas de fémur distal.

INTRODUCTION: The incidence of periprosthetic fractures of the knee is increasing due to the increase in the number of total knee arthroplasties performed, together with population aging. We found few studies that analyze mortality in our setting after surgery. Our objective was to evaluate mortality and survival after surgical treatment of periprosthetic fractures of the distal femur in our environment. MATERIAL AND METHOD: We conducted a retrospective observational study of a consecutive series of 97 patients surgically treated in our centre for periprosthetic knee fracture between 2007-2015, with a minimum follow-up of 12months. Diverse sociodemographic, clinical and surgical variables were analyzed. A consultation was made to the National Death Index of the Ministry of Health for the analysis of mortality and survival was analyzed using the Kaplan-Meier method. RESULTS: We reviewed a total of 97 patients with an average age of 75years, of which 86 were women and 11 were men. Of the patients, 50.5% of patients had some comorbidity. The average delay until the intervention was 3.1days. With respect to the treatment, 45 patients were operated by osteosynthesis with plate (49.5%), 40 with intramedullary nail (41.2%) and 9 with revision of the arthroplasty (9.3%). A total of 30 deaths were recorded during the follow-up, with cumulative mortality in the first year, at 3 and at 10 years of 7.2%, 17.5% and 30.9%, respectively, progressively increasing in people over 75years. There was no significant difference in mortality rates with the osteosynthesis method. The main complication was pseudoarthrosis (6.2%). CONCLUSIONS: Periprosthetic knee fractures are associated with high rates of complications and mortality. The patient's age and the lesion itself are non-modifiable factors that can influence mortality after surgery, while other variables such as the type of intervention or surgical delay did not show differences in mortality rates in our study.

Surgical treatment of periprosthetic humerus fractures and algorithm. / Tratamiento quirúrgico de las fracturas periprotésicas de húmero y algoritmo de actuación.

INTRODUCTION: Periprosthetic humerus fractures are infrequent and sometimes difficult to treat. There is limited literature and no consensus on the handling of these fractures. The objective of this study was to compare our results with those published in the literature, in order to improve our care and propose a management algorithm. MATERIAL AND METHOD: Observational study of 10cases of periprosthetic humerus fractures with a mean follow-up of the patients of 23months. An analysis of sociodemographic, radiological and surgical variables was performed. They were reviewed clinically and by telephone using the UCLA Shoulder Score and Quick-DASH scales. A systematic search was made in Pubmed for periprosthetic humerus fractures, for a literature review with which to compare our series. RESULTS: We analysed 10patients with an average age of 69.4years (37-91). Of the patients, 90% underwent surgery through open reduction and internal fixation. Nine of the ten patients consolidated in a mean time of 6.2months (range 5-12), the remaining suffered a new fracture 5months after the intervention, who were reoperated and a new osteosynthesis performed with bone allograft. In the UCLA scale there was a decrease of 10.66points, and an increase of 27.3points in the Quick-DASH, at the end of the follow-up. CONCLUSIONS: In our series of cases we found similarities in the literature, in relation to demographic aspects and obtaining good radiographic results, which do not correspond to the functional outcome of patients.

Fracturas de astrágalo. Resultados funcionales en pacientes politraumatizados / Talus fractures. Functional results for polytraumatized patients

Las fracturas de astrágalo son lesiones poco frecuentes (0,1-0,9%) y con un alto índice de complicaciones. Una de las situaciones en las que puede darse una fractura de astrágalo es en el contexto de un politraumatismo, lo que puede comprometer aún más el pronóstico funcional. El objetivo del presente trabajo ha sido analizar los resultados funcionales en los pacientes con fracturas de astrágalo según se produjeran en el contexto de un politraumatismo o no. Estudio observacional sobre una cohorte retrospectiva de 24 pacientes intervenidos por fractura de astrágalo en nuestro centro (2008-2016). Se agruparon según fuesen politraumatizados (ISS>16) o no (ISS≤16). Revisión de variables sociodemográficas, radiográficas, funcionales (escala EVA de dolor y FADI -Foot and Ankle Disability Index-) y la aparición de complicaciones como artrosis o necrosis avascular. Revisión de 25 fracturas de astrágalo en 24 pacientes con una edad media de 38 años (19-75) y un seguimiento medio de 4,2 años (0,5-9). Según el ISS un 44% de pacientes (11) fueron politraumatizados y un 56% (14) no. Respecto a los resultados funcionales entre politraumatizados y no politraumatizados, la puntuación media según la escala FADI fue de 62 puntos y de 76,9 respectivamente y según la escala EVA fue de 5,8 y 4,3 puntos respectivamente. Respecto a las complicaciones, en el grupo de politraumatizados se presentaron en un 64% de los pacientes y en los no politraumatizados en un 43%. Un 36% de los pacientes politraumatizados tuvieron signos clínicos y radiológicos de artrosis subastragalina y un 27% fueron intervenidos mediante una artrodesis frente al 35% y al 27% del grupo de no politraumatizados, Respecto a la necrosis avascular del astrágalo, se registro un 27% frente a un 0% de los no politraumatizados

Talar fractures are uncommon lesions (0.1-0.9%) and have a high rate of complications. One of the situations in which a fracture of the talus can occur is in the context of polytrauma which may further compromise the functional prognosis. The aim of this study was to analyze the functional results in patients with talar fractures whether or not they occurred in the context of polytrauma. Observational study on a retrospective cohort of 24 patients operated in our centre (2008-2016). They were grouped according to whether they were polytraumatized (ISS>16) or not (ISS≤16). Review of sociodemographic, radiographic, functional variables (VAS pain scale and FADI -Foot and Ankle Disability Index-) and the onset of complications such as arthrosis, arthrodesis or avascular necrosis. Review of 25 talar fractures in 24 patients with a mean age of 38 years (19-75) and a mean follow-up of 4.2 years (0.5-9). According to the ISS, 44% of patients (11) were polytraumatized and 56% (14) were not. The average score according to the FADI scale was 62 points for the polytraumatized patients and 76.9 for the non-polytraumatized patients. The pain according to the VAS scale was 5.8 points in the group of polytraumatized patients and 4.3 in the non-polytraumatized patient group. Regarding complications, 64% of the polytraumatized patients and 43% of the non-traumatized patients had a complication. 36% of the polytraumatized patients had clinical and radiological signs of subtalar arthrosis compared to 35% of the non-traumatized patients, of whom 27% underwent arthrodesis compared to 28% of the non-traumatized patients. 27% of the polytraumatized patients were diagnosed with avascular necrosis as opposed to 0% of the non-polytraumatized patients

Talus fractures. Functional results for polytraumatized patients. / Fracturas de astrágalo. Resultados funcionales en pacientes politraumatizados.

Talar fractures are uncommon lesions (0.1-0.9%) and have a high rate of complications. One of the situations in which a fracture of the talus can occur is in the context of polytrauma which may further compromise the functional prognosis. The aim of this study was to analyze the functional results in patients with talar fractures whether or not they occurred in the context of polytrauma. Observational study on a retrospective cohort of 24 patients operated in our centre (2008-2016). They were grouped according to whether they were polytraumatized (ISS>16) or not (ISS≤16). Review of sociodemographic, radiographic, functional variables (VAS pain scale and FADI -Foot and Ankle Disability Index-) and the onset of complications such as arthrosis, arthrodesis or avascular necrosis. Review of 25 talar fractures in 24 patients with a mean age of 38 years (19-75) and a mean follow-up of 4.2 years (0.5-9). According to the ISS, 44% of patients (11) were polytraumatized and 56% (14) were not. The average score according to the FADI scale was 62 points for the polytraumatized patients and 76.9 for the non-polytraumatized patients. The pain according to the VAS scale was 5.8 points in the group of polytraumatized patients and 4.3 in the non-polytraumatized patient group. Regarding complications, 64% of the polytraumatized patients and 43% of the non-traumatized patients had a complication. 36% of the polytraumatized patients had clinical and radiological signs of subtalar arthrosis compared to 35% of the non-traumatized patients, of whom 27% underwent arthrodesis compared to 28% of the non-traumatized patients. 27% of the polytraumatized patients were diagnosed with avascular necrosis as opposed to 0% of the non-polytraumatized patients.

Treatment of posttraumatic bone defects of the forearm with vascularized fibular grafts. Follow up after fourteen years.

BACKGROUND: Among several techniques proposed for the reconstruction of posttraumatic bone defects of the forearm, that of free vascularised fibular graft (FVFG) is one of the most widely used. PATIENTS AND METHOD: We study the long-term outcomes of 14 patients who underwent FVFG between 1994 and 2009, with a minimum follow up of 8 years and a maximum of 23 years (mean: 13.9 years). Demographic, clinical and radiological variables were collected retrospectively. The DASH scale was used for clinical assessment. RESULTS: Fourteen patients were operated on by the same surgeon, applying FVFG for the reconstruction of posttraumatic bone defects of the forearm (three septic non-union of the ulna or radius, five radius fractures, two ulna fractures and four fractures of both bones). The maximum length of the defect was 11 cm and the minimum length was 6 cm. In four cases, reconstruction of the two bones was achieved using the double barrel technique, and in another four cases, an osteoseptocutaneous flap was used. Fixation was performed with 3.5 mm reconstruction plates in thirteen cases and with 3.5 mm screws in one case. Consolidation was obtained in 12 cases (85.7%) after an average time of 4.2 months (range: 2-6.5 months). In one case, consolidation of the proximal ulnar fracture site was not achieved, and in another, following the failure of reconstruction attempts, an arthrodesis was performed. At the end of the follow-up period, the patients had an average DASH score of 17.1 points (range 1.8-68.1). CONCLUSIONS: FVFG is a valid option for the reconstruction of posttraumatic bone defects of the forearm. Its use via the double barrel method or as an osteocutaneous composite graft enables the simultaneous reconstruction of both forearm bones and associated soft tissue injuries. Long-term follow-up of patients who have undergone this technique confirms its satisfactory functional and radiological results.

Correlación entre la exploración física y los hallazgos intraoperatorios de patología de hombro tratada mediante artroscopia. Análisis estadístico de 150 pacientes / Correlation between physical examination and intraoperative findings in shoulder disease treated by arthroscopy. Statistical analysis of 150 patients

Introducción. En la patología del hombro pocas son las maniobras exploradoras verdaderamente discriminatorias y útiles en la clínica. El objetivo de nuestro trabajo es correlacionar la exploración física del hombro con el diagnóstico real hallado por artroscopia. Métodos. Estudio retrospectivo tipo serie de casos de 150 pacientes con las principales patologías quirúrgicas de hombro. Se recogieron datos de la sospecha de cada patología según la exploración física del paciente y el hallazgo real de las mismas durante la cirugía artroscópica. Resultados. Las maniobras de exploración de la lesión de Bankart es la que ha obtenido mejores resultados con un valor predictivo positivo (VPP) del 92,1% y un valor predictivo negativo (VPN) del 99,1%, seguida por el síndrome subacromial con un VPP del 94,4%, la rotura total del manguito con un VPP del 92,3%. La exploración en la lesión SLAP tiene un VPN de 99,1%. Conclusión. La exploración física es suficiente para diagnosticar o descartar una lesión de Bankart. Una exploración física positiva es diagnóstica de rotura total del manguito de los rotadores y no requiere estudios complementarios. Los pacientes con sospecha de síndrome subacromial solo necesitarán una RM confirmatoria si los test físicos son negativos. Las conclusiones extraídas del presente trabajo pueden tener una importante repercusión tanto en ahorro de costes (por reducción de pruebas complementarias), como por ahorro de tiempo en determinados casos en los que, tras la exploración física adecuada, se puede indicar cirugía sin necesidad de pasos intermedios (AU)

Introduction. Only a few clinical exploratory manoeuvres are truly discriminatory and useful in shoulder disease. The aim of this study is to correlate the physical examination results of the shoulder with the true diagnosis found by arthroscopy. Methods. A retrospective case series of 150 patients with the most common surgical conditions of the shoulder. Data were collected on the suspicion of each pathology, the physical examination of the patient, and the actual discovery of the disease during arthroscopic surgery. Results. The Bankart examination manoeuvres of the lesion show the best results, with a 92.1% positive prediction value (PPV), a 99.1% negative predictive value (NPV), followed by the impingement syndrome, with a PPV of 94.4%, and total cuff rupture with a PPV of 92.3%.Exploration of the superior labrum anterior to posterior (SLAP) lesion had an NPV of 99.1%. Conclusion. Physical examination is sufficient to diagnose or rule out Bankart. A positive physical examination provides the complete rupture of the rotator cuff, and requires further studies. The patients suspected of subacromial syndrome only need an NMR if the physical tests are negative. The conclusions drawn from this work can have a significant impact on both cost savings (by reducing forward tests), and saving time in certain cases in which, after appropriate physical examination, surgery may be indicated without losing time in intermediate steps (AU)

Correlation between physical examination and intraoperative findings in shoulder disease treated by arthroscopy. Statistical analysis of 150 patients. / Correlación entre la exploración física y los hallazgos intraoperatorios de patología de hombro tratada mediante artroscopia. Análisis estadístico de 150 pacientes.

INTRODUCTION: Only a few clinical exploratory manoeuvres are truly discriminatory and useful in shoulder disease. The aim of this study is to correlate the physical examination results of the shoulder with the true diagnosis found by arthroscopy. METHODS: A retrospective case series of 150 patients with the most common surgical conditions of the shoulder. Data were collected on the suspicion of each pathology, the physical examination of the patient, and the actual discovery of the disease during arthroscopic surgery. RESULTS: The Bankart examination manoeuvres of the lesion show the best results, with a 92.1% positive prediction value (PPV), a 99.1% negative predictive value (NPV), followed by the impingement syndrome, with a PPV of 94.4%, and total cuff rupture with a PPV of 92.3%.Exploration of the superior labrum anterior to posterior (SLAP) lesion had an NPV of 99.1%. CONCLUSION: Physical examination is sufficient to diagnose or rule out Bankart. A positive physical examination provides the complete rupture of the rotator cuff, and requires further studies. The patients suspected of subacromial syndrome only need an NMR if the physical tests are negative. The conclusions drawn from this work can have a significant impact on both cost savings (by reducing forward tests), and saving time in certain cases in which, after appropriate physical examination, surgery may be indicated without losing time in intermediate steps.

Biomechanical design of less invasive stabilization system femoral plates: computational evaluation of the fracture environment.

Less Invasive Stabilization System femoral plates are currently accepted as a suitable fixation technique for supra-intercondylar femoral fractures. However, general agreement does not exist regarding the optimum design of this fixator type. Therefore, the aim of this article is to reduce the intrinsic Less Invasive Stabilization System complications by clarifying, from a biomechanical point of view, how the number of screws, the screw connection type (unicortical or bicortical), or the structured position of the screws can influence the outcome of the fracture site. These studies include a specific finite element analysis that determines how several biomechanical variables, such as the movement at the fracture site, are influenced by the preconditions of bone healing. The results of this study show that the screw type affects the mechanical stabilization of the femur to a greater extent than the material type of the Less Invasive Stabilization System femoral plates. The most significant differences among all the analyzed configurations are observed in the shear interfragmentary strain between screw types. Values are approximately 50% higher with unicortical screws than with bicortical ones.

Pacientes con fractura de pelvis inestables hemodinámicamente in extremis ¿packing pélvico o arteriografía? / Patients with hemodynamic unstable pelvic fractures in extremis: Pelvic packing or angiography?

El manejo multidisciplinar de los pacientes con traumatismo pélvico ha mejorado su pronóstico, sin embargo la mortalidad sigue siendo muy elevada. La estrategia de un tratamiento adecuado es aún controvertida, sobre todo respecto al control de la hemorragia en pacientes cuya situación clínica es extrema mediante el uso de arteriografía o packing pélvico. Planteamos mediante una herramienta de medicina basada en evidencia (CAT) el beneficio de la realización del packing pélvico en relación a una pregunta clínica específica desde una situación concreta, ¿qué es mejor para el manejo del sangrado, packing pélvico extraperitoneal o arteriografía, en pacientes con fractura de pelvis inestables hemodinámicamente in extremis? De este estudio podemos concluir que la arteriografía puede mejorar el control de la hemorragia en los pacientes con sangrado arterial y hemodinámicamente estables, pero el packing tiene prioridad en los pacientes con fracturas de pelvis e inestabilidad hemodinámica (AU)

The multidisciplinary management of patients with pelvic trauma has improved prognosis, but mortality is still very high. The appropriate treatment strategy remains controversial, especially regarding the control of bleeding in patients whose clinical situation is extreme by using angiography or pelvic packing. We propose using a tool of evidence-based medicine (CAT) the benefit of the completion of pelvic packing in relation to a specific clinical question from a specific situation. What is best for the management of bleeding, extraperitoneal pelvic packing or angiography, in patients with hemodynamically unstable pelvic fracture in extremis? From this study we can conclude that angiography may improve control of bleeding in patients with arterial bleeding and hemodynamically stable but the packing has priority in patients with pelvic fractures and hemodynamic instability (AU)

[Patients with hemodynamic unstable pelvic fractures in extremis: pelvic packing or angiography?]. / Pacientes con fractura de pelvis inestables hemodinámicamente in extremis ¿packing pélvico o arteriografía?

The multidisciplinary management of patients with pelvic trauma has improved prognosis, but mortality is still very high. The appropriate treatment strategy remains controversial, especially regarding the control of bleeding in patients whose clinical situation is extreme by using angiography or pelvic packing. We propose using a tool of evidence-based medicine (CAT) the benefit of the completion of pelvic packing in relation to a specific clinical question from a specific situation. What is best for the management of bleeding, extraperitoneal pelvic packing or angiography, in patients with hemodynamically unstable pelvic fracture in extremis? From this study we can conclude that angiography may improve control of bleeding in patients with arterial bleeding and hemodynamically stable but the packing has priority in patients with pelvic fractures and hemodynamic instability.

Análisis del síndrome Inestable-Doloroso de la articulación subastragalina mediante el sistema estrés dinámico BaroPodoTAC / Analysis of Unstable-painful Subtalar Joint Syndrome using Dynamic Stress System CT scan

Introducción: La inestabilidad de tobillo y de retropié coexisten frecuentemente sin que existan en la actualidad métodos objetivos no quirúrgicos para su diagnóstico diferencial. Además, la inestabilidad y el dolor en la articulación subastragalina pueden desembocar en la temida artrosis de retropié en pacientes de cualquier edad. El presente trabajo tiene como propósito principal comparar el rango de movilidad del retropié sintomático respecto al retropié sano en una serie consecutiva de pacientes afectos de inestabilidad de tobillo. Material y Método: Se diseñó un dispositivo que simula condiciones de carga con movimientos extremos de la articulación subastragalina sobre la mesa de TAC (Estrés-BaroPodo-TAC). Se realizó TAC en carga y en dos posiciones extremas de inversión-rotación interna y eversión-rotación externa sobre 26 pies de 13 pacientes diagnosticados de inestabilidad crónica de tobillo. Se midieron los ángulos de divergencia y flexión astrágalo-calcánea en las dos posiciones mencionadas y se calculó el rango de movimiento total. Se comparó el retropié problema con el retropié sano en cada paciente. Resultados: Los pies problemas presentaron mayor rango de movilidad de divergencia astrágalo-calcáneo que los pies sanos de los pacientes. No hubo diferencias en el rango de movilidad de flexión astrágalo-calcáneo. No se correlacionó estadísticamente el movimiento de divergencia en el plano axial con el movimiento de flexión astrágalo-calcánea en el plano sagital. Conclusión: Mediante este método se midió objetivamente mediante TAC el rango de movimiento de la articulación subastragalina. Los pacientes con inestabilidad de tobillo y dolor en retropié presentaron mayor rango de movilidad en la articulación subastragalina en el retropié doloroso respecto al contralateral (AU)

Introduction: In many cases, unstable ankle and heel coexist without there currently being any objective, non-surgical method for a differential diagnosis. Moreover, instability and pain in the subtalar joint could deteriorate into the so dreaded osteoarthritis of the heel in patients of any age. The main objective of this work is to compare the movement range of a symptomatic heel with regards to a healthy heel in a consecutive series of patients affected with ankle instability. Material and method: A device was designed to simulate weight-bearing conditions with extreme subtalar joint movement on the CAT scan examination table (Estrés-BaroPodo-TAC). A CAT scan was performed during weight-bearing and in two extreme positions of internal inversion rotation and external eversion rotation of 26 feet in 13 patients, all diagnosed with chronic, unstable ankle. The divergence and flexion of heel angles in the two positions mentioned and the total movement range was calculated. The heel problem was compared with the healthy heel in each patient. Results: The problem foot presented a greater range of heel divergence mobility than the patient’s healthy foot. There were no differences in the mobility range for heel flexion. The divergence of movement in the axial plane was not statistically correlated with the heel flexion movement in the sagittal plane. Conclusion: With this method, we objectively measured the movement range of the heel joint, using CAT scan. Patients with unstable ankle and heel pain presented a greater range of movement in the heel joint of the painful heel with respect to the contralateral movement (AU)

Secuela de fractura de pelvis. A propósito de un caso y revisión de la literatura / Pelvis fracture sequelae. A case report and literature review

Objetivos: Presentación y análisis crítico de paciente con secuela post-fractura de pelvis que permita exponer la complejidad de su manejo y tratamiento. Caso clínico: Mujer de 29 años con dolor invalidante en región sacroilíaca a la sedestación y la marcha. Exploración: Deformidad externa pélvica con repercusión estética, dismetría de miembro inferior izquierdo de 4 cm y dolor sacroilíaco a la apertura pélvica o al apoyo monopodal izquierdo. Limitación funcional a la marcha con cojera y problemas de sedestación (sitting imbalance). Estudio radiográfico convencional y TAC con signos de asimetría pélvica, elevación de hemipelvis izquierda y pseudoartrosis sacra y de ramas ilioisquiopubianas izquierdas post-fractura. Diagnóstico: Secuela compleja de Fractura de Pelvis con deformidad, tipo III de Mears y Velyvis. Tratamiento: Secuenciado en 2 fases. (1) Liberación Anterior: Desarticulación sinfisaria, esqueletización de ramas y osteotomía sacra anterior. Liberación Posterior: Liberación ligamentos suelo pélvico y osteotomía sacra posterior. Tracción progresiva de la extremidad izquierda 2 semanas. (2) Osteosíntesis Anterior: Fijación sacroilíaca anterior con placa de reconstrucción, doble placa anterior sinfisaria y aporte de autoinjerto. Osteosíntesis Posterior: Fijación posterior mediante barra transilíaca. Evolución: Infección herida quirúrica posterior que se resolvió con curas quirúrgicas y antibioterapia. Se consiguió disminución del nivel de dolor, resolución del trastorno de sedestación y mejora de la cojera. SF-36 con PCS 60 y MCS de 50, Majeed-Score excelente. Discusión: La pseudoartrosis y la deformidad son entidades infrecuentes generadas por tratamientos conservadores o inadecuados en lesiones con gran inestabilidad pélvica. El tratamiento puede ser realizado de forma directa o en varias fases. Los pacientes deben ser informados de que el tratamiento implica riesgos más elevados que respecto a la cirugía aguda convencional. Suele obtener mejoras en resultados de consolidación y funcionalidad. El paciente aquí referido ha sido tratado de forma análoga a lo establecido por la comunidad científica, a pesar de ello, no existe evidencia clínica respecto a protocolos de manejo en dicha enfermedad. La realización de estudios multicéntricos ayudaría a la comprensión de los patrones lesionales y al desarrollo de herramientas estandarizadas de tratamiento. Conclusión: La secuela de la fractura pélvica es una entidad compleja de dificultosa resolución y difícil manejo incluso para expertos en dicha materia. Es preciso un abordaje multidisciplinar de dichos paciente en centros de tercer nivel para la obtención de los mejores resultados en esta patología (AU)

Objectives: Critical assessment of a case report related to complications in pelvis fracture. The aim is to determine the complexity in management and treatment of pelvic sequelae. Case Report: 29 years old woman with disabling pain in sacroiliac joint when sitting and walking. External pelvic deformity with aesthetic evidence, left lower limb with 4 cm dysmetria and sacroiliac pain pelvic when examination maneuvers opening pelvis or standing on one foot. Functional limitation with sitting and gait problems. Conventional X-rays and CT-scan reveal pelvic asymmetry, upper left hemipelvis and nonunions in sacrum and left ilioischiopubic ramus fractures. Diagnosis: Pelvic fracture complication Velyvis and Mears type III. A two phases sequenced treatment was performed: (1) Anterior Release: Symphyseal disjoint, branches skeletonization and anterior sacral osteotomy. Posterior Release: Posterior sacroiliac complex and pelvic floor ligaments release with posterior sacral osteotomy. Progressive left extremity traction 2 weeks. (2) Anterior Osteosynthesis: Anterior sacroiliac fixation with reconstruction plate, double symphyseal plate and patient bonegrafting. Posterior Osteosynthesis: Transiliac bar. Outcome with surgical wound infection solved with antibiotics and surgical treatment. A pain decrease, sitting disorder resolution and improvement of lameness was achieved. SF-36 with 60 PCS and 50 MCS. Excelent Majeed-Score. Discussion: Pelvic malalignement and nonunions are rare entities, usually associated with initial conservative or inadequate treatment in pelvic instable fractures. Treatment may be accomplished directly or in stages. Patients should be informed that treatment involves higher risks than over conventional acute surgery. It often obtains improved consolidation and functionality results. The patient here referred has been treated similarly to that established by the scientific community, nevertheless, there is no clinical evidence regarding management protocols in the disease. Multicenter studies would help the understanding about patterns and development of standardized treatment algorithms. Conclusion: Pelvic fracture complications are complex entities. It involves a hard resolution and difficult management even for expert surgeons. A multidisciplinary approach of these patients in tertiary centers is needed to obtain the best results in this pathology (AU)

Biomechanical analysis of a new minimally invasive system for osteosynthesis of pubis symphysis disruption.

INTRODUCTION: We analysed the effectiveness of a new percutaneous osteosynthesis system for the treatment of pelvis fractures with rotational instability. METHODS: A pre-clinical cross-sectional experimental study wherein Tile type B1 injuries (open-book fractures) were produced in 10 specimens of fresh human cadavers, including the L4-5 vertebrae, pelvic ring, and proximal third of the femur, keeping intact the capsular and ligamentous structures, is presented in this paper. The physiological mobility of the intact pelvis in a standing position post-injury was compared to that following the performance of a minimally invasive osteosynthesis of the symphysis with two cannulated screws. A specially designed test rig capable of applying loads simulating different weights, coupled with a photogrammetry system, was employed to determine the 3D displacements and rotations in three test cases: intact, injured and fixed. RESULTS: After applying an axial load of 300 N, no differences were observed in the average displacement (mm) of the facet joints of the intact pubic symphysis in comparison to those treated with screws (p >0.7). A statistical difference was observed between the average displacements of the sacroiliac facet joints and pelvises with symphyseal fractures treated with screws after the application of a load (p <0.05). CONCLUSION: The symphyseal setting with two crossed screws appears to be an effective alternative to osteosynthesis in pelvic fractures with rotational instability.

Diseño y desarrollo de un modelo experimental para estudios biomecánicos de fracturas tipo B de Tile del anillo pélvico / Design and development of an experimental model for biomechanical studies of Tile type B1 fracture of the pervic ring

Objetivo: Diseñar un modelo estandarizado y reproducible para la realización de ensayos biomecánicos de fracturas tipo B1 de Tile del anillo pélvico. Metodología: Establecida en dos fases. Fase 1, determinación de requerimientos fundamentales del sistema. Fase 2, diseño, testado y elección de las piezas del modelo experimental. Se empleó una máquina universal de ensayos (MTS- 810), programas de diseño gráfico (Solid Edge Academic), fantomas, rail de carga deslizante y materiales industriales de Fabricación del Sistema de Fijación. Resultados: Se obtuvo un modelo constituido por dos sistemas de anclaje, superior e inferior, que permiten articular la pelvis a la máquina de ensayo tanto proximalmente, a través del sacro y L5, como a nivel distal con ambos fémures. El sistema permitió fijación adecuada de especímenes a máquina de ensayo, mantener la estática postural de bipedestación a la carga y reproductibilidad de lesión B1 de Tile. Conclusión: Es posible diseñar y fabricar un sistema estandarizado de fijación de pelvis humanas a una máquina de análisis de materiales para el estudio biomecánico de las fracturas tipo B1 de Tile del anillo pélvico (AU)

Objetive: The aim of the study is to design a standardized and reproducible procedure for biomechanical testing of Tile B1 fractures of the pelvic ring. Methodology: The methodology for this study was divided in two phases. In the first phase, the requirements to be covered by the system were determined, and in the second one experimental model pieces were designed and chosen. An Universal Testing Machine (MTS-810), Graphic Design Plans Program Software (Solid Edge Academic), Fantomas, Bearing, Sliding Rail and Manufacturing Material Fixing System were used. Results: A specific loading biomechanic system has been created, consisting on an upper and a lower anchor, which allows pelvis ring fix to the test machine both proximally through the sacrum and the last lumbar vertebra, and in terms of both femurs to the database of the testing machine. The procedure make a correct bone fixation, place the pelvis in a stand position, getting to align the upper and lower anterior iliac spines in the same plane and reproduce Tile B1 fracture. Conclusion: It is possible to design and manufacture a simple standard system for determining human pelvis to a testing machine for biomechanical studies of Tile type B1 pelvic ring fractures (AU)

[Benefit of the stabilization of long-bone fractures in polytraumatized patients]. / Beneficio de la estabilización de fracturas de huesos largos en politraumatizados.

INTRODUCTION: Early fracture fixation is increasingly common in medical practice, and femur shaft fractures are the perfect prototype of the lesion warranting early surgery in polytraumatized patients. Damage control orthopedics (DCO) is defined as the minimally-traumatic interventions intended to provide quick stabilization of orthopedic injuries to minimize the systemic inflammatory response. MATERIAL AND METHODS: By means of an evidence-based medicine tool (CAT) we approach the benefit of long-bone fracture stabilization in polytraumatized patients trying to answer a specific clinical question from a concrete situation: What is the evidence of the safety and benefit of early stabilization of long-bone fractures in polytraumatized patients? RESULTS: The patient group whose fractures were stabilized after 48 hours had more clinical complications, alterations of lung parameters and a longer hospital stay. There is no complete evidence showing that early stabilization of long bones in patients with moderate or severe head trauma worsens or improves the outcomes. CONCLUSIONS: Urgent fracture stabilization should be an adjuvant to resuscitation. Early fracture stabilization contributes to reducing the ICU stay, the incidence of acute respiratory distress syndrome (ARDS), multiple organ failure (MOF) and sepsis, thus improving patient survival.

Estudio epidemiológico de factores de riesgo asociados a refractura en mujeres con fractura vertebral osteoporótica durante 10 años de seguimiento / Epidemiological study of risk factors associated to refracture in women osteoporotic vertebral fracture during a 10-year follow-up

Objetivos. Los objetivos de este estudio son analizar las características epidemiológicas de las fracturas vertebrales osteoporóticas no quirúrgicas en mujeres, así como la posible relación que se da entre refractura y la existencia o no de tratamiento preventivo secundario contra la misma tras la primera fractura vertebral en un período de seguimiento de diez años. Métodos. Se realiza un estudio de cohortes clínicas retrospectivas de un total de 77 mujeres con fractura vertebral osteoporótica no quirúrgica con un tiempo de seguimiento de diez años. Como variable dependiente se considera el riesgo de refractura y como variables independientes la edad al ingreso, el número de fracturas vertebrales osteoporóticas, los cambios en la actividad de la vida, el dolor de espalda, el tratamiento, el tratamiento previo con corticoides, las benzodiacepinas o psicotrópicos, el tabaco, el consumo de alcohol, el déficit estrogénico, el peso, la vida sedentaria, el déficit visual, la patología tiroidea y la dificultad para levantarse de la silla. Resultados. El riesgo de nueva fractura vertebral o no vertebral a los 10 años tras la primera fractura es del 26%. Al comparar los riesgos de refractura atendiendo las características epidemiológicas, observamos que el porcentaje de refracturas aumenta con respecto al número de fracturas vertebrales en el primer episodio, siendo del 21,4% en el caso de una fractura vertebral, del 25,4% en el caso de dos fracturas vertebrales y del 50% cuando se trata de tres. La mayoría de las fracturas ocurren tras accidentes dentro de la rutina de la vida diaria. Sin embargo, no todos los pacientes experimentan un restablecimiento completo tras la fractura, ya que alrededor del 35% de estos enfermos sufren síntomas persistentes. Conclusiones. Los factores relacionados estadísticamente con la refractura son la edad mayor de 70 años, la deprivación de estrógenos y la dificultad para levantarse de la silla. Las pacientes que han recibido tratamiento frente a la osteoporosis tras la primera fractura vertebral tienen menos riesgo de refractura (odds ratio [OR]: 0,32) con respecto al grupo que no ha recibido tratamiento alguno frente a la osteoporosis(AU)

Objectives. This study has aimed to study the epidemiological characteristics of non-surgical osteoporotic vertebral fractures in women and the possible relationship existing between refracture and the existence or non-existence of secondary preventive treatment against it after the first vertebral fracture in a 10-year follow-up period. Methods. A clinical retrospective study of cohorts of a total of 77 women with non-surgical osteoporotic vertebral fracture with a 10-year follow-up period was performed. The dependent variable was considered to be risk of refracture and independent variables as age on admission, number of osteoporotic vertebral fractures, changes in life activity, back pain, treatment, previous treatment with corticosteroids, benzodiazepines or psychotropics, tobacco, alcohol consumption, estrogen deficit, weight, sedentary lifestyle, visual deficit, thyroid disease and difficulty getting up from the chair. Results. The risk of a new vertebral or non-vertebral fracture at 10 years after the first fracture is 26.0%. When the risks of refracture are compared according to the epidemiological characteristics, we observe that the percentage of refractures increases in regards to the number of vertebral fractures in the first episode, this being 21.4% in the case of one vertebral fracture, 25.4% in the case of two vertebral fractures and 50% when there are three vertebral fractures. Most of the fractures occur after accidents within the daily life routine. However, not all the patients have complete restablishment after the fracture, since approximately 35% of these patients suffer persistent symptoms. Conclusions. The factors that are statistically related with refracture are age over 70 years, estrogen deprivation and difficulty getting out of the chair. Patients who received treatment for osteoporosis after the first vertebral fracture have a lower risk of refracture (OR of 0.32) in regards to the group that did not receive any treatment for osteoporosis(AU)

Fractura abierta del antebrazo con pérdida de sustancia ósea por airbag en un niño de 12 años / Airbag-induced open forearm fracture with bone loss in a 12-year-old child

Objetivo: Se presenta una lesión poco frecuente en un pasajero de edad pediátrica y su mecanismo de acción. Caso clínico: Varón de 12 años que viajaba en el asiento delantero derecho en un vehículo todoterreno que se vio involucrado en un accidente de circulación, y por el que sufrió una fractura abierta grado IIIB del cúbito y el radio derechos con pérdida de sustancia ósea de éste último. Discusión: No se conoce otro caso similar que se haya publicado en la bibliografía médica. La lesión que se presenta es infrecuente en un pasajero de un vehículo y excepcional en pacientes de edad pediátrica. Conclusiones: El despliegue del airbag puede salvar una vida, pero es un acontecimiento violento que pone en riesgo la vida de los niños. La posibilidad de tener lesiones por airbag no se debe infravalorar; deben adoptarse las medidas oportunas, además de investigar más profundamente el tema para evitar estas lesions (AU)

Purpose: To report on an unusual type of injury for a pediatric patient and describe its probable mechanism. Clinical case: A 12-year old male traveling in the right front seat of a 4-wheel drive vehicle that was involved in a road accident and sustained an open grade IIb right ulna and radius fracture with bone loss in the latter. Discussion: We do not know of any other case like this in the literature. The injury we present is not only unusual for a passenger in a vehicle, but is – in our view – also exceptional in pediatric patients. Conclusions: Life-saving as it can be, airbag deployment is a violent occurrence that can threaten a child's life. The possibility of sustaining airbag-induced injuries must not be underestimated. Such injuries should be prevented by taking appropriate prevention measures and by conducting further research into the subject (AU)

Tratamiento de la fractura y luxación de la articulación sacroilíaca mediante un acceso anterior extraperitoneal / Treatment of iliosacral joint fracture dislocations by means of an extraperinoneal approach

Objetivo: Valorar los resultados del tratamiento de las fracturas del ala ilíaca con afectación de la articulación sacroilíaca mediante una reducción abierta y una fijación interna con placas a través de abordaje anterior extraperitoneal de la articulación sacroilíaca. Material y método: Se han revisado las fracturas de pelvis tratadas en el hospital y se han recogido los datos epidemiológicos de aquéllas en las que el patrón de lesión posterior correspondía a una fractura que alcanzaba la articulación sacroilíaca. En los 14 casos incluidos en el estudio se realizó la valoración funcional según la escala de Majeed y la valoración radiológica según la clasificación propuesta por Matta. Resultados: Al realizar la valoración funcional, en 8 casos se consiguió un resultado excelente, en 5 casos se consiguió un resultado bueno y sólo en un caso el resultado fue malo. De acuerdo con la valoración radiológica postoperatoria, la reducción fue excelente en 10 casos y fue buena en los 4 casos restantes. No se produjo ninguna pérdida de reducción ni complicaciones mayores. Conclusiones: La técnica descrita confiere suficiente estabilidad para la consolidación de las fracturas y su incidencia de complicaciones es pequeña. Se indica especialmente en los sujetos politraumatizados a los que se desaconsejan posiciones distintas al decúbito supino, cuando hay compromiso de partes blandas posteriores y en aquellos casos en que se precisa realizar una reducción abierta de la fractura (AU)

Purpose: To assess the outcome of addressing iliac wing fractures with involvement of the iliosacral joint by means of open reduction and internal fixation (ORIF) with plates, using an anterior extraperitoneal approach. Materials and methods: We reviewed pelvic fractures treated in our hospital, collecting epidemiological data of those with a posterior injury pattern that corresponded to a fracture affecting the iliosacral joint. For all 14 cases included in the study, we carried out a functional assessment according to the Majeed scale, as well as a radiological evaluation according to the Matta classification. Results: The functional assessment revealed that an excellent result was achieved in 8 cases and a good result in 5. A poor outcome was obtained in one single case. According to the postoperative radiological evaluation, reduction was excellent in 10 cases and good in the remaining 4. There was no loss of reduction or any major complications. Conclusions: The technique described in our paper affords sufficient stability for fracture healing and it is associated with a low incidence of complications. It is especially indicated for multiple-trauma patients where the only position recommended in the supine one, for cases where the posterior soft tissues are compromised, and for instances when an open reduction of the fracture is needed (AU)