GEDOS-SECOT consensus on the care process of patients with knee osteoarthritis and arthoplasty. / Consenso GEDOS-SECOT sobre el proceso de atención a pacientes con artrosis de rodilla e indicación de artroplastia.

OBJECTIVE: To develop recommendations on the evaluation and management procedure in patients undergoing total knee replacement based on best evidence and the experience of a panel of experts. METHODS: A multidisciplinary group of 12 experts was selected that defined the scope, users and the document parts. Three systematic reviews were performed in patients undergoing knee replacement: (i)efficacy and safety of fast-tracks; (ii)efficacy and safety of cognitive interventions in patients with catastrophic pain, and (iii) efficacy and safety of acute post-surgical pain management on post-surgical outcomes. A narrative review was conducted on the evaluation and management of pain sensitization, and about the efficacy and safety of pre-surgical physiotherapy. The experts generated the recommendations and explicative text. The level of agreement was evaluated in a multidisciplinary group of 85 experts with the Delphi technique. The level of evidence was established as well for each recommendation. RESULTS: A total of 20 recommendations were produced. An agreement higher than 80% was reached in all of them. We found the highest agreement on the need for a full discharge report, on providing proper information about the process and on following available guidelines. CONCLUSIONS: There is consensus among professionals involved in the management of patients undergoing total knee replacement, in that it is important to protocolize the replacement process, performing a proper, integrated and coordinated patient evaluation and follow-up, paying special attention to the surgical procedure and postoperative period.

Growth factor expression after supraspinatus tear: a quantitative polymerase chain reaction (PCR) study in rats.

INTRODUCTION: The objective of this study was to evaluate the temporal expression pattern of three different growth factors (VEGF, IL-1ß, and TGF-1ß) in a supraspinatus tendon lesion in an animal model. The hypothesis of this study is that there are variations in the expression of these factors in the first 8 weeks after injury. MATERIALS AND METHODS: A full thickness defect was made in the supraspinatus tendon of 40 rat shoulders. The animal were sacrificed at 0, 3, 7, 14 and 56 days after injury and three tissue samples were obtained: bone from the tendon footprint; the supraspinatus tendon stump, and a fragment of the myotendinous junction. After mRNA extraction, quantitative PCR analysis was performed, and the expression of three different growth factors were evaluated in each zone. RESULTS: There was an increased expression of IL-1ß during the first week after injury at all levels evaluated with a clear peak in the first day after injury. There was also a significant increase in TGF-1ß expression levels all along the first week in the three zones. There were no variations in VEGF expression in the three zones along the 8 weeks. CONCLUSION: IL-1ß was expressed predominantly in the initial stages after injury; TGF initiated its expression after the initial phase since day three, whereas VEGF remained basically unchanged during the entire process.

Preventive analgesia in hip or knee arthroplasty: a systematic review.

OBJECTIVE: To analyze the efficacy and safety of preventive analgesia in patients undergoing hip or knee arthroplasty due to osteoarthritis. METHODS: A systematic literature review was performed, using a defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undergoing knee and/or hip arthroplasty, adults with moderate or severe pain (≥4 on a Visual Analog Scale). The intervention, the use (efficacy and safety) of pharmacological treatment (preventive) close to surgery was recorded. Oral, topical and skin patch drugs were included. Systematic reviews, meta-analysis, controlled trials and observational studies were selected. RESULTS: A total of 36 articles, of moderate quality, were selected. The patients included were representative of those undergoing knee and/or hip arthroplasty in Spain. They had a mean age >50 years, higher number of women, and reporting moderate to severe pain (≥4 on a Visual Analog Scale). Possurgical pain was mainly evaluated with a Visual Analog Scale. A wide variation was found as regards the drugs used in the preventive protocols, including acetaminophen, classic NSAID, Cox-2, opioids, corticosteroids, antidepressants, analgesics for neuropathic pain, as well as others, such as magnesium, ketamine, nimodipine or clonidine. In general, all of them decreased post-surgical pain without severe adverse events. CONCLUSIONS: The use or one or more pre-surgical analgesics decreases the use of post-surgical drugs, at least for short term pain.

SECOT-GEDOS consensus on pre-surgical pain management in knee and hip arthrosis.

OBJECTIVE: To develop recommendations, based on best evidence and experience, on pain management in patients undertaking total knee or hip replacement. METHODS: Nominal group methodology was followed. A group of experts was selected (5 orthopedics, 1 anesthesiologist), who defined the scope, users, topics, preliminary recommendations, and 3 systematic reviews: efficacy and safety of pre-surgical analgesia regarding to post-surgical pain, efficacy and safety of pre-emptive analgesia and pre-operative factors of post-operative pain. The level of evidence and grade of recommendation was established using the Oxford Centre for Evidence Based Medicine, and the level of agreement with the Delphi technique (2 rounds). The Delphi was extended to 39 orthopedics and anesthesiologists. The whole document was reviewed by all the experts. RESULTS: A total of 21 recommendations were produced. They include specific pharmacological treatment, as well as the evaluation and monitoring of patients on this treatment, and post-operative pre-emptive treatment. Agreement above 70% was reached in 19 recommendations. CONCLUSIONS: In patients undergoing total knee or hip replacement, a proper evaluation, follow-up, pharmacological and non-pharmacological treatment of predictors of poor surgical outcomes should be performed, especially those related to pre-operative pain. This can improve post-operative pain and surgery outcomes.

Early postoperative transtibial articular fistula formation after anterior cruciate ligament reconstruction: a review of three cases.

INTRODUCTION: This is a retrospective case report of three cases with an early postoperative transtibial fistula after anterior cruciate ligament reconstruction (ACL). MATERIALS AND METHODS: The patients had undergone ACL reconstruction and complained of fluid drainage through the not-healed wound or swelling localized on the anteromedial aspect of the ipsilateral proximal tibia during the early postoperative. Magnetic resonance imaging showed a multilocular fluid-filled cyst arising from the distal hole of the tibial bone tunnel. Open resection of the fistula and the cyst was performed in all cases and communication between the tibial tunnel and the joint space was confirmed. During revision surgery the distal hole of the tibial tunnel was covered with a fascio-periosteal flap. RESULTS: All wounds healed without complications. There was no recurrence of drainage or cyst formation. At 2 years follow-up the knee function was normal and was not affected by the complication in any of the patients. Early postoperative transtibial fistulae after ACL reconstruction are rare complications that clinically present either as anterior tibial cysts or persistent wound drainage. Surgical treatment is required, and some delay in the rehabilitation routine is required, but the final outcome is not affected.

[The new guidelines for deep venous thromboembolic disease prophylaxis in elective hip and knee replacement surgery. Are we nearer or further away from a consensus?]. / Las nuevas guías de profilaxis de enfermedad tromboembólica venosa en artroplastia de cadera y rodilla electivas: ¿nos acercamos o nos alejamos del consenso?

Venous thromboembolism events (VTE) prophylaxis after elective hip or knee replacement surgery is a subject of controversy. Three sets of guidelines (NICE, ACCP and AAOS) on this topic have recently been updated. The guidelines have points in common: prophylaxis is necessary, it is recommended to combine mechanical and pharmacological prophylaxis in patients who have suffered a previous VTE, isolated mechanical measures and low molecular weight heparins are effective, the new oral anticoagulants and fondaparinux are effective drugs. There is some consensus in recommending regional anaesthesia, in advising against echography studies in asymptomatic patients, and in the promotion of early mobilisation of the patient. There is controversy over the most suitable pharmacological treatment and the time of starting, and the duration of this, as well as on vena cava filters, antiplatelet drugs, and VTE or bleeding risk factors.

Total hip arthroplasty infected by Brucella: a report of two cases.

Infection caused by Brucella following total joint arthroplasty is very rare. We present 2 cases of brucellar infection following total hip arthroplasty (THA). A 66-year-old woman who had prolonged contact with cattle presented with pain at the thigh and groin areas. The patient had undergone an uncemented THA for a hip fracture 3 years previously. Cultures of articular liquid were positive for Brucella abortus. The implant was loosened and was managed with a 2-stage re-implantation. A 71-year-old man presented with painless suppuration of the hip joint through the scar from previous surgeries. Radiography demonstrated a well-integrated THA. When postoperative cultures were found positive for Brucella melitensis, antibiotic treatment of rifampicin 900 mg, streptomycin 1 g, and doxycycline 200 mg daily were prescribed. At 5.5-year and 5-year follow-up, respectively, both patients were asymptomatic and free of infection with well-integrated implants. As the Brucella pathogen is highly susceptible to antibiotics, standard 2-stage revision arthroplasty for loosened implant or debridement and antibiotic treatment for well-fixed implant should suffice.

La osteotomía de Weil en el tratamiento de las metatarsalgias de los radios centrales / Weil osteotomy in the treatment of central metatarsalgia

Objetivo. Evaluar los resultados de la osteotomía de Weil para el tratamiento y prevención de la metatarsalgia de sobrecarga de los radios centrales del pie. Material y método. Se revisaron de forma retrospectiva los primeros 42 pacientes consecutivos a los que se les había realizado una o más osteotomías de Weil para el tratamiento o profilaxis de una metatarsalgia de los radios centrales. Dos sujetos no consintieron en participar en el estudio por lo que sólo fueron incluidos 48 pies de 40 sujetos a los que se les realizaron 96 osteotomías. Se revisó la historia clínica y se entrevistó a los pacientes evaluando los resultados estéticos, radiográficos y funcionales con ayuda de la escala para metatarsianos menores e interfalángicas de la Sociedad Americana de Pie y Tobillo (AOFAS) (100 puntos máximo). Resultados. Considerado como bueno o excelente en el 87,5% de los pies desde el punto de vista funcional y en el 81,3% desde el punto de vista estético. La puntuación final media en la escala de la AOFAS fue de 85 ± 12,6 puntos. No aparecieron infecciones o retrasos de consolidación. Un paciente fue reintervenido en el postoperatorio inmediato por una fractura y en cuatro casos se tuvo que retirar el material de osteosíntesis. El 66,7% de los pies presentaban un defecto leve de movilidad metatarsofalángica y en cuatro casos el defecto era grave. Conclusiones. La osteotomía de Weil es una técnica adecuada y segura para tratar las metatarsalgias de los radios centrales. Tiene inconvenientes relacionados con la intolerancia al material de osteosíntesis y con defectos de movilidad metatarsofalángica

Purpose. To assess the results of Weil osteotomy in the treatment and prevention of overload metatarsalgia in the foot's central metatarsals. Materials and methods. A retrospective examination was performed of the first forty-two consecutive patients who had been subjected to one or more Weil osteotomies for the treatment or prophylaxis of central metatarsalgia. Two subjects refused to be included in the study, which means that only 48 feet were included from 40 subjects who were subjected to 96 osteotomies. All clinical records were studied and the patients were interviewed in order to determine the aesthetic, radiographical and functional results obtained on the basis of the American Orthopedic Foot and Ankle Society (AOFAS)'s lesser metatarsal and interphalangeal bones' score. Results. 87.5% of results were considered good or excellent from the functional point of view, with 81.3% being considered good or excellent from the aesthetic point of view. The final score as measured by the AOFAS score was 85 ± 12.6 points. Neither infections nor osseointegration delays were noted. One of the patients was reoperated in the immediate post-op because of a fracture and in four cases the osteosynthesis material had to be retrieved. 66.7% of feel presented with a mild metatarsophalangeal mobility defect. In four patients this defect was serious. Conclusions. Weil osteotomy is a safe and appropriate technique to address central metatarsalgia. It has drawbacks that stem from intolerance to the osteosynthesis material and to metatarsophalangeal mobility defects

Inclinación pélvica en el plano sagital. Descripción y validación de un nuevo sistema de medida. Valores normales en 75 sujetos / Pelvic tilt in the sagittal plane. Description and validation of a new measurement method. Normal values in 75 subjects

Las alteraciones de la inclinación pélvica en el plano sagital en bipedestación son importantes en el dolor lumbar crónico y la espondilolistesis. Los métodos habituales que se usan para medir este parámetro necesitan de la realización de radiografías o requieren de aparataje complejo. Se describe un nuevo sistema de medida rápido y fácil de utilizar. El sistema determina la altura respecto al suelo de las espinas ilíacas anterosuperiores y posterosuperiores y las distancias entre sí, y calcula la inclinación del plano que pasa por estos cuatro puntos. Se analizó la reproducibilidad del sistema midiendo de manera repetida un grupo de 12 sujetos. El coeficiente de correlación intraclase intraobservador fue de 0,90 y el interobservador fue de 0,80, por lo que el sistema tiene una buena reproducibilidad. Se analizó la validez del método comparando las medidas obtenidas con las realizadas sobreradiografías laterales de pelvis en 27 sujetos. Se observaron errores medios de 1,3° con una gran correlación entre ambos datos (R2 = 0,68; p < 0,001) por lo que el sistema se considera válido. Se realizaron medidas sobre 75 voluntarios sanos. La inclinación pélvica media fue de 9,88° (desviación estándar [DE]: 5,43°). El análisis de regresión lineal multivariante observó una inclinación pélvica menor en los hombres que en las mujeres (p = 0,044) y que la edad se relaciona inversamente con la inclinación pélvica (p = 0,004)

Variations in pelvic tilt in the sagittal planeare important in chronic lumbar pain and spondylo listhesis. The current methods used to measure this parameter require the use of roentgenograms or need complex instruments. A new method is described that is quick an easy to use. The system determines the height from the floor of the posterior superior and anterior superior iliac spines and the distances between them, and calculates the inclination of the plane that traverses these four points. The reproducibility of the system was assessed with repeated measurements in a group of 12 subjects. The intraobserverintra class correlation coefficient was 0.90 and the interobserver coefficient was 0.80, implicating a good reproducibility. The validity of the system was assessed comparing the measurements with those obtained over lateral pelvic roentgenograms in 27 subjects. Mean error was 1.3° with a high correlation between measurements (R2 = 0,68, p < 0,001)so the system is valid. Seventy-five healthy volunteers were measured. Mean pelvic tilt was 9.88° (standard deviation 5.43°). Multivariate linear regression analysis appreciated less pelvic tilt in males than in females (p = 0.044) and that age was inversely related to pelvic tilt (p = 0.004)

Estudio de ocho casos de rotura de clavo gamma en 1.478 implantes / Study of eight cases of gamma nail fracture in 1,478 implants

Objetivo. Analizar las roturas de clavo gamma ocurridas en nuestro centro y establecer las causas y mecanismos de las mismas. Material y método. Estudio retrospectivo de 1.287 clavos gamma estándar, 174 clavos gamma largos y 17 clavos gamma trocantéricos. Se identificaron 8 roturas de clavo gamma. Resultados. De los 1.287 clavos gamma estándar colocados se rompieron dos (tasa de fracaso del 0,15 por ciento). De los 174 clavos gamma largos colocados se rompieron 6 (3,4 por ciento). La rotura se produjo una media de 15,6 meses tras la intervención inicial. En 5 casos ésta tuvo lugar sobre una fractura en pseudoartrosis y fueron tratados con extracción del implante y recambio por otro clavo, consiguiéndose la consolidación en todos los casos. En tres casos la rotura ocurrió en una fractura consolidada. De éstos, en un caso se conservó el implante y en dos se retiró el clavo sin otra actuación. Todas las fracturas consolidaron. Las roturas se produjeron a la altura del tornillo cefálico y de los tornillos de bloqueo en el clavo estándar y a la altura del tornillo cefálico y en la zona subtrocantérea en el clavo gamma largo. Conclusiones. La tasa de rotura del clavo gamma estándar es 0,15 por ciento y del clavo gamma largo de 3,4 por ciento. Las roturas se observaron tanto en fracturas en pseudoartrosis como en fracturas consolidadas. Cuando existía una pseudoartrosis la retirada del implante y la colocación de un nuevo clavo fue efectiva siempre (AU)

Carta 3 / Letter 3

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