Fractura de cadera en adultos mayores: Impacto del tratamiento quirúrgico oportuno en la morbimortalidad / Hip Fracture in Elderly Patients: The Impact of Timely Surgical Treatment in Morbimortality

Resumen Introducción Las fracturas de cadera comprenden las regiones de la cabeza, el cuello femoral y la región intertrocantérica. Son una de las causas de morbilidad y mortalidad más importantes en adultos mayores y afectan el equilibrio físico, mental, funcional y social de estos pacientes. Hasta 50% de los pacientes con fractura de cadera, muere en los primeros 6 meses posteriores a la lesión y un gran número de los que sobrevive no recupera su nivel previo de independencia y funcionalidad. La pronta solución quirúrgica disminuye la mortalidad y las complicaciones; cada dos días de espera quirúrgica duplica el riesgo de muerte. Caso clínico Paciente del sexo femenino, de 74 años, que cayó desde su propio plano de sustentación, a consecuencia de lo cual presentó incapacidad para la marcha y dolor progresivo a nivel de cadera derecha. Acudió al servicio de ortopedia para ser valorada 42 días después de la caída. A la exploración física ortopédica: El miembro pélvico derecho en actitud de rotación externa y acortamiento de 1 cm; los arcos de movilidad de cadera, limitados por dolor; la fuerza por grupos musculares no se valoró debido al dolor. Se le realizó radiografía anteroposterior (AP) de pelvis, en la que se observó un trazo simple a nivel subcapital en la cadera derecha. 52 días después de la caída, se le realizó una artroplastia total de cadera derecha. Conclusiones La fractura de cadera es una patología común en pacientes ancianos, y se relaciona con alta morbimortalidad. Es imprescindible un manejo temprano, disminuir el riesgo de complicaciones y la mortalidad.

Abstract Introduction Hip fracture, may occur in the femoral head, neck or in the intertrochanteric line. It is one of the most important causes of morbidity and mortality in elderly patients and it affects the physical, mental, functional and social equilibrium of these patients. Up to 50% of patients with hip fracture die in the first six months after the injury and many those who survive don´t recover their previous level of independence and functionality. Early surgical resolution diminishes mortality and complications. Every two days that the surgery is postponed doubles the risk of death. Case report study A 74-year-old female patient who presented a fall from her own height, is rendered incapable of walking and presents progressive pain in her right hip. She consults an orthopedic doctor for examination 42 days after the fall. Physical examination: right pelvic lower limb with an external rotation and a 1 cm shortness, hip mobility arches limited by pain. Muscle group strength was not examined because of the pain. An AP x-ray of the pelvis was performed that showed a simple trace at subcapital level on the right hip. A total arthroplasty of the right hip was performed 52 days after the patient's fall. Conclusions Hip fracture is a common problem in elderly patients and is associated with a high morbimortality. It is important to handle these cases early to diminish the risk of complications and mortality.

Fractura de cadera: un reto multidisciplinario. Reporte de caso de una víctima del sismo del 19 de septiembre de 2017 / Hip fracture: a multi-disciplinary challenge. Case report from a victim on the September 19, 2017 earthquake

Resumen Introducción La fractura de cadera es la solución de continuidad ósea en la región de la cabeza, cuello o a nivel de trocánter mayor y menor de la cadera. Se estima que 50% de estas afectan el cuello del fémur, 80% se dan en mujeres y estas ocurren principalmente en adultos mayores de 55 años. Es importante recalcar que esta patología tiene un 20-30% de mortalidad dentro del primer año posterior a la lesión, y que más del 50% será incapaz de reincorporarse a sus actividades de la vida cotidiana1. La mayoría de los pacientes que la padecen presenta una patología sistémica asociada (siendo las más frecuentes enfermedades cardiovasculares, enfermedades respiratorias, diabetes mellitus, déficit sensoriales o neurológicos, problemas de movilidad o equilibrio, desnutrición y demencia). Presentación del caso clínico Mujer de 22 años con antecedente de DM Tipo I diagnosticada a los 10 años, tuberculosis pulmonar diagnosticada en diciembre de 2016 en tratamiento y desnutrición; quien sufrió caída de su propia altura e inició con dolor y limitación del movimiento de la pierna del lado derecho. A la exploración física dirigida: miembro pélvico derecho con arcos de movilidad de cadera limitados con dolor a nivel de trocánter mayor, presencia de acortamiento clínico de aproximadamente 2 cm y en rotación externa. Se le realizó radiografía AP de pelvis donde se observó un trazo simple a nivel transtrocantérico y fragmentación del trocánter menor. Se le realizó reducción cerrada fijación interna con PBM de tutor, más protección con clavo centromedular para fémur proximal PF 110 × 75 y se interconsulta al servicio de medicina interna, psiquiatría, nutrición y rehabilitación del hospital. Conclusiones Las fracturas de cadera son una patología con un elevado índice de morbimortalidad en un periodo de un año posterior a la lesión. Requieren un abordaje quirúrgico inmediato y un enfoque multidisciplinario para disminuir esta incidencia. El objetivo tras el tratamiento es conseguir el nivel de independencia y de deambulación previos.

Abstract Introduction The hip fracture is the bone continuity solution in the head, neck or at the level of the greater and lesser trochanter of the hip. Aproximately, 50% of the fractures affect the neck of the femur, 80% occur in women and they occur mainly in adults over 55 years old. It's important to emphasize that this pathology has a 20-30% mortality within the first year after the injury and more than 50% will be unable to rejoin their daily activities1. The majority of patients who suffer from it have an associated systemic pathology (the most frequent being cardiovascular diseases, respiratory diseases, diabetes mellitus, sensory or neurological deficits, mobility or balance problems, malnutrition and dementia). Case report study 22-year-old female with a history of DM Type I diagnosed at age 10, in treatment for a pulmonary tuberculosis diagnosed in December of 2016, and malnutrition. She suffered a fall, starting with pain and limited movement in the leg on the right side. On the directed physical examination: right pelvic member with limited hip arc movement with pain at the level of greater trochanter, presenting clinical shortening of approximately 2 cm and in external rotation of the leg. An AP pelvis radiography was performed where a simple trace at the transtrochanteric level and fragmentation of the lesser trochanter was observed. A closed reduction with internal fixation with an intramedullary nail for proximal femur PF 110 × 75 was performed and was channeled to interconsultation to the departments of internal medicine, psychiatry, nutrition and rehabilitation of the hospital. Conclusions Hip fractures are a pathology with a high rate of morbidity and mortality in a period of one year after the injury. They require an immediate surgical solution and a multidisciplinary approach to reduce the incidence of complications. The objective after the treatment is to achieve the same amount of independence and ambulation as before the injury.

[High tibial dome osteotomy complications in genu varum patients]. / Complicaciones en pacientes con osteotomía tibial proximal alta en domo por genu varo.

OBJECTIVE: To identify if pre-surgical risk factors or the surgical technique were associated with the complications of the osteotomy in genu varus patients. METHODOLOGY: A case-control study was conducted in patients that underwent Maquet proximal tibial osteotomy for treatment of genu varus between January and December 2003. The risk factors were the following: age 50 or more years old, comorbidity such as type 2 diabetes, hypertension, rheumatoid arthritis, overweight and obesity (BMI > or = 25 and > or = 30), duration of ischemia longer than 60 min and local pain. Cases were those who developed one or more complications. Descriptive and inferential statistical analyses were performed. RESULTS: One hundred and thirty-four patients were included, among which 53% had complications. None of the risk factors were statistically significant (p > 0.05). CONCLUSIONS: None of pre-surgical risk factors were associated with the complications of osteotomy; therefore, these could be attributable to the surgical technique. It is necessary to outweigh the temporary benefits of the tibial osteotomy versus the increase in the risk of complications when performing total knee arthroplasty.

Complicaciones en las fracturas complejas de la meseta tibial y factores asociados / Complications in complex fractures of the tibial plateau and associated factors

Objetivo: identificar factores asociados a complicaciones con el manejo quirúrgico de las fracturas complejas de la meseta tibial. Material y métodos: estudio de casos y controles. Muestra integrada con expedientes de 56 pacientes diagnosticados con fractura compleja de la meseta tibial (tipos IV, V y VI de Schatzker), tiempo de seguimiento promedio de 12.9 ± 3.2 meses (8 a 18), y con uno o más de los siguientes factores de riesgo: edad mayor de 50 años, comorbilidad, tiempo de isquemia mayor de 60 minutos y fractura tipo IV, V o VI. Se consideró caso al paciente que presentara una o más complicaciones. Resultados: la edad promedio fue de 50.1 ± 15.7 años (17 a 87); 35 pacientes (62.5 %) pertenecieron al sexo masculino. Los pacientes con o sin complicaciones mostraron homogeneidad respecto a edad, sexo, lado, tipo de fractura y tiempo de seguimiento; 41.1 % presentó antecedentes patológicos. En todos los procedimientos se utilizó torniquete neumático. El tiempo promedio de cirugía fue de 91 ± 27.2 minutos (40 a 175). Los tratamientos empleados fueron placa más tornillos (53.6 %), fijadores externos más tornillos (35.7 %), doble placa y clavo centromedular. 37.5 % desarrolló complicaciones: infección superficial, 16.1 %; deformidades angulares residuales, 10.7 % (varo, 7.1 %); lesión del nervio peroneo, 5.4 %, pseudoartrosis, 3.5 %; trombosis venosa profunda, 1.8 %. Presentó más de una complicación, 22.2 %. Conclusiones: los factores de riesgo asociados significativamente a complicaciones con el manejo de la fractura compleja de la meseta tibial, fueron la edad mayor de 60 años y el tiempo de isquemia transoperatoria mayor de 120 minutos. Los pacientes en estas condiciones presentaron tres veces más riesgo para desarrollar complicaciones.

BACKGROUND: We undertook this study to identify factors associated with surgical complications of complex fractures of the tibial plateau. METHODS: We designed a case-control study with 56 patients with a diagnosis of complex fracture in the tibial plateau (IV-VI Schatzker) and with 12.9 +/- 3.2 (8-18) months of follow-up. Risk factor exposure was defined as having one or more of the following characteristics: age >60 years; co-morbidity (diabetes mellitus, systemic arterial hypertension); time of [quot ]Kidde[quot ] (>60, >90, >120 min) and fracture type IV, V or VI. A case was considered with one or more complications. Results: Mean age was 50.1 +/- 15.7 (17-87) years old; 35 patients (62.5%) were males. Homogeneity between groups was shown for age, sex, side effects, type of fracture and time of follow-up; 41.1% of patients had pathological history. All surgeries used pneumatic compression (Kidde) for 91 +/- 27.2 (40-175) min. The implants used were plate plus cancellous screws (53.6%), external fixators plus cancellous screws (35.7%), double plate and intramedullary nail. Complications appeared in 37.5% of all patients. Complications reported were superficial infection (16.1%), residual angular deformities (10.7%, varum [7.1%]), peroneal nerve injury (5.4%), non-union (3.5%) and deep venous thrombosis (1.8%); 22.2% of all patients presented more than one complication. CONCLUSIONS: Statistically significant risk factors were age >60 years and pneumatic compression >120 min. Patients with one of these characteristics had a three-times risk of complications. No association was demonstrated between type of fracture, surgical treatment, time between injury and the surgery, with development of complications.

[Complications in complex fractures of the tibial plateau and associated factors]. / Complicaciones en las fracturas complejas de la meseta tibial y factores asociados.

BACKGROUND: We undertook this study to identify factors associated with surgical complications of complex fractures of the tibial plateau. METHODS: We designed a case-control study with 56 patients with a diagnosis of complex fracture in the tibial plateau (IV-VI Schatzker) and with 12.9 +/- 3.2 (8-18) months of follow-up. Risk factor exposure was defined as having one or more of the following characteristics: age >60 years; co-morbidity (diabetes mellitus, systemic arterial hypertension); time of "Kidde" (>60, >90, >120 min) and fracture type IV, V or VI. A case was considered with one or more complications. RESULTS: Mean age was 50.1 +/- 15.7 (17-87) years old; 35 patients (62.5%) were males. Homogeneity between groups was shown for age, sex, side effects, type of fracture and time of follow-up; 41.1% of patients had pathological history. All surgeries used pneumatic compression (Kidde) for 91 +/- 27.2 (40-175) min. The implants used were plate plus cancellous screws (53.6%), external fixators plus cancellous screws (35.7%), double plate and intramedullary nail. Complications appeared in 37.5% of all patients. Complications reported were superficial infection (16.1%), residual angular deformities (10.7%, varum [7.1%]), peroneal nerve injury (5.4%), non-union (3.5%) and deep venous thrombosis (1.8%); 22.2% of all patients presented more than one complication. CONCLUSIONS: Statistically significant risk factors were age >60 years and pneumatic compression >120 min. Patients with one of these characteristics had a three-times risk of complications. No association was demonstrated between type of fracture, surgical treatment, time between injury and the surgery, with development of complications.

The Amerindian's genes in the Mexican population are associated with development of gallstone disease.

BACKGROUND: It has been suggested that genes related to Amerindian ancestry account for the high prevalence of gallstone disease (GD) observed in Mexican-Americans. The HLA-B39 is an allele found in higher frequency in Amerindians whereas HLA-B15 is rarely found. The aim of this study was to test the hypothesis that gallstone susceptibility genes are more prevalent in Mexicans with recent Amerindian ancestry. METHODS: We carried out a prospective case-controlled study. Subjects were divided into those who had stones visible on gallbladder ultrasound (cases), and those whose ultrasounds were negative for gallstones (controls). Body mass index (BMI) was calculated, and serum lipids and lipoprotein, and glucose levels were measured. Class I HLA (HLA-B) typing was performed by PCR amplification of genomic DNA. RESULTS: Of the 1,101 subjects, 146 were classified as subjects with GD (cases) and 955 as subjects without GD (controls). Mean age of the cases was 53.5 +/- 12.5 yr versus 44.78 +/- 12.0 yr for the controls, p= 0.001. A family history of GD was observed in 48% of the cases versus 28.4% of the controls, p= 0.001. HLA-B39 was more frequently increased in GD subjects (0.162), compared with controls (0.063), p= 0.008. The odds ratio of having HLA-B39 was 2.8 and 95% (CI 95%= 1.3-6.3) for GD; HLA-B15 was more frequently increased in controls than in cases. CONCLUSIONS: The most prevalent HLA alleles detected in these GD cases are characteristic of Amerindian populations, supporting the role of genetics in the high prevalence of the development of GD in Mexican mestizos.

Plasma leptin and the cholesterol saturation of bile are correlated in obese women after weight loss.

Increased cholesterol secretion is a major alteration of biliary function in obese subjects Leptin is a regulator of food intake and is increased in plasma of subjects with low energy expenditure and high adiposity. We investigated the relationship between leptin and the cholesterol saturation of bile in obese women before and after weight reduction by energy restriction (5.02 MJ/d). We studied women (n = 14) with a body mass index (BMI) > or = 30 kg/m(2) who were 35.4 +/- 2.3 y old and who did not have a history of gallstones. They were studied by ultrasound to ensure absence of stones or sludge. BMI, gallbladder bile composition, plasma leptin, serum lipids and lipoproteins cholesterol levels were recorded at baseline and after 6 wk of weight reduction. There were decreases in BMI (33.9 +/- 3.1 to 31.1 +/- 3.6 kg/m(2), P < 0.0001) and leptin levels (16.7 +/- 9.7 to 10.0 +/- 6.7 micro mol/L, P < 0.05) during weight loss. After the experimental period, there were positive correlations between plasma leptin levels and BMI (r = 0.71, P < 0.004); leptin levels and the cholesterol saturation index (CSI) (r = 0.53, P < 0.05); the CSI and LDL cholesterol (r = 0.73, P < 0.003); and negative correlations between leptin levels and HDL cholesterol (r = -0.54, P < 0.05) and LDL cholesterol (r = -0.57, P < 0.03). We have shown relationships among HDL cholesterol, CSI and leptin. This could be useful in understanding the pathophysiology of cholesterol gallstone formation in obese people.