Dehiscencia de herida quirúrgica y exposición material de osteosíntesis. ¿Infección segura? / Surgical wound dehiscence and exposed hardware. Infection foretold?

Resumen: Introducción: la dehiscencia de herida quirúrgica con exposición de material de fijación interna es un grave problema en cirugía ortopédica y un factor importante de infección. Objetivo: descripción del caso inusual de un paciente adulto con dehiscencia de la herida quirúrgica y exposición completa de 20 cm de largo de una placa de cúbito tras seis años de la cirugía, sin signos de infección, consolidación ósea y reepitelización debajo de la placa y adherida al hueso. Caso clínico: hombre de 39 años que sufrió una fractura-luxación de Monteggia, abierta grado II y multifragmentaria. El paciente tenía historia de drogodependencia en tratamiento con metadona. Fue tratado con fijación interna del cúbito mediante una placa de reconstrucción larga. Postoperatoriamente, el paciente dejó de acudir para evaluación. A los seis años de la cirugía presentaba una completa exposición de la placa (20 cm de longitud), sin signos de infección y consolidación con malalineación de la fractura. Tras el retiro de la placa se observó epitelización espontánea adherida al lecho óseo cubital. La cobertura cutánea fue completa a los dos meses. Conclusión: aunque inusual, es posible la consolidación ósea y la ausencia de infección en una fractura abierta con exposición de larga evolución de una placa de antebrazo en el adulto.

Abstract: Introduction: surgical wound dehiscence with exposure of internal fixation material is a serious problem in orthopedic surgery and an important factor for infection. Objective: presentation of an unusual case of an adult patient with surgical wound dehiscence and complete exposure of 20 cm of the ulnar plate after six years of surgery, without infection signs, with bone healing and skin behind the plate. Case presentation: 39-year-old man with an open Gustilo II Monteggia fracture-dislocation multifracture. The patient had a history of drug dependence. He had an open reduction and internal fixation with an ulnar reconstruction plate. The patient did not have any follow-up. After six years of the surgery, there was a complete exposure of the plate (20 cm) without infection and healing of the fracture with misalignment. After removing the plate, we observed spontaneous epithelialization attached to the bone bed. Skin coverage was complete at two months. Conclusion: although unusual, bone consolidation without infection is possible in an open fracture with long-standing exposure to a forearm plate in the adult.

[Surgical wound dehiscence and exposed hardware. Infection foretold?] / Dehiscencia de herida quirúrgica y exposición material de osteosíntesis. ¿Infección segura?

INTRODUCTION: surgical wound dehiscence with exposure of internal fixation material is a serious problem in orthopedic surgery and an important factor for infection. OBJECTIVE: presentation of an unusual case of an adult patient with surgical wound dehiscence and complete exposure of 20 cm of the ulnar plate after six years of surgery, without infection signs, with bone healing and skin behind the plate. CASE PRESENTATION: 39-year-old man with an open Gustilo II Monteggia fracture-dislocation multifracture. The patient had a history of drug dependence. He had an open reduction and internal fixation with an ulnar reconstruction plate. The patient did not have any follow-up. After six years of the surgery, there was a complete exposure of the plate (20 cm) without infection and healing of the fracture with misalignment. After removing the plate, we observed spontaneous epithelialization attached to the bone bed. Skin coverage was complete at two months. CONCLUSION: although unusual, bone consolidation without infection is possible in an open fracture with long-standing exposure to a forearm plate in the adult.

INTRODUCCIÓN: la dehiscencia de herida quirúrgica con exposición de material de fijación interna es un grave problema en cirugía ortopédica y un factor importante de infección. OBJETIVO: descripción del caso inusual de un paciente adulto con dehiscencia de la herida quirúrgica y exposición completa de 20 cm de largo de una placa de cúbito tras seis años de la cirugía, sin signos de infección, consolidación ósea y reepitelización debajo de la placa y adherida al hueso. CASO CLÍNICO: hombre de 39 años que sufrió una fractura-luxación de Monteggia, abierta grado II y multifragmentaria. El paciente tenía historia de drogodependencia en tratamiento con metadona. Fue tratado con fijación interna del cúbito mediante una placa de reconstrucción larga. Postoperatoriamente, el paciente dejó de acudir para evaluación. A los seis años de la cirugía presentaba una completa exposición de la placa (20 cm de longitud), sin signos de infección y consolidación con malalineación de la fractura. Tras el retiro de la placa se observó epitelización espontánea adherida al lecho óseo cubital. La cobertura cutánea fue completa a los dos meses. CONCLUSIÓN: aunque inusual, es posible la consolidación ósea y la ausencia de infección en una fractura abierta con exposición de larga evolución de una placa de antebrazo en el adulto.

Concomitant low back pain impairs outcomes after primary total knee arthroplasty in patients over 65 years: a prospective, matched cohort study.

INTRODUCTION: Knee osteoarthritis and low back pain (LBP) are two conditions with relatively high prevalence in patients over 65 years. The objective was to determine the effect of symptomatic LBP on the patient-reported outcome after primary TKA. MATERIAL AND METHOD: A cohort of 48 patients with concomitant LBP was prospectively matched 1:2 with patients without LBP for gender, age, body mass index and preoperative knee function. LBP severity was measured with the Oswestry Disability Index (ODI). Patient-reported outcomes were assessed with reduced Short-Form (SF12), Western Ontario and McMaster Universities score (WOMAC), and visual analogue scale (VAS) for satisfaction. Functional outcome was assessed with the Knee Society Scores (KSS). RESULTS: The mean postoperative follow-up was 3.2 years. At last follow-up, LBP cohort had significantly worse SF12, WOMAC, KSS and VAS scores than those patients without LBP. Preoperative ODI score was significantly correlated with outcomes. CONCLUSION: Worse functional and patient-reported outcomes were obtained in patients over 65 years with concomitant LBP, and this was related to the intensity of preoperative LBP. Despite successful outcome in the knee, the LBP usually remains after TKA and this may impair satisfaction and patient-reported outcomes. These patients should be properly informed about their potential outcomes.

Early rehospitalization after hip fracture in elderly patients: risk factors and prognosis.

INTRODUCTION: Hip fracture usually occurs in older patients. These patients remain at risk for developing new medical complications even after discharge from the hospital. The objective of this study was to identify risk factors for hospital readmission 30 days after hip fracture and the prognosis of the readmitted patients. MATERIALS METHODS: A prospective, observational cohort study of 732 consecutive patients over 65 years surgically treated for hip fracture and discharged alive in 2010-2014 was conducted. The measurements were patient demographic characteristics, residential and discharge status, Katz Index, Merle D'aubigné Hip Score, Mini-Mental Test, comorbid conditions, Charlson Index, ASA group, type of fracture and repair, and postoperative complications. Patient characteristics were tested by bivariate and multivariate analyses. RESULTS: 8.3 % of patients were readmitted within 30 days (56.0 % of these within 2 weeks). Medical reasons were 13 times more frequent than surgical reasons. Diagnoses more prevalent for readmission were pulmonary disease, deep vein thrombosis, heart failure, and renal failure. Predictors of readmission were female gender (HR 1.9, 95 % CI 1.1-3.4), grade III-IV ASA (HR 2.1, 95 % CI 1.1-4.2), and pre-existing pulmonary disease (HR 5.3, 95 % CI 3.4-9.6). In-hospital mortality among readmitted patients was 22.9 %. In bivariate analyses, male gender, ASA III-IV, cognitive impairment, and more than two comorbidities were potential predictive factors for readmission, and in multivariate analysis only male gender and ASA III-IV. Mortality risk among readmitted patients was significantly higher compared to the in-hospital mortality in the overall cohort (OR 1.8, 95 % CI 1.5-2.3). CONCLUSIONS: Hospital readmissions after hip fracture were mainly due to medical complications and a fraction of these may be preventable. Readmission was associated with increased morbidity and mortality.

Prognostic factors of health-related quality of life in patients after tibial plafond fracture. A pilot study.

BACKGROUND: Tibial plafond fractures are a uncommon injury, and the outcomes described in literature are generally poor. The purposes were to determine the effect of the tibial plafond fractures on general health-related quality of life, and to examine the factors that influence these outcomes. METHODS: Retrospective study of 43 patients with average age of 45.6 (range 18-69) years who were also invited for a clinical and radiological reassessment. The primary outcome measure was quality of life assessed by the Short Form-36 questionnaire. Visual analogue scale for pain, and motion of both ankle and subtalar joints were also assessed. Radiological evaluation was performed to assess bone healing, fracture reduction quality, and tibial alignment. RESULTS: The mean follow-up at last visit was 8.1 (range, 4-12) years. Patients who had suffered plafond fracture had significantly poorer quality of life compared with age- and gender-matched general population of our country regardless of the treatment method used. Multivariate analyses showed that the age had influence on the emotional outcomes, educational level and fracture pattern on physical outcomes, and marital status, fracture reduction quality, and ankle motion on both physical and mental component summaries. CONCLUSION: Tibial plafond fractures have a significant negative impact on general health-related quality of life regardless of the operative treatment used which reflects injury severity. In addition, psychosocial characteristics of patients may influence the outcomes.

Debridement with prosthesis retention and antibiotherapy vs. two-stage revision for periprosthetic knee infection within 3 months after arthroplasty: a case-control study.

Sixty-four patients with periprosthetic infection within 3 months of index arthroplasty, of whom 39 underwent debridement with prosthesis retention and antibiotherapy (DPRA), and 25 underwent two-stage revision (2SR), were compared regarding control of infection and functional outcomes by use of Knee Society scores. Failure was defined as the need for subsequent surgery to control infection. The failure rate after DPRA was 61.5%, and that after 2SR was 12.0% (p 0.001). The failure risk was not significantly associated with the duration of symptoms (≤4 weeks). The only predictor of failure was isolation of Staphylococcus aureus or Staphylococcus epidermidis. Treatment with 2SR required fewer surgical operations, a shorter duration of hospitalization, and a shorter duration of treatment. All patients who required a second debridement ultimately underwent prosthesis removal. The functional outcome was significantly better for 2SR at the last follow-up.

Artrodesis sin fusión ósea con clavo modular intramedular para revisión de prótesis total de rodilla infectada / Arthrodesis without bone fusion with an intramedullary modular nail for revision of infected total knee arthroplasty

Objetivo. Evaluar los resultados de la fijación de rodilla sin fusión ósea, con clavo intramedular e interposición de cemento. Material y métodos. Estudio retrospectivo de 29 prótesis total de rodilla infectadas con datos recogidos prospectivamente y seguimiento medio de 4,2 años (3-5). Resultados. Las complicaciones fueron 2 infecciones recurrentes, una fractura periimplante y una erosión cortical en la punta del componente femoral, siendo todas revisadas con buen resultado. La dismetría media fue 0,8 cm, con 24 < 1 cm. Veinticinco pacientes no referían dolor. El valor medio de WOMAC-dolor fue 86,9, WOMAC-función 56,4, SF12-físico 45,1, y SF12-mental 53,7. Cuatro pacientes precisaron andador y solo 2 eran dependientes para actividades diarias. Conclusiones. El clavo Endo-Model Link® es un efectivo método de fijación de rodilla, restaurando la alineación del miembro y adecuada longitud del mismo (AU)

Objective. To evaluate the outcome of knee fixation without bone fusion using an intramedullary modular nail and interposed cement. Material and methods. Retrospective study of 29 infected total knee arthroplasties with prospective data collection and a mean follow-up of 4.2 years (3-5). Results. Complications included 2 recurrent infections, 1 peri-implant fracture, and 1 cortical erosion due to the tip of the femoral component. All of these were revised with successful results. The mean limb length discrepancy was 0.8 cm, with 24 < 1 cm. Twenty-five patients reported no pain. The mean WOMAC-pain was 86.9, WOMAC-function 56.4, SF12-physical 45.1, and SF12-mental 53.7. Four patients needed a walking frame, and only two were dependent for daily activities. Conclusions. The Endo-Model Link nail is an effective method for knee fixation that restores the anatomical alignment of the limb with adequate leg length (AU)

[Arthrodesis without bone fusion with an intramedullary modular nail for revision of infected total knee arthroplasty]. / Artrodesis sin fusión ósea con clavo modular intramedular para revisión de prótesis total de rodilla infectada.

OBJECTIVE: To evaluate the outcome of knee fixation without bone fusion using an intramedullary modular nail and interposed cement. MATERIAL AND METHODS: Retrospective study of 29 infected total knee arthroplasties with prospective data collection and a mean follow-up of 4.2 years (3-5). RESULTS: Complications included 2 recurrent infections, 1 peri-implant fracture, and 1 cortical erosion due to the tip of the femoral component. All of these were revised with successful results. The mean limb length discrepancy was 0.8 cm, with 24<1cm. Twenty-five patients reported no pain. The mean WOMAC-pain was 86.9, WOMAC-function 56.4, SF12-physical 45.1, and SF12-mental 53.7. Four patients needed a walking frame, and only two were dependent for daily activities. CONCLUSIONS: The Endo-Model Link nail is an effective method for knee fixation that restores the anatomical alignment of the limb with adequate leg length.

Sistema pedicular de estabilización dinámica. Resultados funcionales y complicaciones del implante en pacientes con enfermedad degenerativa discal lumbar, tras un seguimiento mínimo de 4 años / Pedicular dynamic stabilization system. Functional outcomes and implant-related complications for the treatment of degenerative lumbar disc disease with a minimum follow-up of 4 years

Introducción: El sistema de estabilización Dynesys® es un sistema pedicular de estabilización dinámica sin fusión. El objetivo de nuestro estudio es evaluar los resultados clínicos en pacientes con enfermedad degenerativa discal y/o estenosis, así como medir la prevalencia de aflojamiento de tornillos tras 4 años de seguimiento. Material y métodos: Se trata de un estudio de serie de casos retrospectivo donde fueron incluidos todos los pacientes intervenidos desde enero a diciembre de 2008 con Dynesys®. Se indicó la cirugía si presentaban dolor lumbar de más de 6 meses de evolución y una RM positiva para enfermedad degenerativa discal y/o estenosis. Resultados: Veintidós pacientes (11 mujeres y 11 varones) con una edad media de 44,40 ± 11 años fueron evaluados. Veinte pacientes (91%) recibieron el implante Dynesys® sin ninguna maniobra de descompresión asociada. La evaluación del dolor de espalda y piernas (0-10 mm) registró una disminución media de 2,4 ± 2,06 mm (p = 0,0001). El valor preoperatorio del índice de discapacidad de Oswestry fue de 52,36 ± 16,56% (limitación funcional severa). Tras la cirugía este valor fue de 34,27 ± 17,87% (limitación funcional moderada) con una disminución de 18,09 ± 16,03% (p = 0,001). Cuatro pacientes (18%) mostraron signos de aflojamiento de tornillos. Un paciente (4,5%) presentó rotura de tornillo. Conclusiones: La cirugía con Dynesys® muestra resultados clínicos favorables, sin embargo el rango de mejoría en nuestra serie es menor a los comunicados por otros autores. Estudios comparativos entre Dynesys® y descompresión deberían realizarse para poder aislar el beneficio de la estabilización dinámica del obtenido por la descompresión. Las complicaciones relacionadas con el implante no son infrecuentes (AU)

Introduction: The Dynesys® system is a non-fusion pedicular dynamic stabilization system. The aim of our study is to evaluate the clinical outcomes in patients with degenerative disc disease and/or stenosis, and to measure the prevalence of screw loosening and breakage after 4 years of follow up. Material and methods: All patients who underwent surgery with Dynesys® system in 2008 were reviewed. The surgery was performed in cases of low back pain of more than 6 months duration and a positive MRI for degenerative disc disease and/or stenosis. Results: A total of 22 patients (11 females, 11 males) with a mean age of 44.40 ± 11 years were included, 20 patients (91%) underwent Dynesys® without any associated decompression maneuver. The evaluation of back and leg pain (0–10 mm) showed a mean decrease of 2.4 ± 2.06 mm (P = .0001). The preoperative value of the Oswestry disability index was 52.36 ± 16.56% (severe functional limitation). After surgery, this value was 34.27 ± 17.87% (moderate functional limitation) (P = .001) with a decrease of 18.09 ± 16.03% (P = .001). A total of 4 (18%) patients showed signs of loosening screws. One patient (4.5%) had a screw breakage. Conclusions: Surgery with Dynesys® shows favorable long term clinical results, however the range of improvement in our series is lower than those reported in other studies. Comparative studies between Dynesys® and decompression need to be performed in order to isolate the benefit of the dynamic stabilization system. Implant-related complications are not uncommon (AU)

[Pedicular dynamic stabilization system. Functional outcomes and implant-related complications for the treatment of degenerative lumbar disc disease with a minimum follow-up of 4 years]. / Sistema pedicular de estabilización dinámica. Resultados funcionales y complicaciones del implante en pacientes con enfermedad degenerativa discal lumbar, tras un seguimiento mínimo de 4 años.

INTRODUCTION: The Dynesys(®) system is a non-fusion pedicular dynamic stabilization system. The aim of our study is to evaluate the clinical outcomes in patients with degenerative disc disease and/or stenosis, and to measure the prevalence of screw loosening and breakage after 4 years of follow up. MATERIAL AND METHODS: All patients who underwent surgery with Dynesys(®) system in 2008 were reviewed. The surgery was performed in cases of low back pain of more than 6 months duration and a positive MRI for degenerative disc disease and/or stenosis. RESULTS: A total of 22 patients (11 females, 11 males) with a mean age of 44.40 ± 11 years were included, 20 patients (91%) underwent Dynesys(®) without any associated decompression maneuver. The evaluation of back and leg pain (0-10mm) showed a mean decrease of 2.4 ± 2.06 mm (P=.0001). The preoperative value of the Oswestry disability index was 52.36 ± 16.56% (severe functional limitation). After surgery, this value was 34.27 ± 17.87% (moderate functional limitation) (P=.001) with a decrease of 18.09 ± 16.03% (P=.001). A total of 4 (18%) patients showed signs of loosening screws. One patient (4.5%) had a screw breakage. CONCLUSIONS: Surgery with Dynesys(®) shows favorable long term clinical results, however the range of improvement in our series is lower than those reported in other studies. Comparative studies between Dynesys(®) and decompression need to be performed in order to isolate the benefit of the dynamic stabilization system. Implant-related complications are not uncommon.

Ingeniería tisular del tejido óseo. Diseño y desarrollo de materiales híbridos biológicamente activos basados en vitrocerámicas para sustitución ósea / Bone tissue engineering. Design and development of biologically active vitroceramic-based hybrid materials to be used as bone substitutes

Objetivo: Describir el desarrollo y caracterización de un material vitrocerámico y la respuesta inicial de células madre mesenquimales adultas (MSC-A) aisladas de la medula ósea. Material y metodología: El material se obtuvo por calentamiento de un vidrio 55SiO2-41CaO-4P2O5 (mol/%) por el método sol-gel. Las células se aislaron por aspirados directos de cresta ilíaca de pacientes adultos jóvenes. Se estudió el grado de adherencia, proliferación y diferenciación a osteoblastos de las MSC-A sembradas sobre el material. La diferenciación celular se evaluó mediante la producción de osteocalcina y la pérdida del marcador mesenquimal CD90. La proliferación celular sobre el sustrato se realizó mediante el ensayo de reducción de sales de tetrazolio. El material sembrado se implantó en un defecto crítico realizado en fémur de conejo para valorar su capacidad osteorregeneradora, y se observó mediante TAC. Resultados: Las MSC-A se adhirieron, expandieron, proliferaron y produjeron matriz extracelular mineralizada sobre el material durante el tiempo en cultivo, al mismo tiempo que mostraron fenotipo osteoblástico, e incrementaron la producción de osteocalcina y la pérdida de expresión de CD90. El material se reabsorbió parcialmente al final del estudio. Conclusión: El material es citocompatible, osteoconductor, bioactivo, con capacidad de promover la diferenciación de MSC-A a osteoblastos y la neoformación ósea después de su implantación en asociación con MSC-A; es una matriz adecuada para la regeneración del tejido óseo (AU)

Purpose: To describe the development and characterization of a vitroceramic material as well as the initial response of adult mesenchymal stem (MSCs-A) isolated from bone marrow. Material and methodology: The material was obtained by heating glass with composition in mol% 55SiO2-41CaO-4P2O5 by a sol gel method. Cells were isolated from direct iliac crest aspirates from young adult patients. An analysis was performed of the degree of adhesion, proliferation and osteoblastic differentiation of MSCs-A seeded onto the material. Cell differentiation was evaluated through the production of osteocalcin and the loss of the CD90 mesenchymal marker. Cell proliferation on the substrate was performed using the tetrazolium salt reduction method. The seeded material was implanted in a critical defect caused in a rabbit femur in order to determine its osteogenerating capacity; CT observations were carried out. Results: MSCs-A se bound to the material, expanded, proliferated and produced mineralized extracellular matrix on the material during the culture period. At the same time, they showed an osteoblastic phenotype, increasing osteocalcin production and losing CD90 expression. The material was partially resorbed at the end of the study. Conclusion: The material is cytocompatible, osteoconductive, bioactive and has a capacity to promote osteoblastic differentiation of MSCs-A as well as new bone formation following its implantation in association with MSCs-A; an appropriate matrix for bone tissue regeneration (AU)

In vitro behaviour of adult mesenchymal stem cells seeded on a bioactive glass ceramic in the SiO(2)-CaO-P(2)O(5) system.

This work describes the evaluation of a glass ceramic (55S41C4P-1300) as a potential substrate for bone tissue engineering. For that purpose, the capacity of mesenchymal stem cells (MSCs), isolated from rabbit bone marrow, to adhere, proliferate and differentiate into osteoblast (OBs) with or without 55S41C4P-1300 was investigated. Two types of culture medium, i.e. growth medium (GM) and osteogenic medium (OM), were evaluated. The bioactive 55S41C4P-1300, containing pseudowollastonite, wollastonite, tricalcium phosphate and crystoballite as crystalline phases, was obtained by heat treatment of a sol-gel glass (55SiO(2), 41CaO, 4P(2)O(5) (mol.%)) at 1300 degrees C. The results showed that the MSCs adhered, spread, proliferated and produced mineralized extracellular matrix on 55S41C4P-1300 regardless of the culture medium used. As the same time, they showed an osteoblastic phenotype, and this phenomenon was accompanied by the gradual diminution of the marker CD90 expression. The 55S41C4P-1300 was able to induce the differentiation of MSCs into OBs in the same way as OM without glass ceramic. This effect increased with the combination of 55S41C4P-1300 with OM. The glass ceramic evaluated in this work is bioactive, cytocompatible and capable of promoting the differentiation of MSCs into OBs. For that reason, it could be regarded as a suitable matrix in tissue engineering for bone tissue regeneration.

Consideraciones anatómicas, mecanismos y valoración de resultados en las fracturas de astrágalo / Talar fractures: anatomical considerations, mechanisms and assessment of results

Introducción. El astrágalo es esencial en la función del tobillo y del pie, por transmitir la carga del peso del cuerpo y facilitar la adaptación del pie al terreno. Al estar rodeado de superficies articulares es frecuente que sus fracturas sean articulares, con la consiguiente posibilidad de secuelas artrósicas y de consolidación viciosa que pueden afectar gravemente a la funcionalidad de la marcha.Vascularización. Su vascularización es muy lábil debido avarios factores: el estar cubierto de cartílago en dos tercios de su superficie, zonas por las que no penetran vasos; el no disponer de inserciones tendinosas ni musculares, que pudieran aportar algunos vasos, ni de vasos perforantes de adecuado calibre para asegurar su irrigación intraósea. De ahí que las fracturas desplazadas, o las maniobras de reducción y acceso quirúrgico, frecuentemente lesionen la red arterialextraósea con la consiguiente posibilidad de necrosisaséptica del hueso. Es irrigado por las tres grandes arterias de la pierna: tibial posterior con la arteria del canal del tarso, tibial anterior y peronea con la arteria del seno del tarso y pedia dorsal con los ramos del cuello del astrágalo. Las arterias del canal y del seno del tarso se unen formando una arcada vascular plantar de la que parten ramos perforantes para el cuerpo del astrágalo. El mayor caudal corresponde ala arteria del canal del tarso y su lesión en raras ocasiones es suficientemente suplida por las otras.Etiología. La etiología de las fracturas se produce generalmente por traumatismos de alta energía (tráfico y precipitaciones), aunque están en ascenso los de moderada o baja energía debido a accidentes deportivos. Hay gran diversidad de tipos condicionados en su pronóstico por la situación anatómica del trazo de fractura. Cada tipo de fractura presenta un mecanismo de producción diferente, aunque en general lo más frecuente es la aplicación de fuerzas de compresiónsobre un pie en flexión dorsal.Valoración. La evaluación de resultados en las fracturas del astrágalo no debe limitarse a la exploración y puntuación clásicas, sino que debe asociarse a la valoración de otros aspectos, como la intensidad del dolor, la satisfacción y la calidad de vida percibida por el paciente. Los cuestionarios genéricos valoran la calidad de vida, independientemente del lugar estudiado, y de entre los existentes el más útil para la extremidad inferior es el cuestionario de salud SF-36, queestá validado en castellano. Las mediciones supuestamenteobjetivas como la movilidad, deformidad o estabilidad sondifícilmente reproducibles y no validadas, y dependen mucho del momento en que se realicen. Aun reconociendo sus limitaciones se ha generalizado el uso de puntuaciones subjetivas, como las de la AOFAS y la de Olerud y Molander; sin embargo los más eficaces para la valoración de resultados clínicos tras sufrir una fractura de astrágalo siguen siendo los criterios propuestos por Hawkins

Introduction. The talus is essential for the function of the ankle and the foot since it transfers the load from the body and it facilitates adaptation to the terrain during ambulation. Being surrounded by articular surfaces, it does not come as a surprise that most of the fractures it sustains are joint fractures,which may later result in sequelae like osteoarthritisand malunion that are likely to seriously impair the individual’s gait.Blood supply. Its blood supply is very scarce as a result of various factors: two-thirds of its surface is covered by cartilage hence no vessels can gain access to it; it does not contain tendon or muscle attachments that may contribute blood vessels; there are no perforating vessels of enough caliber to provide intraosseous irrigation. This means thatdisplaced fractures and indeed the maneuvers involved infracture reduction and surgical access often injure the extraosseous arterial network increasing the risk of aseptic bone necrosis. The talus is irrigated by the three large arteries in the leg: the artery of the tarsal canal, a branch of the posterior tibial artery; the artery from the sinus tarsi, arising fromthe anterior tibial artery and perforating peroneal artery; and the dorsalis pedis at the level of the talar neck. The arteries of the tarsal canal and the sinus tarsi anastomose giving rise to a plantar arch, which gives off the perforating branches that connect it to the talar body. The most plentiful supply comes from the artery of the sinus tarsi, whose disruptioncan rarely be compensated for by the others.Etiology. Fractures are generally caused by high-energytrauma (road accidents and falls), although there is a growing incidence of low-energy trauma caused by sports accidents. There is a wide range of fracture types, the prognoses of which depend on their anatomical location. Although each fracture type corresponds to a different production mechanism, they are all generally due to the application of compression forces on a dorsiflexed foot.Assessment. The assessment of results in talar fracturesshould not be limited to the standard examination and scoring; it should rather be associated to evaluating other aspects like the intensity of pain, and the satisfaction and quality of life perceived by the patient. There are generic questionnaires that assess quality of life independently of other variables. Of these, the most appropriate for the lowerlimb is the SF-36 form, which has in addition been validated in Spanish. Allegedly objective measurements like mobility, deformity or stability are difficult to reproduce and, if they are not validated, they depend largely on when they are carried out. Although their limitations are well understood, a series of subjective scores have been developed, like the AOFAS and the Olerud and Molander scales, but the most effective one to assess clinical results after sustaining a talarfracture is the one proposed by Hawkins

Consideraciones anatómicas, mecanismos y valoración de resultados en las fracturas de astrágalo / Talar fractures: anatomical considerations, mechanisms and assessment of results

Introducción. El astrágalo es esencial en la función del tobillo y del pie, por transmitir la carga del peso del cuerpo y facilitar la adaptación del pie al terreno. Al estar rodeado de superficies articulares es frecuente que sus fracturas sean articulares, con la consiguiente posibilidad de secuelas artrósicas y de consolidación viciosa que pueden afectar gravemente a la funcionalidad de la marcha.Vascularización. Su vascularización es muy lábil debido avarios factores: el estar cubierto de cartílago en dos tercios de su superficie, zonas por las que no penetran vasos; el no disponer de inserciones tendinosas ni musculares, que pudieran aportar algunos vasos, ni de vasos perforantes de adecuado calibre para asegurar su irrigación intraósea. De ahí que las fracturas desplazadas, o las maniobras de reduccióny acceso quirúrgico, frecuentemente lesionen la red arterial extraósea con la consiguiente posibilidad de necrosis aséptica del hueso. Es irrigado por las tres grandes arterias de la pierna: tibial posterior con la arteria del canal del tarso, tibial anterior y peronea con la arteria del seno del tarso y pedia dorsal con los ramos del cuello del astrágalo. Las arterias del canal y del seno del tarso se unen formando una arcada vascular plantar de la que parten ramos perforantes para el cuerpo del astrágalo. El mayor caudal corresponde ala arteria del canal del tarso y su lesión en raras ocasiones es suficientemente suplida por las otras.Etiología. La etiología de las fracturas se produce generalmente por traumatismos de alta energía (tráfico y precipitaciones), aunque están en ascenso los de moderada o baja energía debido a accidentes deportivos. Hay gran diversidad de tipos condicionados en su pronóstico por la situación anatómica del trazo de fractura. Cada tipo de fractura presentaun mecanismo de producción diferente, aunque en generallo más frecuente es la aplicación de fuerzas de compresión sobre un pie en flexión dorsal.Valoración. La evaluación de resultados en las fracturas del astrágalo no debe limitarse a la exploración y puntuación clásicas, sino que debe asociarse a la valoración de otros aspectos, como la intensidad del dolor, la satisfacción y la calidad de vida percibida por el paciente. Los cuestionarios genéricos valoran la calidad de vida, independientemente del lugar estudiado, y de entre los existentes el más útil parala extremidad inferior es el cuestionario de salud SF-36, que está validado en castellano. Las mediciones supuestamente objetivas como la movilidad, deformidad o estabilidad son difícilmente reproducibles y no validadas, y dependen mucho del momento en que se realicen. Aun reconociendo sus limitaciones se ha generalizado el uso de puntuaciones subjetivas,como las de la AOFAS y la de Olerud y Molander;sin embargo los más eficaces para la valoración de resultados clínicos tras sufrir una fractura de astrágalo siguen siendo los criterios propuestos por Hawkins

Introduction. The talus is essential for the function of the ankle and the foot since it transfers the load from the body and it facilitates adaptation to the terrain during ambulation. Being surrounded by articular surfaces, it does not come as a surprise that most of the fractures it sustains are joint fractures,which may later result in sequelae like osteoarthritisand malunion that are likely to seriously impair the individual’s gait.Blood supply. Its blood supply is very scarce as a result of various factors: two-thirds of its surface is covered by cartilage hence no vessels can gain access to it; it does not contain tendon or muscle attachments that may contribute blood vessels; there are no perforating vessels of enough caliber to provide intraosseous irrigation. This means thatdisplaced fractures and indeed the maneuvers involved infracture reduction and surgical access often injure the extraosseous arterial network increasing the risk of aseptic bone necrosis. The talus is irrigated by the three large arteries in the leg: the artery of the tarsal canal, a branch of the posteriortibial artery; the artery from the sinus tarsi, arising from the anterior tibial artery and perforating peroneal artery; and the dorsalis pedis at the level of the talar neck. The arteries of the tarsal canal and the sinus tarsi anastomose giving rise to a plantar arch, which gives off the perforating branchesthat connect it to the talar body. The most plentiful supply comes from the artery of the sinus tarsi, whose disruption can rarely be compensated for by the others.Etiology. Fractures are generally caused by high-energytrauma (road accidents and falls), although there is a growing incidence of low-energy trauma caused by sports accidents. There is a wide range of fracture types, the prognoses of which depend on their anatomical location. Although each fracture type corresponds to a different production mechanism, they are all generally due to the application of compression forces on a dorsiflexed foot.Assessment. The assessment of results in talar fracturesshould not be limited to the standard examination and scoring; it should rather be associated to evaluating other aspects like the intensity of pain, and the satisfaction and quality of life perceived by the patient. There are generic questionnaires that assess quality of life independently of other variables. Of these, the most appropriate for the lowerlimb is the SF-36 form, which has in addition been validated in Spanish. Allegedly objective measurements like mobility, deformity or stability are difficult to reproduce and, if they are not validated, they depend largely on when they are carried out. Although their limitations are well understood, a series of subjective scores have been developed, like theAOFAS and the Olerud and Molander scales, but the mosteffective one to assess clinical results after sustaining a talar fracture is the one proposed by Hawkins

Osteonecrosis del astrágalo y leucemia linfoblástica aguda / Talar osteonecrosis and acute lymphoblastic leukemia

Introducción. La necrosis ósea avascular es una patología infrecuente en la población infantil. El aumento de la supervivencia de los niños que han sido tratados de leucemia linfoblástica aguda ha provocado que nos hallemos ante un grupo de pacientes en fase de crecimiento con un elevado riesgo de osteonecrosis inducida por glucocorticoides. Caso clínico. Niño de 9 años diagnosticado de leucemia linfoblástica aguda que desarrolló un cuadro compatible con necrosis avascular del astrágalo izquierdo a los 16 meses de iniciado el tratamiento antileucémico. El diagnóstico de confirmación se realizó mediante biopsia. Se indicó descarga absoluta y fisioterapia. La evolución de la sintomatología fue satisfactoria desapareciendo el dolor al mes de realizada la biopsia. Tras 6 años de seguimiento el paciente presenta una disminución de la movilidad del tobillo y una degeneración de las articulaciones tibioastragalina y astragaloescafoidea. Conclusiones. La administración de altas dosis de glucocorticoides en niños puede provocar necrosis óseas. Es fundamental la sospecha clínica para un diagnóstico y tratamiento precoces

Introduction. Avascular bone necrosis is an unusual pathology in the pediatric population. The increasing survival rate of children treated for acute lymphoblastic leukemia has confronted us with a group of patients in their growth phase who present with a high risk of developing glucocorticoid-induced osteonecrosis. Clinical case. The patient was a 9-year-old boy diagnosed with acute lymphoblastic leukemia who developed a disease compatible with left talar avascular necrosis 16 months after he had been put on antileukemic treatment. Confirmation diagnosis was made through a biopsy. No weight-bearing was allowed and physical therapy was indicated. The evolution of symptoms was satisfactory, with pain disappearing a month after the biopsy had been performed. In her 6-month follow-up, the patient showed a reduction in the mobility of his ankle as well as a degeneration in the tibial-talar and talar-scaphoid joints. Conclusions. The administration of high doses of glucocorticoids to children can provoke bone necroses. Clinical suspicion is fundamental for early diagnosis and treatment

Cinética de crecimiento in vitro de osteoblastos humanos sobre cerámica porosa de hidroxiapatita / In vitro growth kinematics of human osteoblasts on porous hydroxyapatite ceramics

Objetivo. Estudio de la respuesta in vitro de osteoblastos humanos frente a una cerámica porosa de hidroxiapatita para su consideración como matriz en ingeniería tisular. Material y método. Se han aislado caracterizado y cultivado osteoblastos humanos. Se sembraron sobre discos del material y sobre plástico (control) y se ha estudiado mediante técnica de reducción de la sal de tetrazolio su adherencia, extensión y proliferación. Se comprobó sus características funcionales, determinando la producción de fosfatasas alcalinas, osteocalcina, colágeno I y mineralización in vitro. Resultados. Las células se adhirieron y crecieron sobre la superficie del material, y en el interior de los poros. A las 24 horas se adhirieron el 20% de las células sembradas, mientras que en el control lo hicieron el 95%, además, se observó un crecimiento más lento. La producción de fosfatasas alcalinas, osteocalcina y colágeno I por las células que crecieron sobre la cerámica fue positiva y en similar rango que los controles. Conclusiones. Los osteoblastos colonizaron la cerámica de forma más lenta que el control, mantuvieron su fenotipo y produjeron matriz extracelular. El ensayo de reducción de las sales de tetrazolio (XTT) fue satisfactorio para cuantificar la proliferación de osteoblastos sobre la cerámica. El modelo utilizado permite cuantificar y observar la funcionalidad in vitro de osteoblastos en respuesta a cerámicas de hidroxiapatita. En función de los resultados obtenidos el material utilizado en el estudio puede ser considerado, en el campo de la ingeniería tisular, como una matriz adecuada para soportar el crecimiento de osteoblastos humanos

Purpose. To study the in vitro response of human osteoblasts when in contact with porous hydroxyapatite ceramics, with a view to considering them a matrix for tissue engineering. Materials and methods. Human osteoblasts were isolated, characterized and cultured. They were seeded onto discs made of HA and onto a plastic material (control) and their adhesiveness, extension and proliferation were studied by means of a tetrazolium salt reduction test. Their functional characteristics were examined in order to determine the production of alkaline phosphatases, osteocalcin, collagen I as well as in vitro mineralization. Results. The cells adhered to and grew onto the material's surface and inside its pores. Within 24 hours, 20% of seeded cells had adhered; in the control group this percentage was 95% and the growth was slower. The cells growing onto the ceramics were found to produce alkaline phosphatases, osteocalcin and collagen in amounts similar to those in the control group. Conclusions. Osteoblasts colonized the ceramics at a lower pace than plastic; they also retained their phenotype and generated extracellular matrix. The tetrazolium salt reduction test served the purpose of validating the proliferation of osteoblasts on the ceramics. The model used makes it possible to quantify and observe the in vitro functionality of osteoblasts in their response to hydroxyapatite ceramics. On the basis of the results obtained, the material used in the study can be considered, in the field of tissue engineering, a suitable matrix to support the growth of human osteoblasts

Fracturas del pilón tibial / Tibial pilon fractures

Las fracturas del pilón tibial son un gran reto debido a la gran dificultad de su tratamiento. En este artículo de revisión se analizan los datos de mayor interés referentes a tan interesantes fracturas: concepto, epidemiología, mecanismo lesional, clasificaciones, valoración clínica, evaluación radiológica, tratamiento, complicaciones, resultados y evaluación de dichos resultados. La mayoría de los autores coinciden en que la afectación de las partes blandas, el patrón de cada fractura y la experiencia del cirujano son los parámetros fundamentales para decidir qué forma de tratamiento es el más adecuado (conservador o quirúrgico) para cada tipo de fractura (AU)

[Palliative surgical treatment of spastic paralysis in the lower extremity]. / Cirugía paliativa de la parálisis espástica en las extremidades inferiores.

AIMS: The purpose of this paper is to describe our experience with and to review the best results in the surgical treatment of patients suffering from spastic paralysis of the lower limbs. DEVELOPMENT: To enable a correct indication of the techniques to be employed the authors recommend a thorough examination of the types of deformity (fixed, dynamic or mixed) and the use of specific tests for exploring the different deformities. These are necessary steps to be able to interpret the different disorders in a global manner and thus reach diagnostics that provide us with a proper surgical therapeutic orientation about the spastic hip, knee, ankle and foot. Due to the importance of the overall problem, it is becoming increasingly more frequent to advise multidisciplinary work involving the collaboration of different specialists (neurologists, rehabilitators, physiotherapists, psychologists, paediatricians, neurophysiologists and orthopaedic surgeons). Spasticity is as heterogeneous as the results of the different treatment projects. The techniques used must allow the rehabilitation therapy to be continued. Surgical intervention is recommended when the damage to the CNS has stabilised and the patient is over 4 years old. The psychic state of the patient and the family must also be evaluated. CONCLUSIONS: The objective of the treatment in patients who can walk is to improve motor functioning, the type of gait and to prevent fixed deformities from developing. In patients who do not walk, the aim is to improve their hygiene and their capacity to sit and to walk. These indications are indispensable to be able to successfully perform a little-known area of orthopaedic surgery which does not respond to the techniques used in flaccid paralysis surgery.

[Palliative surgical treatment of spastic paralysis in the upper extremity]. / Cirugía paliativa de la parálisis espástica en las extremidades superiores.

AIMS: In this paper we review the main studies conducted on therapy applied to the bony and soft parts in spastic paralysis of the upper extremity. DEVELOPMENT: Spasticity presents muscular hypertonia and hyperexcitability of the stretch reflex, which are typical of upper motoneuron syndrome. Physiopathologically, spasticity is due to the medullar and supramedullar alteration of the afferent and efferent pathways. Treatment is multidisciplinary and involves the collaboration of rehabilitators, neurophysiologists, neurologists, paediatricians, orthopaedic surgeons and psychologists, who all contribute with their different therapeutic aspects and characteristics (which can be pharmacological, peripheral neurological blockages, surgical, etc.). The characteristic posture of the upper extremities in spastic cerebral palsy is the inward rotation of the shoulder, flexion of the elbow and pronated forearm, and the deformity of the fingers (swan-neck and thumbs-in-palm). The primary objectives in these patients will be to improve communication with their surroundings, perform activities of daily living, increase mobility and walking. CONCLUSIONS: The surgical treatment applied by orthopaedic surgeons in the upper extremities are aimed at achieving an enhanced adaptive functionality rather than morphological normality. Factors to be taken into account include age, voluntary control over muscles and joints, level of severity of the spasticity (Ashworth scale) and stereognostic sensitivity. In general, on soft parts we will use procedures such as dehiscence or lengthening of the flexor muscles of the shoulder and elbow or of the adductor of the thumb; transfer of the pronators in order to adopt the supinating function or of the flexors so as to reinforce the extensors of the forearm, and capsulodesis or tenodesis in the hand. The bony procedures will consist in derotational osteotomies of the humerus and radius and arthrodesis in the wrist or in the metacarpophalangeal joints of the thumb, depending on whether there is greater rigidity or age in the former cases or instability in the latter.

Cirugía paliativa de la parálisis espástica en las extremidades inferiores / Palliative surgical treatment of spastic paralysis in the lower extremity

Objetivo. En el presente trabajo se expone nuestra experiencia y la revisión de los mejores resultados en el tratamiento quirúrgico de los enfermos afectados de parálisis espástica de los miembros inferiores. Desarrollo. Para la correcta indicación de las técnicas a emplear, los autores recomiendan el examen exhaustivo de los tipos de deformidades (fija, dinámica o mixta) y el empleo de los test de exploración específicos de las distintas deformidades, pasos necesarios para poder interpretar las distintas alteraciones de una forma global, y llegar así a unos diagnósticos que nos permitan una adecuada orientación terapéutica quirúrgica sobre la cadera, la rodilla, el tobillo y el pie espásticos. Debido a la importancia que tiene el problema global, cada vez más frecuente, se aconseja el trabajo multidisciplinar con la colaboración de distintos especialistas (neurólogo, rehabilitador, fisioterapeuta, psicólogo, pediatra, neurofisiólogo y cirujano ortopédico). La espasticidad es tan heterogénea como los resultados de los diversos proyectos de tratamiento. Las técnicas utilizadas deben permitir la continuación del tratamiento rehabilitador. Se aconseja la intervención quirúrgica cuando se ha estabilizado el daño del SNC y el paciente tiene más de 4 años. Ha de valorarse el psiquismo del paciente y de la familia. Conclusiones. El objetivo del tratamiento en los pacientes que deambulan es mejorar la función motora y el tipo de marcha, y prevenir el desarrollo de deformidades fijas, mientras que en los pacientes que no deambulan se pretende mejorar la higiene y la capacidad de sentarse y deambular. Estas indicaciones son imprescindibles para llegar a realizar con éxito una parcela de la cirugía ortopédica poco conocida y que no responde a las técnicas empleadas en la cirugía de las parálisis flácidas (AU)

Aims. The purpose of this paper is to describe our experience with and to review the best results in the surgical treatment of patients suffering from spastic paralysis of the lower limbs. Development. To enable a correct indication of the techniques to be employed the authors recommend a thorough examination of the types of deformity (fixed, dynamic or mixed) and the use of specific tests for exploring the different deformities. These are necessary steps to be able to interpret the different disorders in a global manner and thus reach diagnostics that provide us with a proper surgical therapeutic orientation about the spastic hip, knee, ankle and foot. Due to the importance of the overall problem, it is becoming increasingly more frequent to advise multidisciplinary work involving the collaboration of different specialists (neurologists, rehabilitators, physiotherapists, psychologists, paediatricians, neurophysiologists and orthopaedic surgeons). Spasticity is as heterogeneous as the results of the different treatment projects. The techniques used must allow the rehabilitation therapy to be continued. Surgical intervention is recommended when the damage to the CNS has stabilised and the patient is over 4 years old. The psychic state of the patient and the family must also be evaluated. Conclusions. The objective of the treatment in patients who can walk is to improve motor functioning, the type of gait and to prevent fixed deformities from developing. In patients who do not walk, the aim is to improve their hygiene and their capacity to sit and to walk. These indications are indispensable to be able to successfully perform a little-known area of orthopaedic surgery which does not respond to the techniques used in flaccid paralysis surgery (AU)