Metaphyseal chondroblastoma in a pediatric patient.

Chondroblastoma is a rare, benign neoplasm usually located in the epiphyses and apophyses of the long bones in the immature skeleton. Radiologically, these tumors have a classic appearance of a lytic lesion with chondroid matrix surrounded by a thin sclerotic rim. Here, we describe the case of a 5-year-old male who presented with a chondroblastoma unusually located exclusively in the metaphyseal region, which led to an elusive diagnosis. The presence of tumors outlying the traditional location or epidemiological spectrum, along with the potential for histopathological misdiagnosis, can pose a diagnostic and therapeutic challenge for the treating team.

Quiste óseo aneurismático en el cuboides de un niño de 13 años. Presentación de un caso clínico / Aneurysmal bone cyst of the cuboid. Case report and review of the literature

Se presenta un caso clínico poco frecuente de un quiste óseo aneurismático localizado en el cuboides de un niño de 13 años. Se llegó al diagnóstico mediante la tríada de síntomas, estudios por imágenes (radiografía, resonancia magnética) y anatomía patológica. El tratamiento consistió en el abordaje y curetaje minuciosos dentro de la lesión, el fresado de alta velocidad, la electrocauterización y el relleno con aloinjerto óseo liofilizado con chips cortico-esponjosos. Pese al diagnóstico tardío, la evolución clínica fue favorable con remisión completa de los síntomas y retorno a las actividades deportivas, sin recidiva local. Nivel de Evidencia: IV

A rare clinical case of an aneurysmal bone cyst located at the level of the cuboid in a 13-year-old boy is presented. The diagnosis was reached through clinical evaluation, imaging studies (radiograph-MRI), and a pathological anatomy analysis. Its treatment consisted of thorough intralesional curettage, high speed burring, electrocautery, and filling with lyophilized bone allograft with cortical/cancellous chips. Despite the late diagnosis, we would like to highlight the favorable clinical evolution of the patient, with ad integrum remission of the symptoms and return to his sport activities, without elements of local recurrence. Level of Evidence: IV

Monocyte Distribution Width as a predictor of community acquired sepsis in patients prospectively enrolled at the Emergency Department.

BACKGROUND: Monocyte Distribution Width (MDW), a simple cellular marker of innate monocyte activation, can be used for the early recognition of sepsis. We performed an observational prospective monocentric study to assess the predictive role of MDW in detecting sepsis in a sample of consecutive patients presenting at the Emergency Department. METHODS: Prospective observational study using demographic and clinical characteristics, past medical history and other laboratory measurements to predict confirmed sepsis using multivariate logistic regression. RESULTS: A total of 2724 patients were included in the study, of which 272 (10%) had sepsis or septic shock. After adjusting for known and potential risk factors, logistic regression found the following independent predictors of sepsis: SIRS equal to 1 (OR: 2.32, 1.16-4.89) and 2 or more (OR: 27.8, 14.8-56.4), MDW > 22 (OR: 3.73, 2.46-5.70), smoking (OR: 3.0, 1.22-7.31), end stage renal function (OR: 2.3, 1.25-4.22), neurodegenerative disease (OR: 2.2, 1.31-3.68), Neutrophils ≥ 8.9 × 103/µL (OR: 2.73, 1.82-4.11), Lymphocytes < 1.3 × 103/µL (OR: 1.72, 1.17-2.53) and CRP ≥ 19.1 mg/L (OR: 2.57, 1.63-4.08). A risk score derived from predictive models achieved high accuracy by using an optimal threshold (AUC: 95%; 93-97%). CONCLUSIONS: The study suggests that incorporating MDW in the clinical decision process may improve the early identification of sepsis, with minimal additional effort on the standard procedures adopted during emergency care.

Aggressive atraumatic myositis ossificans in a toddler.

Myositis ossificans (MO) is a benign disorder where bone forms within muscles or other soft tissues. This condition usually follows trauma and is rare in pediatric patients. Here we present the case of a 2-year-old male who developed MO of his right elbow without obvious trauma to the area. Imaging of MO in the initial phase is highly unspecific and obtaining tissue samples through a biopsy can render misleading reports. In most cases MO is a self-limited process with complete resolution, however, some cases may present a diagnostic and therapeutic challenge.

Osteosarcoma extraesquelético. Presentación de un caso / Extraskeletal osteosarcoma. Case report

El osteosarcoma extraesquelético es un tumor maligno de alto grado que representa menos del 2% de los sarcomas de partes blandas y que afecta principalmente a personas entre la quinta y sexta década de la vida. Típicamente el diagnóstico es tardío, con un período síntomas-diagnóstico extenso, >6 meses en comparación con el del osteosarcoma convencional. Comunicamos el caso de un hombre de 43 años que acudió con una tumoración en la región glútea y el muslo izquierdo de un año de evolución. Luego de estudios complementarios y una biopsia no concluyentes, se procedió a la resección quirúrgica del tumor con márgenes amplios. El estudio histológico de la pieza indicó osteosarcoma extraesquelético. El paciente tuvo una evolución muy buena, sin elementos de recidiva local ni compromiso a distancia luego de 20 meses de seguimiento. Nivel de Evidencia: IV

Extraskeletal osteosarcoma (EOS) is a high-grade malignant tumor that accounts for less than 2% of soft tissue sarcomas and mainly engages people between the fifth and sixth decade of life. It is typically of late diagnosis, with an extensive symptom-diagnosis period greater than 6 months compared to conventional osteosarcoma. We report the case of a 43-year-old patient who presented in our service with a 1-year-old tumor localized in the gluteal and left thigh region. After inconclusive paraclinical studies and biopsy, the tumor was surgically resected with wide margins and diagnosed as EOS after the histological analysis of the piece. The patient showed a very good clinical and paraclinical progression without signs of local or distant recurrence after 20 months of follow-up. Level of Evidence: IV

Long-term use of denosumab in giant cell tumors and vertebral aneurysmal bone cysts / Uso prolongado de denosumab no tumor de células gigantes e cistos ósseos aneurismáticos vertebrais / Uso prolongado de denosumab en tumor de células gigantes y quistes óseos aneurismáticos vertebrales

ABSTRACT Introduction: Denosumab is a human monoclonal antibody that binds to the receptor activator of nuclear factor kB (RANKL), it is used in the treatment of Osteoporosis. The Giant Cell Tumor (GCT) and the Aneurysmal Bone Cyst (ABC) use the same RANKL, and for this reason this drug began to be used for its treatment. There is consensus on the use, dose-time and 12-month duration for Denosumab treatment of GCT. Not so for ABC. In unresectable, disabling or recurrent tumors, its use could be for life. The adverse events of the habitual use of the drug are known, but it is not known if these increase with time. The objective of the present work is to identify the possible adverse events of treatment with Denosumab for more than 12 months. Material and Method: Series of cases with a diagnosis of GCT or ABC in spine, treated with Denosumab for more than 12 months. Adverse events are: arthralgia, fatigue, spinal pain, pain in extremities, headache, hypokalaemia, hypocalcemia, osteonecrosis of the jaw, malignant transformation, pathological fractures. Results: Eight patients, 6 TCG and 2 ABC, with a mean age at diagnosis of 25,6 years; presenting a mean treatment of 4.18 years (range 1.7 - 8.7). Of 6 operated patients, 4 had recurrence (2 to 36 months after surgery). One patient had to suspend treatment due to necrosis of the jaw, another hypocalcemia, both returned to treatment when stabilized. Conclusions: A minor adverse event (hypocalcemia) and a major adverse event (jaw bone necrosis) were observed. Level of Evidence IV; Original.

RESUMO Introdução: O denosumab é um anticorpo monoclonal humano que se liga ao receptor ativador do fator nuclear kB (RANKL), sendo utilizado no tratamento da Osteoporose. O Tumor de Células Gigantes (TCG) e o Cisto Ósseo Aneurismático (CAO) utilizam o mesmo RANKL, por isso esse medicamento passou a ser utilizado para seu tratamento. Há consenso sobre o uso, o tempo de dosagem e a duração de 12 meses para o tratamento com Denosumabe de TCG. Não é assim para CAO. Em tumores irressecáveis, incapacitantes ou recorrentes, seu uso pode ser vitalício. Os eventos adversos do uso habitual do medicamento são conhecidos, mas não se sabe se aumentam com o tempo. O objetivo do presente trabalho é identificar os possíveis eventos adversos do tratamento com Denosumabe por mais de 12 meses. Material e Método: Série de casos com diagnóstico de TCG ou CAO na coluna, tratados com Denosumabe por mais de 12 meses. Os eventos adversos são: artralgia, fadiga, dor na coluna, dor nas extremidades, cefaleia, hipocalemia, hipocalcemia, osteonecrose da mandíbula, transformação maligna, fraturas patológicas. Resultados: Oito pacientes, 6 TCG e 2 LRA, com média de idade ao diagnóstico de 25,6 anos; apresentando um tratamento médio de 4,18 anos (variação 1,7 - 8,7). Dos 6 pacientes operados, 4 tiveram recorrência (2 a 36 meses após a cirurgia). Um paciente teve que suspender o tratamento por necrose da mandíbula, outro hipocalcemia, ambos voltaram ao tratamento quando estabilizados. Conclusões: Um evento adverso menor (hipocalcemia) e um evento adverso maior (necrose óssea da mandíbula) foram observados. Nível de Evidência IV; Original.

RESUMEN Introducción: El Denosumab es un anticuerpo humano monoclonal que se une al receptor activador del factor nuclear kB (RANKL), se lo utiliza en el tratamiento de Osteoporosis. El Tumor de Células Gigantes (TCG) y el Quiste Óseo Aneurismático (QOA), utilizan los mismos RANKL, y por ello se comenzó a utilizar esta droga para su tratamiento. Existe consenso en la utilización, dosis-tiempo y 12 meses de duración para el tratamiento con Denosumab del TCG. No así para el QOA. En tumores irresecables, incapacitantes o con recidiva, su uso podría ser de por vida. Se conocen los eventos adversos de la utilización habitual de la droga, pero no se sabe si estas aumentan con relación al tiempo. El objetivo del presente trabajo, es identificar los posibles eventos adversos del tratamiento con Denosumab por más de 12 meses. Material y Método: Serie de casos con diagnóstico de TCG o QOA de columna, tratados con Denosumab por más de 12 meses. Los eventos adversos son: artralgias, fatiga, raquialgia, dolor en extremidades, cefalea, hipopotasemia, hipocalcemia, osteonecrosis de mandíbula, transformación maligna, fractura patológica. Resultados: Ocho pacientes, 6 TCG y 2 QOA, con promedio de edad al diagnóstico de 25,6 años; presentando una media de tratamiento de 4.18 años (rango 1,7 - 8,7). De 6 pacientes operados, 4 presentaron recidiva (2 a 36 meses después de la cirugía). Un paciente se debió suspender el tratamiento al presentar una necrosis de mandíbula, otro hipocalcemia, ambos retornaron al tratamiento al estabilizarse. Conclusiones: Se observa un evento adverso menor (hipocalcemia) y un evento adverso mayor (necrosis ósea de mandíbula). Nivel de Evidencia IV; Original.

Displasia fibrosa poliostótica - síndrome de McCune-Albright: reporte de un caso / Polyostotic fibrous dysplasia - McCune-Albright syndrome: a case report / Displasia fibrosa poliostótica - síndrome de McCune-Albright: relato de um caso

Resumen: Introducción: la displasia fibrosa poliostótica es una patología de muy baja prevalencia, por lo que su diagnóstico pasa desapercibido en la mayoría de los casos. Cuando se asocia a endocrinopatías o a lesiones cutáneas hiperpigmentadas corresponde al síndrome de McCune-Albright. Caso clínico: escolar de 8 años, sexo femenino, que presentó una fractura patológica de fémur izquierdo traumática, en la cual se diagnosticó una displasia fibrosa poliostótica. Por presentarse acompañada de pubertad precoz periférica configura el denominado síndrome de McCune-Albright. El control y tratamiento fue multidisciplinario. El equipo de traumatología realizó osteosíntesis con placa y tornillos de la lesión ósea con evolución a la consolidación en plazos habituales (tres meses). A los seis meses de seguimiento la niña se encuentra sin dolor y sin repercusiones funcionales para la vida diaria. Del punto de vista endocrinológico se realizó tratamiento de su pubertad precoz con inhibidores de la aromatasa con el fin de mejorar su talla final y evitar repercusiones psicológicas y emocionales. En este estudio se analizan características de esta patología y su pronóstico vital y funcional.

Summary: Introduction: polyostotic fibrous dysplasia is a low prevalence disease, and for this reason, it often goes undetected. When associated to endocrinopathies and/or hyperpigmented skin lesions we speak about McCune Albright syndrome. Clinical case: eight-year old school girl who presented pathological fracture of the left femur, which was diagnosed as polyostotic fibrous dysplasia. As it was accompanied by peripheral precocious puberty it constituted an indicative clinical picture of the so-called McCune Albright. Control and treatment were multidisciplinary. The traumatology team performed osteosynthesis with plaques and nails to fix the bone lesion, and evolution consolidated in a regular time frame (3 months). Upon six months follow-up, the girl has no pain and presents no functional repercussion in daily life. From the endocrinological perspective, the girl received precocious puberty treatment with aromatase inhibitors with the purpose of improving her final size and avoid psychological and emotional implications. The study presents the characteristics of this condition, as well as its vital and functional prognosis.

Resumo: Introdução: a displasia fibrosa poliostótica é uma doença de prevalência muito baixa, por isso seu diagnóstico passa despercebido na maioria dos casos. Quando associada a endocrinopatias e / ou lesões cutâneas hiperpigmentadas, corresponde à síndrome de McCune Albright. Caso clínico: estudante do sexo feminino, 8 anos, com quadro de fratura patológica traumática do fêmur esquerdo, com diagnóstico de displasia fibrosa poliostótica. Por estar acompanhada de puberdade precoce periférica, configura a chamada síndrome de McCune Albright. O controle e o tratamento foram multidisciplinares. A equipe de trauma realizou osteossíntese de placa e parafuso da lesão óssea com progressão à consolidação nos prazos usuais (3 meses). Aos 6 meses de seguimento, a paciente não apresenta dor e tampouco repercussões funcionais no dia a dia. Do ponto de vista endocrinológico, sua puberdade precoce foi tratada com inibidores da aromatase para melhorar sua altura final e evitar repercussões psicológicas e emocionais. Este estudo analisa as características desta patologia, seu prognóstico vital e funcional.

Valgus slipped capital femoral epiphysis: presentation, treatment, and clinical outcomes using patient-reported measurements.

Valgus slipped capital femoral epiphysis (SCFE), is rare. This study describes the diagnosis, treatment and outcome of valgus SCFE in Uruguay. The medical records and radiographs were reviewed in eight consecutive children [mean age 11.9 years (range 9-13; six female)] with valgus SCFE between 1997-2017. In 2018-2019, all patients were reexamined clinically, new radiographs obtained, and patient-reported outcomes completed using the international tool of hip results (iHOT-12). The prevalence of clinical femoroacetabular impingement (FAI), avascular necrosis, and surgical complications were also studied. There were 11 valgus SCFEs in eight patients; two had primary bilateral SCFEs, and one child later developed a valgus SCFE in the contralateral hip. Seven out of eight patients were overweight. All were stable idiopathic SCFEs. The mean femoral head shaft angle on the anteroposterior radiographs for the 11 SCFEs was 145° (range 140-168) and 141° (range 139-145) for the six healthy contralateral hips. Slip severity measured on the Lauenstein projection was mild (<30°) in eight hips and moderate (30°-60°) in three hips. At a mean follow-up of 87 months (range 24-252), there were no cases of avascular necrosis. The mean iHOT12 was 74 (range 13-97). Significant remodeling was detected in both head shaft angle (8°) and alpha angle (10°) in the affected hips. Nine hips (81%) demonstrated clinical signs of FAI. Our study is the first to describe long-term results using both clinical and patient outcome measures (iHOT-12). A majority of patients have residual symptoms, likely associated with FAI.

Escoliosis idiopática del adolescente, análisis postoperatorio. Serie de casos / Idiopathic adolescent scoliosis, post-operative analysis. Case Series

Introducción La escolisis es una deformidad tridimencional de la columna vertebral. El objetivo principal del tratamiento es evitar la progresión, lograr la máxima corrección y la artrodesis del menor numero de segmentos, con buen balance coronal y sagital que permita una fusión indolora. El objetivo del estudio es evaluar los resultados de los pacientes operados por escolisis idiopática del adoelscente en nuestro centro. Materiales y Métodos se realizó un estudio tipo serie de casos, se incluyeron pacientes operados entre 2011 y 2017; en ellos se estudiaron: los datos demografícos, el tipo de curva, la densidad de tornillos utilizados, el porcentaje de reducción lograda al año y las complicaciones. Resultados Se obtuvieron datos de 27 pacientes. Pedominaron las curva Lenke 1B. El ángulo de Cobb preoperatorio promedio fue de 66,5o con un postoperatorio de24,4o. La densidad de tornillo presentó un promedio de 1,4. Presentaron complicaciones el 25,6% de los pacientes, siendo la más frecuente la infección. En el cuestionario SRS-22 se obtuvieron buenas resultados. Discusión Se ha reportado una densidad de 0,8-1,69 tornillos por vértebra fusionada con un porcentaje de corrección de 64-70%. En nuestro resultados la densidad de tornillos por vertebra fusionado fue de 1,4 lográndose una reduccion de 64,1%. Aumentar el número de tornillos no aumentó el grado de corrección de las curvas. En concordancia con la literatura la complicación mas frecuente fue la infección, con baja incidencia de lesión neurológica. Concluimos que la técnica de artrodesis utilizada en nuestro centro, con tornillos pediculares de tercera generación, obtiene buenos resultados de reducción, con porcentaje de complicaciones similares a los reportados previamente.

Background Scoliosis is a three-dimensional deformity of the spine. The main objective of treatment is to avoid progression, achieve maximum correction and arthrodesis of the least number of segments, with good coronal and sagittal balance that allows a painless fusion. The aim of the study is to evaluate the results of patients who underwent to surgical fusion for adolescent idiopathic scoliosis. Material and Methods A case series study was conducted by analyzing medical records of patients who underwent to surgical fusion for adolescent idiopathic scoliosis. between 2011 through 2017.An analysis of demographic data, the type of curve, the density of screws used, the percentage of reduction achieved after one year, and complications was performed. Results Data of 27 patients was included. Lenke 1B curves were predominant. The mean preoperative Cobb angle was 66.5o with a postoperative 24.4o. Screw density presented an average of 1.4. Complications were presented in 25.6% of the patients, the most frequent being infection. Good results were obtained in the SRS-22 questionnaire. Discussion A density of 0.8-1.69 screws per fused vertebra has been reported with a correction percentage of 64-70%. In our results, the density of screws per fused vertebra was 1.4, achieving a reduction of 64.1%. Increasing the number of screws did not increase the degree of correction of the curves. In accordance with the literature, the most frequent complication was infection, with a low incidence of neurological injury. We conclude that the arthrodesis technique used in our center, with third-generation pedicle screws, obtains good reduction results, with a percentage of complications similar to those previously reported.

Funcionalidad y calidad de vida luego de la cirugía de escoliosis neuromuscular / Functionality and quality of life after neuromuscular scoliosis surgery

Introducción: El objetivo de este trabajo fue estudiar las complicaciones de la cirugía en pacientes con escoliosis neuromusculares operados en nuestro Centro, así como la funcionalidad y la calidad de vida luego del tratamiento quirúrgico. Materiales y Métodos: Se realizó un estudio retrospectivo, de tipo serie de casos. Se revisó la historia clínica, y se entrevistó al paciente y al cuidador principal. Luego de la cirugía, se evaluaron las complicaciones, la funcionalidad, la calidad de vida y el grado de satisfacción de los cuidadores. Resultados: La tasa de complicaciones fue del 26,7%, por infección y alteraciones hemodinámicas. Se obtuvieron resultados positivos en la funcionalidad y la calidad de vida de los pacientes, y fueron más significativos en cuanto a la capacidad de estar sentado y las actividades de la vida diaria. Conclusiones: La cirugía de los pacientes con escoliosis neuromuscular mejora la capacidad y el equilibrio de estar sentado, lo que favorece la capacidad digestiva, respiratoria y de vida social del paciente. Si bien se trata de cirugías con altas tasas de complicaciones, las tasas de satisfacción por parte de los cuidadores son altas. Nivel de Evidencia: IV

Introduction: The objective of this study was to evaluate surgical complications in patients with scoliosis operated on in our Center, as well as their functionality and quality of life after surgical treatment. Methods: A retrospective case series study was carried out. Medical history was reviewed and the patient and primary caregiver were interviewed. Results after surgery were assessed for complications, function, quality of life and caregivers´ degree of satisfaction. Results: Complication rate was 26.7%, due to infection and hemodynamic alterations. Positive results were obtained regarding function and quality of life of these patients, being more significant in terms of the ability to be seated and activities of daily living. Conclusions: Surgery of patients with neuromuscular scoliosis improves the capacity and balance of sitting, favoring digestive, respiratory and social life capacity. Although rate of complications is high, satisfaction rates on the part of the caregivers are elevated. Level of Evidence: IV

Síndrome SAPHO: Presentación de un caso clínico / SAPHO syndrome. A case report

El síndrome SAPHO incluye cinco entidades: Sinovitis, Acné, Pustulosis, Hiperostosis y Osteítis. Su característica principal es la asociación de múltiples afecciones osteoarticulares inflamatorias con trastornos cutáneos específicos. A propósito del caso clínico de un adolescente de 15 años con síndrome SAPHO, nos propusimos poner en conocimiento de la comunidad científica la importancia del diagnóstico precoz y el tratamiento acertado de esta patología. Las enfermedades de baja prevalencia han originado problemas diagnósticos en la práctica clínica; en el caso del síndrome SAPHO, tiene una demora diagnóstica promedio de ocho meses. El diagnóstico es fundamentalmente clínico. Cabe destacar que es un síndrome generalmente benigno, autolimitado y crónico, con períodos de exacerbaciones y remisiones. La antibioticoterapia y los procedimientos invasivos no son de elección. Nivel de Evidencia: IV

SAPHO syndrome involves synovitis, acne, pustulosis, hyperostosis, and osteitis. Its most important characteristic is the association of osteoarticular inflammatory conditions with specific skin disorders. We present a 15-year-old boy with SAPHO syndrome. The purpose of this paper is to raise awareness within the medical community of the importance of an early diagnosis and correct treatment. Low prevalence diseases have generated diagnostic problems in clinical practice. Delay in diagnosis of SAPHO syndrome averages 8 months. Diagnosis is mainly clinical. This is a generally benign, selflimited and chronic syndrome, with exacerbations and remissions. Antibiotic therapy and invasive procedures are not a choice. Level of Evidence: IV

Colgajo anterior de muslo en hemipelvectomía externa, reporte de caso / Anterior fl ap on external hemipelvectomy, case report

Introducción. La hemipelvectomía es un procedimiento agresivo para el tratamiento de tumores localmente avanzados. Requiere la conformación de un equipo interdisciplinario. Las opciones de cobertura dependen de la topografía de la lesión, existiendo 3 tipos de colgajo: posterior, anterior, y libre. Material y método. Se presenta el caso clínico de un paciente que presentó una ulcera de Marjolin a nivel de región trocantérica y glútea derecha, en el que se realizó una hemipelvectomía externa extendida, asociada a un colgajo anterior de muslo. Se trató de un colgajo músculo-cutáneo pediculado a los vasos femorales superfi ciales y profundos, compuesto por todos los planos de la logia anterior de muslo. Resultados. En este paciente se alcanzó una adecuada cobertura del defecto, que permitió su pronta rehabilitación. Discusión. Este colgajo es descripto como un colgajo pediculado en los vasos femorales superfi ciales. Creemos que si bien presenta vascularización por estos vasos, su mayor vascularización está dada por la arteria femoral profunda y su rama lateral circunfl eja. Este colgajo permite una adecuada cobertura en lesiones posteriores, con buena calidad de cobertura y menor número de complicaciones que el colgajo posterior. Conclusión. La hemipelevectomía externa es un tratamiento agresivo realizado para lesiones localmente avanzadas, con alta morbimortalidad, y que debe ser realizada por un equipo interdisciplinario. En cuanto a la cobertura, el colgajo anterior presenta buenos resultados dada su buena vascularización.

Background. Hemipelvectomy is an aggressive procedure for the treatment of locally advanced tumors. It requires the formation of an interdisciplinary team. The coverage options depend on the topography of the lesion, being 3 types of fl aps: posterior, anterior, and free. Material and Method. We present a case of a patient presenting an ulcer of Marjolin at the right trochanteric region. In which an extended external hemipelvectomy anterior fl ap is performed. It is a muscle cutaneous fl ap pediculated to the superfi cial and deep femoral vessels, composed of all the planes of the anterior thigh lodge. Results. In our patient we have reached an adequate coverage of the defect, which allowed an early rehabilitation of the patient. Discussion. This fl ap is described as a pedicled fl ap in the superfi cial femoral vessels. We believe that this fl ap is vascularized by these vessels, but its major vascularization is given by the deep femoral artery and its circumfl ex lateral branch. This fl ap allows adequate coverage in posterior lesions, with a good quality of coverage, and a lower number of complications than the posterior fl ap. Comments. External hemipelvectomy is an aggressive treatment performed for locally advanced lesions, with high morbidity and mortality, which must be performed by an interdisciplinary team. Regarding the coverage, we highlight the good results achieved by this fl ap given its good vascularization.

Denosumab, tratamiento alternativo en tumor óseo de células gigantes / Denosumab, an alternative treatment for giant cell tumor of bone

Introducción: el tumor óseo de células gigantes (TOCG) es un tumor benigno pero localmente agresivo. Se presenta en población joven y a nivel epifiso-metafisario. Está compuesto por una población celular estromal y otra multinucleada similar a los osteoclastos, donde se destaca la interacción RANK-RANKL (receptor del activador del factor nuclear kappa-B y su ligando, respectivamente). El anticuerpo monoclonal humano denosumab actúa inhibiendo específicamente RANKL, lo que evita la formación y activación de células multinucleadas. En la bibliografía se evidencia que denosumab tiene resultados alentadores como tratamiento adyuvante de algunos TOCG, generando planes terapéuticos con una menor morbimortalidad que los planteados previamente a la administración del anticuerpo. Material y método: se describe la primera experiencia terapéutica en Uruguay con dos pacientes menores de 40 años que consultaron por gonalgia de larga data, realizándose diagnóstico de TOCG estadio III de Campanacci, donde se realiza tratamiento con denosumab de forma protocolar valorando respuesta clínica, imagenológica, efectos adversos y modificación en plan terapéutico inicial. Resultados: se evidenció una respuesta clínica e imagenológica en los pacientes valorados. No se reportaron efectos adversos, logrando preservar la articulación afectada. Conclusiones: los resultados obtenidos son alentadores respecto al uso terapéutico de denosumab en los pacientes seleccionados. Esto permite considerar a denosumab dentro de las opciones terapéuticas de determinados pacientes con diagnóstico de TOCG.

Introduction: giant cell tumor of bone (GCTB) is a benign tumor, although it is locally aggressive. It arises mainly in young people at the epi-metaphyseal level. It consists of stromal cells and osteoclasts-like populations, where the RANK-RANKL (receptor activator of nuclear factor kappa-B and its ligand, respectively) stands out. Denosumab, the human monoclonal antibody, acts by specifically inhibiting RANKL, what prevents the formation and activation of multinucleate cells. The existing bibliography indicates denosumab has obtained encouraging results as adjuvant treatment for some GCTB, enabling therapeutic plans that have lower morbi-mortality rates than those applied prior to administration of the antibody. Method: the study describes the therapeutic experience of two patients younger than 40 years old, who consulted in Uruguay for long standing gonalgia. Campanacci Stage III GCTB was diagnosed, and denosumab treatment was initiated. Clinical response was assessed, as well as imaging response, adverse side effects and the modification of initial treatment. Results: clinical and imaging response was seen in the assessed patients. No adverse side effects were reported, and the affected joint was preserved. Conclusions: the results obtained are encouraging with regard to the therapeutic use of denosumab in the selected patients. This allows for denosumab to be regarded within the therapeutic options for certain patients with a diagnosis of GCTB.

Introdução: O tumor de células gigantes ósseo (TOCG) é um tumor benigno, porém agressivo. Apresenta-se em jovens localizando-se na metáfise e epífise dos ossos; compõe-se de uma população celular estromal e outra multinucleada similar aos osteoclastos, donde se destaca a interação RANK-RANKL (receptor do ativador do fator nuclear kappa-B e seu ligando, respectivamente). O anticorpo monoclonal humano denosumab age inibindo especificamente o RANKL, evitando a formação e a activação de células multinucleadas. A bibliografia mostra que o denosumab tem resultados animadores como tratamento adjuvante de alguns TOCG, com planos terapêuticos com menor morbimortalidade que os utilizados antes da administração do anticorpo. Material e método: descreve-se a primeira experiencia terapêutica no Uruguai com dois pacientes com menos de 40 anos que consultaram por gonalgia de longa data, realizando-se diagnóstico de TOCG estádio III de Campanacci; realizou-se tratamento com denosumab de acordo com o protocolo e avaliando a resposta clínica, a imagenología, os efeitos adversos e a modificação no esquema terapêutico inicial. Resultados: evidenciou-se uma resposta clínica e na imagenología nos pacientes avaliados. Não se informaram efeitos adversos, sendo possivel preservar a articulação afetada. Conclusões: os resultados obtidos são animadores com relação ao uso terapêutico do denosumab nos pacientes selecionados. Isto permite considerar o denosumab como opção terapêutica para determinados pacientes com diagnóstico de TOCG.

Anestesia para cirugía correctiva de escoliosis / Anesthesia for corrective surgery of scoliosis / Anestesia para a cirurgia corretiva de escoliose

La Unidad Docente Asistencial de Anestesiología Pediátrica del Centro Hospitalario Pereira Rossell integra el equipo multidisciplinario de tratamiento de las enfermedades de la columna vertebral desde hace cinco años. La escoliosis es una de las deformidades del raquis que puede requerir cirugía correctiva con implicancias anestesiológicas relevantes. Realizamos un estudio retrospectivo y descriptivo de 95 procedimientos anestesiológicos realizados a los pacientes que fueron sometidos a cirugía correctiva de escoliosis en el período comprendido entre marzo de 2.011 a marzo de 2.016. Los objetivos de este trabajo son comunicar nuestra experiencia junto con una revisión no sistematizada de la evidencia científica disponible en las bases de datos: Pubmed, Medline y SciELO. Concluimos que un manejo óptimo de los pacientes con escoliosis se logra realizando una adecuada evaluación perioperatoria.

The teaching care unit of pediatric anesthesiology of the Pereira Rossell Hospital has taken part for 5 years, in a multidisciplinary team which treats spinal disorders. Scoliosis is a deformity of the rachis that may require corrective surgery with relevant anesthesiological implications. We made a retrospective and descriptive study of 95 anesthesiological procedures realized to patients who had a scoliosis corrective surgery between March 2011 and March 2016. The objectives of this work is to communicate our experience together with a no systematic revision of the scientific evidence available on databases like: Pubmed, Medline and SciElo. The conclusions we have reach is that a better management of patients with scoliosis is achieved by making an adequate preoperative evaluation.

A Unidade Docente Assistencial de Anestesia Pediátrica de o Centro Hospitalar Pereira Rossell, faz cinco anos integra a equipe multidisciplinar de tratamento das doenças da coluna vertebral. A escoliose é uma das deformidades da raque que pode requerer cirurgia corretiva com implicações anestésicas relevantes. Realizamos um estudo retrospectivo e descritivo de 95 procedimentos anestésicos realizados aos pacientes que foram a cirurgia corretiva de escolioses no período compreendido entre março de 2011 a março de 2016. Os objetivos deste trabalho é comunicar nossa experiência e fazer uma revisão não sistematizada da evidencia cientifica disponível nas bases de dados: Pubmed, Medline e Scielo. Concluímos que um manejo ótimo dos pacientes com escolioses se obtém realizando uma apropriada avaliação perioperatoria.

Dysphagia produced by cervical spine osteophyte. A case report / Disfagia produzida por osteófito da coluna cervical. Relato de caso / Disfagia producida por osteofito de columna cervical. A propósito de un caso

We present a case of a 73-year-old male patient with progressive dysphagia, and hoarseness (irritability in the throat). He was studied with the appropriate imaging techniques, and esophagoscopy led to a diagnosis of extrinsic esophageal dysphagia for osteophyte obstruction of the cervical spine due to the arthrosis. A surgical resection was performed, without complications. Some considerations are given on this theme.

Apresentação de caso de paciente com 73 anos de idade e história de disfagia progressiva, com intercorrência de rouquidão (irritação na garganta). O caso foi analisado com técnica de imagem adequada, incluindo esofagoscopia, estabelecendo-se o diagnóstico de disfagia extrínseca por obstrução com osteófito da coluna vertebral cervical decorrente de artrose. Realizou-se a ressecção cirúrgica sem complicações. Apresentam-se algumas considerações sobre o caso.

Se presenta un caso de un paciente de 73 años de edad, de sexo masculino, con historia de disfagia progresiva, a la cual se agregó carraspera (irritación en la garganta). Luego de ser estudiado con imagenología adecuada, y estudio esofagoscópico se estableció el diagnostico de disfagia extrínseca, compresiva por osteofito de la columna cervical debido a artrosis. Se realizó la resección quirúrgica sin complicaciones. Se realizan algunas consideraciones sobre el tema.

Resultados de una encuesta sobre tratamiento de la cifosis torácica causada por enfermedad de Scheuermann / Resultados de uma pesquisa sobre o tratamento da cifose torácica de Scheuermann / Results of a survey on the treatment of thoracic Scheuermann´s kyphosis

OBJETIVO: Conocer que parámetros se deben considerar para encarar el tratamiento de la cifosis torácica causada por la enfermedad de Scheuermann. MÉTODO: Se realizó una recolección de informaciones consistente en aplicar un cuestionario a 25 informantes calificados, colegas de diferentes países de Íbero/Latinoamérica miembros de SILACO (Sociedad Íbero/Latinoamericana de Columna) y se analizaron los resultados de las mismas. RESULTADOS: Como tratamiento ortopédico, la mayoría se inclinó por el uso del corsé de Milwaukee, indicado en pacientes prepúberes y pospúberes con curvas mayores de 60º y en curvas de menos de 60º si tienen dolor. El tiempo de uso: 22 hrs por día, su mantenimiento hasta llegar a Risser 4 o 5. Se observó una tasa de abandono de 48% al plan terapéutico. En lo referente a tratamiento quirúrgico, las indicaciones surgen: por localización de la deformidad, el valor angular, dolor, edad y estética. La extensión del área a fusionar fue determinada con los espinogramas y radiografías dinámicas. Se eligió la vía posterior como vía de abordaje con barras y tornillos, y en algunos casos la combinación con ganchos. Se evaluaron los resultados del tratamiento quirúrgico (de acuerdo a la opinión del médico), que fueron catalogados como buenos en un 64%. CONCLUSIONES: Se realizó una encuesta de opinión sobre el tratamiento de la cifosis torácica causada por enfermedad de Scheuermann .y se analizaron 25 formularios de respuestas de calificados cirujanos de columna, de diferentes países de Ibero/Latinoamérica miembros de SILACO. La encuesta ha permitido establecer normas de conducta terapéuticas (ortopédicas y quirúrgicas) para el tratamiento de esta afección.

OBJETIVO: Obter os parâmetros a serem considerados para realizar o tratamento da cifose torácica de Scheuermann. MÉTODOS: Os dados foram obtidos por meio de um questionário que foi respondido por 25 membros da SILACO (Sociedad Ibero-Latino-americana de Columna) e análise dos resultados das respostas. RESULTADOS: Como tratamento ortopédico, a maioria optou pelo uso do colete de Milwaukee indicado para pacientes pré-púberes e pós-púberes com curvas maiores que 60° e curvas de menos de 60° acompanhadas de dor. O tempo de uso diário do colete foi de 22 horas até atingir Risser 4 ou 5. A taxa de abandono do plano terapêutico foi de 48%. Em relação ao tratamento cirúrgico, a maioria afirmou que as indicações estão relacionadas com localização da deformidade, valor angular, dor, idade e a estética. A extensão da área da artrodese foi determinada por meio de radiografias totais de coluna e dinâmicas. A abordagem posterior foi escolhida como a via de acesso preferida, utilizando-se hastes, parafusos e associação com ganchos. CONCLUSÃO: Realizamos uma pesquisa sobre o tratamento da cifose torácica decorrente de doença Scheuermann. Analisamos 25 formulários de resposta de cirurgiões de coluna qualificados de diferentes países membros da SILACO. A pesquisa permitiu estabelecer normas de conduta terapêutica (ortopédicas e cirúrgicas) para tratamento dessa afecção.

OBJECTIVE: To determine which parameters should be considered to address the treatment of thoracic Scheuermann kyphosis. METHOD: A survey information with a questionnaire applied to 25 informants, colleagues from different countries of Ibero-Latin American members of SILACO (Sociedad Ibero-Latinoamericana de Columna) and to analyze the results. RESULTS: Regarding to the orthopedic treatment the majority tended towards the use of Milwaukee brace for pre-pubertal and post-pubertal patients with curves greater than 60º and in curves of less than 60º if they had pain. Time of use: Twenty two hours per day until reaching Risser of 4 or 5. The rejection rate of the therapeutic plan was 48%. Regarding surgical treatment, the majority established that the indications are related to the location of the deformity, the angular value, pain, age and aesthetics. The extension of the area to be fused was determined by the total column and dynamic X-rays. Posterior approach was chosen to access; rod and screws, and in some cases the combination with hooks. CONCLUSION: We conducted a survey about the treatment of thoracic kyphosis due to Scheuermann disease and analyzed 25 response forms of qualified spine surgeons from different countries that are SILACO members. The survey has allowed to establish standards of management (orthopedic and surgical) for the treatment of this condition.

Anatomic study of lateral pelvic lymph nodes: implications in the treatment of rectal cancer.

PURPOSE: Lateral pelvic lymphadenectomy remains a controversial issue in rectal cancer surgery. Beyond clinical results, disagreement includes surgical anatomy aspects and definitions, as wells as lack of information about location, groups, and number of lymph nodes, all of which makes comparison of results difficult. We performed a systematic examination of the number and distribution of lateral pelvic lymph nodes using cadaveric dissection. METHODS: Sixteen formalin-fixed cadavers were dissected (14 males). Dissection fields were divided according to the three surgical groups of pelvic wall lymph nodes: presacral, obturator, and hypogastric. Number and site of excised lymph nodes was recorded, noting neurovascular relationships. RESULTS: A total of 458 lymph nodes were found, with a mean of 28.6 nodes per pelvis (range, 16-46). Lymph node size ranged from 2 to 13 mm. The highest number of lymph nodes was found in the obturator fossa group (mean, 7; range, 2-18). Hypogastric lymph nodes were found lying predominantly above the inferior hypogastric nerve plexus but reaching the deep pelvic veins. CONCLUSIONS: The mean number of lymph nodes found in lateral pelvic wall compartments was 28.6 per specimen. The group containing most lymph nodes lies in the obturator fossa. Complete excision of hypogastric lymph nodes demands a deep pelvic dissection of neurovascular structures.