Treatment of Infected Pseudarthrosis of the Tibia Using the Ilizarov Method and the Orr Dressing / Tratamento das pseudoartroses infectadas da tÍbia pelo mÉtodo de Ilizarov associado ao curativo de Orr

Abstract Objective This study aims to analyze outcomes and clinical and epidemiological data of infected tibial pseudarthrosis using the Ilizarov method and the Orr dressing. Methods Data from n = 43 patients diagnosed with infected tibial pseudarthrosis were analyzed by descriptive and inferential statistical methods. In addition, Paley's assessment criteria evaluated bone and functional outcomes. Qualitative variables were presented as the distribution of absolute and relative frequencies. The presentation of quantitative variables followed the D'Agostino-Pearson test. Results Thirty-seven (86.04%) subjects were males, and six (13.95%) were females. The most frequent age group among patients was 50 to 59 years old (25.6%), with a p-value = 0.8610. The treatment time was longer for the trifocal treatment (23.8 months) when compared to the bifocal treatment (15.6 months), with a p-value = 0.0010* (highly significant). Excellent bone outcomes represented 72.09% of the sample; 23.25% of outcomes were good. Functional outcomes were excellent in 55.81%, good in 6.97%, and regular in 27.90% of subjects. The Orr dressing (using Vaseline gauze) proved effective, achieving wound healing with soft tissue coverage in all patients evaluated. Conclusions The Ilizarov method resulted in a substantial change in the treatment of bone infections, especially infected pseudarthrosis. The versatility of this method has turned it into an effective tool, allowing the healing of the infectious process and the correction of potential deformities and shortening.

Resumo Objetivo Analisar os resultados e os dados clínicos e epidemiológicos do tratamento das pseudoartroses infectadas da tíbia pelo método de Ilizarov associado ao curativo de Orr. Métodos Para analisar os dados de n = 43 pacientes com diagnóstico de pseudoartrose infectada da tíbia foram aplicados métodos estatísticos descritivos e inferenciais e os resultados ósseos e funcionais foram avaliados de acordo com os critérios de avaliação de Paley. As variáveis qualitativas foram apresentadas por distribuição de frequências absolutas e relativas. As variáveis quantitativas foram apresentadas pelo teste de DAgostino-Pearson. Resultados Foi encontrado que 37 (86,04%) eram do sexo masculino, 6 (13,95%) femininos. A faixa etária mais frequente entre os pacientes foi de 50 a 59 anos (25.6%), p-valor = 0.8610. O tempo de tratamento é maior no tratamento trifocal (23.8 meses) quando comparado com o Bifocal (15.6 meses), p-valor =0.0010* (altamente significante). Os resultados ósseos excelentes representaram 72,09%, 23,25% foram de resultados considerados bons. Os resultados funcionais considerados excelentes foram 55,81%, os resultados bons foram 6,97%, resultados regulares foram 27,90. O curativo com gaze vaselinada (curativo de Orr) mostrou-se eficaz, alcançando assim a cicatrização das feridas com cobertura de partes moles em todos os pacientes avaliados. Conclusões O método de Ilizarov proporcionou uma mudança substancial no tratamentos das infecções ósseas, especialmente das pseudoartroses infectadas. A versatilidade deste método se transformou em uma ferramenta eficaz, permitindo a cura do processo infeccioso, bem como correção das possíveis deformidades e do encurtamento.

Evaluation of the Quality of Life of Patients Using Circular External Fixator in a Trauma Hospital / Avaliação da qualidade de vida dos pacientes em uso de fixador externo circular em um hospital de trauma

Abstract Objective To evaluate the quality of life of patients using an Ilizarov type external fixator for the treatment of complicated fractures and their sequelae. Method This is an observational and cross-sectional study, in which the 36-item short form survey (SF-36) questionnaire (translated into Portuguese) was applied during outpatient consultations in 2 periods, in the months of July 2018 and January 2019. The patients who participated in the study underwent their surgical procedures between January and June 2018. Results We evaluated 36 patients using an external Ilizarov fixator. We observed a predominance of male patients, with a mean age of 37.9 years. Fractures of leg bones and their complications represented half of the sample. Improvement in functional capacity and emotional aspects of the patients was observed throughout the treatment. Conclusion The use of the circular external fixator is an important and effective method for the surgical treatment of complex fractures and their sequelae. This study allowed us to conclude that, after treatment, patients achieved functional return to daily activities with adequate quality of life.

Resumo Objetivo Avaliar a qualidade de vida dos pacientes em uso do fixador externo do tipo Ilizarov para tratamento de fraturas complexas e de suas sequelas Método Trata-se de um estudo observacional e transversal, em que foi aplicado o questionário 36-item short form survey (SF-36) (traduzido para a língua portuguesa) durante as consultas ambulatoriais em 2 períodos, nos meses de julho de 2018 e janeiro de 2019. Os pacientes que participaram do estudo realizaram seus procedimentos cirúrgicos no período de janeiro a junho de 2018. Resultados Foram avaliados 36 pacientes em uso de fixador externo do tipo Ilizarov. Foi observado predomínio do sexo masculino e idade média de 37,9 anos. As fraturas de ossos da perna e suas complicações representaram metade da amostra. Foi observada melhora na capacidade funcional e nos aspectos emocionais dos pacientes ao longo do tratamento. Conclusão O uso do fixador externo circular constitui um método importante e eficaz para o tratamento cirúrgico de fraturas complexas e de suas sequelas. Este trabalho permitiu concluir que, após o tratamento, os pacientes alcançaram retorno funcional às atividades diárias com adequada qualidade de vida.

Lumbar arthrodesis in degenerative spine: post operative results and radiographic evaluation / Artrodese lombar nas afecções degenerativas da coluna: análise radiográfica e resultados pós-operatórios / Lumbar arthrodesis in degenerative spine: post operative results and radiographic evaluation

ABSTRACT Objective: To relate the radiographic fusion rate and the surgical results in patients undergoing posterolateral arthrodesis with instrumentation of the lumbar spine for the treatment of degenerative disorders. Method: A descriptive, retrospective, case series, observational study, based on medical records and imaging studies of 76 patients over 18 years of age (39 to 88 years) who underwent posterolateral lumbar arthrodesis. Data related to the presence of comorbidities were compiled and clinical outcomes were measured using specific questionnaires collected pre-surgical and 1 year after surgery. Fusion quality, as described by Christensen, was assessed from radiographic images by two examiners. The VAS, EQ-5D and Roland Morris questionnaires were used preoperatively and 1 year after surgery to assess pain, quality of life and function, respectively. Result: It was observed improvement in pain, function and quality of life after 1 year post-surgical. Pain, measured by VAS, had a reduction from 7.92 to 3.16 (p-value <0.001), the function evaluated by the Roland Morris score, also showed a reduction from 14.90 to 7.06 (p-value <0.001) . Culminating with the improvement in quality of life, measured by the EQ-5D, where there was a median increase in the score from 0.5672 to 0.7002 (p-value = 0.002). Conclusion: The absence of radiographic fusion has no direct correlation with worse results in clinical outcomes at 01 year after surgery. Most patients showed clinical improvement with no statistical difference in relation to cases in which bone fusion was obtained. Level of evidence IV; retrospective observation.

RESUMO: Objetivo: Relacionar a taxa de fusão radiográfica e os resultados cirúrgicos nos pacientes submetidos a artrodese posterolateral com instrumentação da coluna lombar para tratamento de afecções degenerativas. Método: Estudo observacional retrospectivo descritivo, tipo série de casos, com base em prontuários médicos e exames de imagem de 76 pacientes maiores de 18 anos (39 a 88 anos), submetidos a artrodese lombar posterolateral. Dados relacionados a presença de comorbidades foram compilados e os desfechos clínicos mensurados por meio de questionários específicos coletados no pré-cirúrgico e após um ano pós-cirúrgico. A qualidade da fusão, conforme descrita por Christensen, foi avaliada a partir de imagens radiográficas por dois examinadores. Os questionários de EVA, EQ-5D e Roland Morris foram utilizados no pré-cirúrgico e um ano pós-cirúrgico para avaliar dor, qualidade de vida e função, respectivamente. Resultado: Observou se melhora na dor, função e qualidade de vida após um ano pós-cirúrgico. A dor, mensurada pelo EVA teve uma redução de 7,92 para 3,16 (p-valor <0,001), a função avaliada pelo escore Roland Morris, também apresentou redução de 14,90 para 7,06 (p-valor <0,001). Culminando com a melhora na qualidade de vida, mensurada pelo EQ-5D, onde observou-se um aumento mediano escore de 0,5672 para 0,7002 (p-valor = 0,002). Conclusão: A ausência de fusão radiográfica não tem correlação direta com piores resultados nos desfechos clínicos em um ano de pós-cirúrgico. Maioritariamente, os pacientes apresentaram melhora clínica sem diferença estatística em relação aos casos em que foi obtido fusão óssea. Nível de evidência IV; Observacional retrospectivo.

RESUMEN: Objetivo: Relacionar ei índice de fusión radiográfica y los resultados quirúrgicos en pacientes sometidos a artrodesis posterolateral con instrumentación de columna lumbar para el tratamiento de trastornos degenerativos. Método: Estudio descriptivo, retrospectivo, serie de casos, observacional, basado en historias clínicas y estudios de imagen de 76 pacientes may ores de 18 anos (39 a 88 anos) a quienes se les realizó artrodesis lumbar posterolateral. Se recopilaron datos relacionados con la presencia de comorbilidades y se midieron los resultados clínicos mediante cuestionarios específicos recogidos antes de la cirugía y al año de la cirugía. La calidad de la fusión, según lo descrito por Christensen, fue evaluada a partir de imágenes radiográficas por dos examinadores. Los cuestionarios VAS, EQ-5D y Roland Morris se utilizaron en el preoperatorio y 1 año después de la cirugía para evaluar el dolor, la calidad de vida y la función, respectivamente. Resultado: Se observó mejoría en el dolor, función y calidad de vida después de 1 año posquirúrgico. El dolor, medido por EVA, tuvo una reducción de 7,92 a 3,16 (p-valor <0,001), la función evaluada por el puntaje de Roland Morris, también mostró una reducción de 14,90 a 7,06 (p-valor <0,001). Culminando con la mejora en la calidad de vida, medida por el EQ-5D, donde hubo un aumento mediano en el puntaje de 0,5672 a 0,7002 (p-valor = 0,002). Conclusión: La ausencia de fusión radiográfica no tiene correlación directa con peores resultados en los resultados clínicos al 01 año de la cirugía. La mayoría de los pacientes presentaron mejoría clínica sin diferencia estadística en relación a los casos en los que se obtuvo fusión ósea. Nivel de evidencia IV; observación retrospectiva.

Cura quirúrgica de pseudoartrosis atrófica infectada de diáfisis tibial / Surgical Cure of Infected Atrophic Nonunion of the Tibial Shaft

Introducción: La fractura de un hueso se define como la solución de continuidad de cierta porción ósea. Las fracturas diafisarias representan un bajo porcentaje de todas las fracturas, y el hueso tibial es el más afectado, debido a su escasa vascularidad, poca protección y existencia de diversos factores que hacen más propensos algunos problemas como pseudoartrosis y osteomielitis, que complican el tratamiento. Objetivo: Demostrar la eficacia de los resultados clínicos funcionales con la cura quirúrgica de pseudoartrosis infectada de diáfisis tibial con aporte de injerto óseo heterólogo de cadáver, y autoinjerto cortical esponjoso de cresta iliaca. Presentación del caso: Se presenta el caso de un paciente varón de 42 años que ingresa con diagnóstico de fractura expuesta II postraumática. Se realiza fijación externa en 2 ocasiones, con un intervalo de 6 días para corrección de valgo. El paciente se ausenta de sus controles clínicos y reingresa después de 10 meses aproximadamente por diagnóstico de pseudoartrosis atrófica infectada de tibia izquierda, según clasificación anatómica de Cierny-Mader IV. Se hospitaliza para cura quirúrgica y reconstrucción con aloinjerto óseo y autoinjerto de cresta iliaca, lo que da lugar a la consolidación y controles favorables. Actualmente el paciente ha recuperado la funcionalidad de su pierna izquierda, y queda como secuela una fístula con exposición de aloinjerto. Conclusiones: La cura quirúrgica de pseudoartrosis infectada de diáfisis tibial con aporte de injerto óseo heterólogo de cadáver, y autoinjerto cortical esponjoso de cresta iliaca presenta buenos resultados clínicos y funcionales, lo que constituye un método eficaz(AU)

Introduction: The fracture of a bone is defined as the solution of continuity of a certain bone portion. Diaphyseal fractures represent a low percentage of all fractures, and the tibial bone is the most affected, due to its scarce vascularity, little protection and the existence of various factors that make them more prone to some problems such as pseudoarthrosis and osteomyelitis, which complicate treatment. Objective: To demonstrate the efficacy of functional clinical results with the surgical cure of infected pseudoarthrosis of the tibial shaft with the contribution of heterologous cadaveric bone graft, and cortical cancellous autograft of the iliac crest. Case report: The case of a 42-year-old male patient admitted with a diagnosis of post-traumatic exposed fracture II is reported here. External fixation was performed on 2 occasions, with an interval of 6 days for valgus correction. The patient was absent from his clinical check-ups and was readmitted after approximately 10 months due to a diagnosis of infected atrophic nonunion of the left tibia, according to the anatomical classification of Cierny-Mader IV. He was hospitalized for surgical cure and reconstruction with bone allograft and iliac crest autograft, resulting in consolidation and favorable controls. Currently, the patient has recovered the functionality of his left leg, and a fistula with allograft exposure remains. Conclusions: Surgical treatment of infected tibial shaft pseudoarthrosis with provision of heterologous cadaveric bone graft and cortical cancellous autograft of iliac crest presents good clinical and functional results, which constitutes an effective method(AU)

Osteogénesis por distracción en pseudoartrosis infectada de tibia. A propósito de un caso / Distraction osteogenesis in infected pseudoarthrosis of the tibia. A clinical case

Los defectos óseos post-traumáticos (DOPT), son por definición una entidad en donde existe pérdida de stock óseo en huesos largos, secundario a trauma de alta energía, infecciones o iatrogenia. Se define como defecto óseo critico a aquel que no es capaz de sanar en forma espontánea, o a aquel que en longitud supera 2 veces el diámetro diafisario del hueso afectado. Son una causa importante de menoscabo en la calidad de vida del que la padece debido a la importante pérdida de funcionalidad osteomuscular. Existe una variedad de técnicas que buscan tratar esta entidad, siendo el injerto de peroné vascularizado, la inducción de membrana y la osteogénesis por distracción las alternativas comúnmente usadas. El objetivo de este reporte es exponer una experiencia local con la técnica de osteogénesis por distracción en un paciente con defecto óseo critico producto de una fractura expuesta de tibia.

Post-traumatic osseous defects are, by definition, a condition in which there is loss of bone stock in the long bones secondary to high energy trauma, infections or iatrogenesis. Critical osseous defect is defined as that which cannot heal spontaneously, or where its length is more than twice the diaphyseal diameter of the affected bone. It is an important cause of impairment in the quality of life of the sufferer due to the significant loss of musculoskeletal functionality. There are a variety of techniques used to treat this, vascularised fibula grafting, membrane induction and distraction osteogenesis being the commonly used alternatives. The objective of this report is to relate local experience of distraction osteogenesis in a patient with a critical osseous defect, product of an exposed tibia fracture.

Pseudoartrosis diafisaria de cúbito y radio con minifijador externo modelo RALCA® e injerto óseo homólogo / Diaphyseal Pseudoarthrosis of the Ulna and Radius Treated with the RALCA® Model External Minifixator and Homologous Bone Graft

RESUMEN Introducción: Las pseudoartrosis diafisarias de cúbito y radio constituyen un desafío terapéutico para el cirujano ortopédico, a causa de la dificultad para lograr y mantener la reducción de dos huesos paralelos en presencia de músculos pronadores y supinadores que ejercen influencias angulares y rotacionales. Objetivo: Evaluar la eficacia de la aplicación del minifijador externo combinado con el injerto óseo homólogo en esta afección. Métodos: Se realizó un estudio longitudinal, retrospectivo de corte transversal en 74 pacientes operados de pseudoartrosis diafisaria de cúbito y radio desde enero de 2000 hasta diciembre de 2014, en el Complejo Científico Ortopédico Internacional Frank País, en los que se utilizó el modelo de minifijación externa RALCA® e injerto óseo homólogo del Banco de Tejidos ORTOP. Resultados: La pseudoartrosis fue más frecuente en hombres (73 por ciento) y en las edades comprendidas entre 30 y 39 años. La localización más frecuente fue en el cúbito, en su tercio superior (52 por ciento). La mayoría de los pacientes presentaron una pseudoartrosis no viable (56 por ciento). Se consolidó en 66 por ciento de los pacientes antes de las 18 semanas y en solo uno no se obtuvo la consolidación. El hueso que menos tiempo requirió para consolidar fue el radio. En la evaluación de la eficacia de la técnica quirúrgica se obtuvo 62 por ciento de resultados buenos, 33 por ciento regulares y 5 por ciento malos. Conclusiones: La asociación de la minifijación externa modelo RALCA® e injerto óseo homólogo de banco mostró buenos resultados en el tratamiento de la pseudoartrosis de cúbito y radio(AU)

ABSTRACT Introduction: Diaphyseal pseudoarthroses of the ulna and radius constitute a therapeutic challenge for the orthopedic surgeon, due to the difficulty to achieve and maintain the reduction of two parallel bones in the presence of pronator and supinator muscles that exert angular and rotational influences. Objective: To evaluate the effectiveness of using external minifixator combined with homologous bone graft in the treatment of this condition. Method: A longitudinal, retrospective and cross-sectional study was carried out with 74 patients operated on, from January 2000 to December 2014, for diaphyseal pseudoarthrosis of the ulna or radius at Frank País International Orthopedic Scientific Complex, cases in which RALCA® external minifixation and homologous bone graft from the ORTOP Tissue Bank were used. Results: Pseudoarthrosis was more frequent in men (73 percent) and at ages 30-39 years. The most frequent location was the ulna, in its upper third (52 percent). Most of the patients had nonviable pseudoarthrosis (56 percent). The condition was consolidated in 66 percent of the patients within 18 weeks, and only one did not achieve consolidation. The bone that took the least time to heal was the radius. In the evaluation of the effectiveness of the surgical technique, 62% obtained good outcomes; 33 percent fair outcomes; and 5 percent, poor outcomes. Conclusions: The association of the RALCA® model miniexternal fixation and homologous bone graft from the Bank showed good outcomes in the treatment of ulna and radius pseudoarthrosis(AU)

Artrodesis transcalcánea con injerto libre del peroné por seudoartrosis de tibia distal / Transcalcaneal Arthrodesis with Free Fibula Graft for Distal Tibial Nonunion

RESUMEN Introducción: Las fracturas abiertas del tercio distal de tibia o pilón son poco frecuentes, en nuestro medio se producen por traumas de alta energía como los accidentes de tránsito, y pueden ser de distintos grados según su envergadura. Entre las complicaciones frecuentes están la seudoartrosis, deformidades y artritis postraumática. Cuando el dolor es refractario a los analgésicos están indicadas las artrodesis. Objetivo: Presentar los resultados del tratamiento realizado en un paciente con seudoartrosis distal de tibia y artritis postraumática del tobillo, dolorosa, con gran lesión de partes blandas, por lo que fue imposible realizar los procedimientos quirúrgicos habituales. Presentación del caso: Se realizó artrodesis de las articulaciones tibio-peronea-astragalina-calcánea, mediante un injerto libre del peroné autólogo, compresión, y estabilización con un fijador externo RALCA®; se asoció un campo electromagnético pulsátil para acelerar la formación del callo óseo y disminuir el dolor posquirúrgico. Durante dos años se le hizo seguimiento. Conclusiones: Se logró el objetivo del tratamiento al fusionar la articulación tibiotarsiana, comenzar el apoyo precoz y su capacidad funcional. Los resultados demuestran además los beneficios de la compresión realizada con los fijadores externos en las artrodesis; el uso del campo electromagnético asociado aceleró la osteogénesis, se consiguió la consolidación ósea, la estabilización, disminuyó el edema y el dolor, además la reincorporación del paciente a la sociedad. No se encontró en la bibliografía revisada otra técnica quirúrgica similar(AU)

ABSTRACT Introduction: Open fractures of the distal third of the tibia or pilon are rare, in our environment they are caused by high-energy traumas such as traffic accidents, and can be of different degrees depending on their size. Common complications include nonunion, deformities, and post-traumatic arthritis. When pain is refractory to analgesics, arthrodesis is indicated. Objective: To report the results of the treatment carried out in a patient with distal tibial pseudoarthrosis and post-traumatic arthritis of the ankle, painful, with a large soft tissue injury, which made it impossible to perform the usual surgical procedures. Case report: Arthrodesis of the tibiofibular-talar-calcaneal joints was performed, using a free graft of the autologous fibula, compression, and stabilization with a RALCA® external fixator. A pulsatile electromagnetic field was associated to accelerate bone callus formation and reduce postoperative pain. This patient was followed up for two years. Conclusions: The treatment objective was achieved by fusing the tibiotarsal joint, by starting early support and functional capacity. The results also prove the benefits of compression performed with external fixators in arthrodesis. The use of the associated electromagnetic field accelerated osteogenesis, bone consolidation and stabilization were achieved, edema and pain decreased, as well as the patient's reincorporation into society. No other similar surgical technique was found in the reviewed literature(AU)

¿Cuándo pensar en pseudoartrosis congénita de clavícula en pediatría? Presentación de 2 casos / When to think about pediatric congenital pseudoarthrosis of the clavicle? Presentation of 2 cases

La pseudoartrosis congénita de la clavícula es una malformación rara y benigna, caracterizada por la ausencia del tercio medio de la clavícula. Suele ser unilateral y mayoritaria en el lado derecho. La etiología es desconocida y se postulan diversas teorías etiopatogénicas (vascular, embriológica y genética).Puede detectarse en el período neonatal o, más frecuentemente, durante la infancia. En ocasiones, puede ser sintomática. Puede requerir tratamiento mediante reconstrucción quirúrgica por injerto óseo.Se presentan 2 casos, uno de diagnóstico neonatal y otro de 3 años de edad realizados con 24 h de diferencia. Se destaca la consideración de este diagnóstico como diferencial de fractura obstétrica o postraumática, displasia cleidocraneal y neurofibromatosis de tipo 1.

The congenital pseudoarthrosis of the clavicle is a rare and benign malformation, characterized by the absence of the middle third of the clavicle. It is usually unilateral and the majority on the right side. The etiology is unknown, postulating diverse etiopathogenic theories (vascular, embryological and genetic).It can be detected in the neonatal period or, more frequently, during childhood. Occasionally it can be symptomatic. It may require treatment by surgical reconstruction by bone graft. Two cases are presented, one of neonatal diagnosis and another one of 3 years of age performed with 24 hours of difference. We emphasize on its consideration as a differential diagnosis of obstetric or post-traumatic fracture, cleidocranial dysplasia and neurofibromatosis type I.

Seudoartrosis del escafoides: experiencia con injerto óseo vascularizado del primer metacarpiano. Serie de casos / Scaphoid pseudoarthrosis: experience with vascularized bone graft of the first metacarpal. Case series

Introducción describir los resultados clínicos, funcionales y radiológicos de pacientes con seudoartrosis de fractura del escafoides, sometidos a cirugía con la técnica de Bertelli. en un centro de cuarto nivel de complejidad. Materiales & Métodos Serie de casos en un centro de cuarto nivel de complejidad entre el 2005 y 2016 de pacientes con fractura de escafoides en seudoartrosis sometidos a cirugía de revisión con injerto vascularizado de la primera arteria dorsal metacarpiana según la técnica de Bertelli. Se tomaron datos de historias clínicas, que se analizaron con medidas descriptivas de resumen. Resultados se analizaron 11 pacientes con una edad promedio de 30,1 años. El 72,7% fue llevado a osteosíntesis como manejo inicial. El procedimiento de revisión se realizó en una mediana de 380 días. Se reportaron complicaciones pos-quirúrgicas: necrosis del injerto en un paciente, necesidad de re-intervención en cuatro y no hubo infecciones. En el 72,7% se observó consolidación de la fractura y ocurrió en promedio a los 7,6 meses. La mitad de los pacientes tuvieron un puntaje DASH de 9 o menos y reportaron percepción de dolor leve - moderado el 90,9%. La mediana de seguimiento fue 14 meses. Discusión la ventaja de esta técnica es su reproducibilidad y versatilidad, pues su pedículo vascular constante y de buena longitud, permite utilizarse por un abordaje dorsal o palmar y para no consolidaciones del polo proximal, cintura o polo distal del escafoides. Este estudio mostró buenos resultados clínicos y funcionales, asociados a una baja tasa de complicaciones. Nivel de evidencia IV

Background The aim of study is to describe the clinical, functional, and radiological results in patients with pseudoarthrosis of scaphoid fractures who that underwent surgery using Bertelli's et al. technique. Methods Case series of patients with nonunion of scaphoid fractures in a high complexity care center between 2005 and 2016, who underwent revision surgery with vascularized bone graft of the first metacarpal dorsal artery according to Bertelli's et al. technique. Data were collected from clinical records, and it waswere analyzed using descriptive summary measures. Results The analysis included 11 patients with a mean age of 30,1 years (S.D: 9). 72,7% of the patients underwent conventional osteosynthesis as the initial approach. The revision surgery was performed with a median of 380 days (interquartile range: 194-470); there were no intraoperative complications. Post- surgery complications, such as graft necrosis, were reported in a one patient (9,1%), the need of for re-intervention in four patients and there were no infection related complications. Fracture union was seen in 72,7% patients in a mean of 7,6 months (S.D: 2,9) after the intervention. Half of the patient had a DASH score of 9 points or less. 54,5 reported pain as mild, 36,4% as moderate and without pain 9,1%. The median follow up period was 14 months and only one patient developed carpal arthritis. Discussion The advantage of this surgical technique is its reproducibility and versatility, thanks due to the constant and long vascular pedicle; this allows using dorsal or palmar approaches, as well as for the management of scaphoid nonunions of the proximal pole, waist, or distal pole. This study shows good clinical and functional results outcomes with a low rate of complications. Evidence Level IV

Maxilla Pseudoarthrosis Ten Years After Orthognathic Surgery: case report / Pseudoartrosis Maxilar Diez Años Después de la Cirugía Ortognática: relato de un Caso

ABSTRACT: Many orthodontic treatments alone cannot reestablish an ideal occlusion, requiring correction through orthognathic surgery. An adequate surgical planning, execution and case follow-up can provide surgical stability between the maxilla and the mandible. Soft tissue conservation and proper correction during a healing phase are important to achieving this goal. Patient C.L.B.S, 38 years old, female, presented with Angle Class I occlusion, facial profile class II, maxilla with mobility, chin surgically advanced and anterior open bite. She was submitted to orthognathic surgery 10 years ago. In the panoramic radiography the absence of bone formation in the maxilla was observed, causing an open bite. For the surgery conventional radiographs were used, as well as the dental cast in articulator for model surgery and preparation of surgical guide. With the surgery an improvement in the patient's aesthetics profile and an ideal occlusion, static and functional were expected. The treatment was orthodontic-surgical, with correction of the dento-facial deformity with counter-clockwise rotation of the maxilla, lowering repositioning in 3 mm of its posterior portion through Le Fort I osteotomy, advancement of the 4 mm mandible with bilateral sagittal osteotomy, and genioplasty for posterior repositioning with a Z-osteotomy, to improve mentual harmony. There was an improvement in the profile and aesthetics of the patient, which developed an Angle Class I profile, a decrease in the mentual projection, and an aesthetic and functional improvement. The orthognathic surgery allowed the advancement of the mandible, the repositioning of the maxilla and the mentual posterior repositioning, obtaining the correction of the Angle class II profile and the anterior open bite, resulting in an important improvement of facial profile and esthetics, presence of skeletal stability, restoration of function, self-esteem and quality of life.

RESUMEN: En muchos casos, el tratamiento ortodóntico por si solo no puede restablecer una oclusión ideal, siendo necesaria una cirúrgia ortognática. Una buena planificación quirúrgica, ejecución y seguimiento del caso, pueden proporcionar estabilidad entre los maxilares. La preservación de los tejidos blandos y una fijación adecuada son esenciales para ese objetivo. La paciente CLBS, 38 años, se presentó con oclusión Clase I de Angle, teniendo perfil clase II, maxilar con movilidad, mentón quirúrgicamente avanzado y mordida abierta anterior. La paciente fue sometida a cirugía ortognática 10 años antes. En radiografía panorámica, se nota la ausencia de formación ósea debido a una fijación maxilar realizada erróneamente, lo que causó la mordida abierta. Durante la planificación, fueron utilizadas radiografías convencionales, modelos de yeso en articulador para cirugía de modelo y confección de guía quirúrgica. Con el procedimento quirúrgico se esperaba obtener una mejora en el perfil de la paciente y una oclusión ideal, estática y funcional. El tratamiento fue ortodóntico-quirúrgico, con corrección de la deformidad dento-facial con giro antihorario de la mandíbula, con reposicionamiento inferior de 3 mm de su parte posterior, por medio de osteotomía Le Fort I, avance de la mandíbula de 4 mm con osteotomía sagital bilateral, y retroceso del mentón en su posición original con osteotomía en Z, mejorando la armonía del mentón. Hubo una mejora en perfil y en la estética de la paciente, como también una mejora en el perfil, estética y funcionalidade, con diminución del mentón. La cirúrgia ortognática permitió el movimiento de la mandíbula, reposicionamiento maxilar y además fue posible retroceder el mentón, obteniendo la corrección del perfil Clase II y de la mordida abierta anterior. El resultado representa una mejora del perfil y de la estética facial, además se nota una estabilidad esquelética, con restablecimiento de la función, autoestima y calidad de vida.

Antegrade x retrograde nailing in femoral fractures: a study on consolidation and infection / Haste anterógrada x retrógrada em fraturas femorais: um estudo sobre consolidação e infecção

ABSTRACT Objective: Osteosynthesis with intramedullary nailing is considered the method of choice to treat diaphyseal femur fractures in adults. The objective of this retrospective study was to evaluate the bone healing time and incidence of infection in patients with diaphyseal femur fractures treated surgically with retrograde and antegrade intramedullary nailing. Methods: The medical records of 123 patients from two university hospitals dated 2011-2013 were evaluated, with 126 diaphyseal femur fractures having been found. The most frequent treatment was antegrade intramedullary nailing (51%), of which 38% involved reaming (n=25). Results: We found evidence of 92% healed fractures at 12 months postoperatively. Complications included chronic osteomyelitis in one patient and femoral neck fracture in another patient, both after reamed antegrade nailing. Pyoarthritis of the knee associated with osteomyelitis affected two patients after reamed retrograde nailing and one patient after unreamed retrograde nailing. Conclusion: We did not observe a significant difference in bone healing rates with the use of reamed or unreamed antegrade or retrograde nailing. Complications included the presence of infection with an incidence similar to that reported in the literature, and of particular significance, unrelated to the type of approach. Level of evidence III, Retrospective comparative study.

RESUMO Objetivo: A osteossíntese com haste intramedular é considerada o método de escolha para tratamento das fraturas diafisárias do fêmur em adultos. O objetivo deste estudo retrospectivo foi avaliar o tempo até a consolidação e a incidência de infecção em pacientes com fratura diafisária do fêmur, operados com haste intramedular retrógrada e anterógrada. Métodos: Foram avaliados os prontuários de 123 pacientes de dois hospitais universitários entre os anos de 2011 e 2013, tendo sido encontradas 126 fraturas diafisárias do fêmur. O tratamento mais frequente foi com haste intramedular anterógrada (51%), das quais 38% (n=25) eram fresadas. Resultados: Com 12 meses de pós-operatório, evidenciamos 92% de consolidação. Entre as complicações, observamos um paciente com osteomielite crônica e um com fratura do colo do fêmur, ambos submetidos à haste intramedular anterógrada fresada e pioartrite do joelho, associada à osteomielite em dois pacientes submetidos à haste intramedular retrógrada fresada e em um paciente após a utilização de haste intramedular retrógrada não fresada. Conclusão: Não observamos diferença significativa entre a taxa de consolidação com o emprego das hastes retrógradas e anterógradas, fresadas ou não fresadas. Dentre as complicações, observamos a presença de infecção em incidência similar à da literatura e particularmente sem relação com a via de acesso escolhida. Nível de evidência III, estudo retrospectivo comparativo.

Paciente pediátrico con tibialización perónea por pseudoartrosis de tibia secundaria a osteomielitis / Pediatric patient with fibular tibialization due to tibial pseudoarthrosis secondary to osteomyelitis

Los defectos óseos secundarios de la tibia en los niños, por procesos infecciosos como la osteomielitis, representan un reto en su tratamiento 1, 2. Históricamente, los defectos en la tibia han sido tratados con un injerto óseo 3. Desde 1983 el uso del injerto autólogo vascularizado con regeneración de los tejidos ha dado resultados favorables 4. La forma más eficaz de estimular la osteogénesis se consigue con un injerto autólogo acompañado de una vascularidad óptima y una conexión con los tejidos blandos.

The bone defects of the tibia in children related to infectious processes such as osteomyelitis, represent a treatment challenge.1,2 Historically, defects in the tibia have been treated with a bone graft.3 Since 1983 use of vascularized autologous graft, with tissue regeneration has met with favorable results.4 The most effective form of osteogenesis is accomplished with an autologous graft accompanied by optimal vascularization and a connection with the soft tissues.

Factors Influencing the Outcome of Osteosynthesis in the Fracture of the Femoral Neck in Young Adult Patients / Fatores que influenciam o resultado da osteossíntese na fratura do colo do fêmur em pacientes adultos jovens

Abstract Objectives To evaluate the factors that influence the outcome of osteosynthesis after closed reduction of the fracture of the femoral neck in young adult patients. Methods A retrospective study was conducted, reviewing the data of patients operated in a large orthopedic hospital from 2003 to 2011; a total of 81 patients met the inclusion criteria. The time interval between the fracture and the surgery, the initial fracture deviation, the quality of the reduction, and the placement of the implant were evaluated. Results The present study observed a strong relationship between the quality of the reduction and therapeutic success. The degree of the initial deviation and the time elapsed between the initial trauma and the osteosynthesis did not influence the surgical outcome regarding bone consolidation. The correct positioning of the implants was associated with a satisfactory evolution in the postoperative period. Conclusion The quality of the reduction and the positioning of the implants are factors that influence the results of osteosynthesis in fractures of the femoral neck in young adult patients.

Resumo Objetivos Avaliar os fatores que influenciam o resultado da osteossíntese pela redução fechada da fratura do colo femoral nos pacientes jovens. Métodos Foi feito um estudo retrospectivo com revisão dos dados dos pacientes operados em um hospital ortopédico de grande porte, de 2003 a 2011, com um total de 81 pacientes que atenderam aos critérios de inclusão. O intervalo de tempo entre a fratura e a cirurgia, o desvio inicial da fratura, a qualidade da redução e o posicionamento dos implantes foram os fatores avaliados. Resultados O estudo encontrou forte relação entre a qualidade da redução e o sucesso terapêutico. O grau de desvio inicial e o tempo entre o trauma inicial e a osteossíntese não influenciaramo desfecho cirúrgico emrelação à consolidação óssea. O correto posicionamento dos implantes mostrou relação com a evolução satisfatória no pós-operatório dos pacientes. Conclusão A qualidade da redução e o posicionamento dos implantes são fatores que influenciamoresultadodaosteossíntesenafraturadocolodofêmurnopacienteadultojovem.

Algoritmo del tratamiento de la seudoartrosis diafisaria / Diaphyseal pseudarthrosis treatment algorithm

Resumen: Se presenta una guía terapéutica de la seudoartrosis diafisaria con los diferentes grados de dificultad a que se enfrenta el cirujano ortopédico, mencionando los principios que deben seguirse para obtener óptimos resultados.

Abstract: We present a therapeutic guide of diaphyseal pseudoarthrosis with the different degrees of difficulty faced by the orthopedic surgeon, mentioning the principles that must be followed to obtain optimal results.

Tratamiento de defectos masivos de tibia: técnica de transporte óseo con fijador AO [Arbeitsgemeinschaft für Osteosynthesefragen] / Treatment of massive defects tibia: bone transport technique with fixator AO / Tratamento de defeitos maciços da tíbia: técnica de transporte ósseo com fixador AO

Introducción: La transportación ósea se refiere al traslado de un fragmento de hueso a través de un defecto óseo, por distracción osteogénica. Objetivo: Describir la técnica quirúrgica con fijador externo AO, y evaluar los resultados de este tratamiento en defectos óseos diafisarios de tibia mayores de 4 cm, secundarios a fracturas expuestas graves o pseudoartrosis infectadas. Material y método: Se realizó un estudio descriptivo de tipo serie de casos, retrospectivo, de los 14 pacientes tratados entre abril del 2011 y abril del 2015, con las lesiones o secuelas mencionadas en diferentes centro de Montevideo. Resultados: Todos los pacientes tenían secuelas a fracturas expuestas graves con defecto segmentario de tibia mayor a 4 cm. El seguimiento promedio fue de 13 meses (entre 6 y 27). La media de edad fue de 32 años (entre 15 y 53), la perdida ósea promedio 6,7 cm (entre 4 y 11), la velocidad de distracción de 0,58 mm/día, el período de distracción promedio fue de 92 días (entre 35 y 172), y el tiempo medio de fijadores externos desde el inicio fue de 194 días. Todos los pacientes requirieron algún procedimiento quirúrgico en el sitio de acoplamiento. Se logró la consolidación en 9 pacientes, hubo 2 pseudoartrosis, 2 pacientes abandonaron el tratamiento y uno decidió la amputación. No hubo ninguna recidiva de infección. Conclusión: La técnica de transportación ósea mediante el uso de fijadores externos AO, es una alternativa válida para el tratamiento de las perdidas óseas diafisarias de tibia con o sin infección.

Introduction: Bone transport is the slow transportation of the bone fragment along a bone defect, providing distraction osteogenesis. Objective: To describe the surgical technique of bone transport using the AO external fixator and to present the result of this procedure in tibial diafisis defects of more than 4 cm long, which were the result of severe open fractures or infected no unions. Material and Methods: This is a retrospective, descriptive study of 14 patients treated in several centers in Montevideo from April 2011 to April 2015. Results: The average age of the patients was 32 years (15-32), the average bone loss 6,7 cm (4-11), the distraction speed 0,58 mm/day, the mean distraction period 92 days (35-172) and the mean time external fixation was 194 days. The mean follow up was 13 months (6-27). All patients needed an additional surgical procedure in the docking site. Bone healing was accomplished in 9 patients and there were 2 no unions. There were 2 further patients who abandoned the treatment and another patient who requested amputation. At the latest follow up there was no recurrence of infection. Conclusion: Bone transport using AO external fixator, is a valid alternative for the treatment of segmental bone loss of the diafisis of the tibia with or without infection.

Introdução: O transporte ósseo é o transporte lento do fragmento ósseo ao longo de um defeito ósseo, que proporciona distração osteogênica. Objetivo: Descrever a técnica cirúrgica de transporte de osso, utilizando o fixador externo AO e apresentar o resultado deste procedimento nos defeitos da diáfise da tíbia de mais de 4 cm de comprimento, que foram um resultado de fracturas expostas graves ou ausência de juntas infectados. Material e métodos: Trata-se de um estudo descritivo e retrospectivo de 14 pacientes atendidos em diversos centros de Montevidéu no período de abril de 2011 a abril de 2015. Resultados: A idade média dos pacientes era de 32 anos (15-32), a 6,7 cm perda óssea média (4-11), a taxa de distracção 0,58 milímetros/dia, período médio de 92 dias distracção (35-172) e o tempo médio de fixação externa foi de 194 dias. O seguimento médio foi de 13 meses (6-27). Todos os pacientes precisaram de um procedimento cirúrgico adicional no local de encaixe. A cicatrização óssea foi realizada em 9 pacientes e não houve 2 articulações. Houve mais 2 pacientes que abandonaram o tratamento e outro paciente que solicitou a amputação. No último seguimento, não houve recidiva da infecção. Conclusão: O transporte ósseo utilizando o fixador externo AO é uma alternativa válida para o tratamento da perda óssea segmentar da diáfise da tíbia com ou sem infecção.

Prevalence of curable and pseudoarthrosis stages of adolescent lumbar spondylolysis / Journal of Rural Medicine

Objective: The aim of this study was to determine the prevalence of curable and pseudoarthrosis stages of adolescent lumbar spondylolysis under high school students complaining of and seeking medical consultation for low back pain.Patients and Methods: We analyzed age, sex, morbidity, presence of spina bifida occulta (SBO), and competitive sport discipline of patients with lumbar spondylolysis. We then stratified their pathological stage using a modified classification system via magnetic resonance imaging and computed tomography.Results: Of 507 patients, 451 lesions in 268 patients were diagnosed with lumbar spondylolysis (average age, 14.7 years; sex ratio, 215:53 male/female). Morbidity levels were as follows: L1, 1 lesion in 1 patient; L2, 9 lesions in 5 patients; L3, 38 lesions in 25 patients; L4, 106 lesions in 74 patients; L5, 297 lesions in 189 patients, and SBO verified in 111 patients. A total of 264 patients played a specific sport: baseball, 93; soccer, 49; volleyball, 21; track and field, 21; basketball, 20; others, 164. The prevalence of curable- and pseudoarthrosis-stage lumbar spondylolysis was 206 lesions in 142 patients, and 141 lesions in 87 patients, respectively.Conclusion: With 59.3% of patients having curable-stage lumbar spondylolysis, adolescent athletes with low back pain are urged to seek consultation. Furthermore, clinicians should perform magnetic resonance imaging to avoid misdiagnosis.

Percutaneous bone cement fusion for the stress fracture of vertebral body adjacent to pseudoarthrosis in patients with ankylosing spondylitis: preliminary results in 4 cases / 介入放射学杂志

Objective To assess the clinical value of percutaneous bone cement fusion in treating stress fracture of vertebral body that is adjacent to pseudoarthrosis in patients with ankylosing spondylitis.Methods The clinical data of 4 ankylosing spondylitis patients with stress fracture of vertebral body adjacent to pseudoarthrosis,which was treated with percutaneous bone cement fusion,were retrospectively analyzed.Bone cement fusion through injection of bone cement was performed for 4 vertebral segments.Visual analogue scale (VAS) of pain and Oswesty disability index (ODI) were determined before and after operation,the results were compared,and the improvements of pain and daily activity were evaluated.Results The operation was successfully accomplished in all the 4 patients.The mean used amount of bone cement for each vertebral segment was 14.5 ml.Small amount of bone cement extravasation was observed in one patient,but no severe clinical complication occurred.The mean VAS score decreased from preoperative 9 points to postoperative 3.5 points;ODI score decreased from preoperative 43.8 points to postoperative 14.5 points.After the treatment,the pain was obviously relieved and the daily activity was markedly improved.Conclusion For the treatment of stress fracture of vertebral body that is adjacent to pseudoarthrosis in patients with ankylosing spondylitis,percutaneous bone cement fusion is minimally-invasive,safe and effective.

Bilateral First Rib Stress Fractures with Pseudoarthrosis in a Young Weightlifter: A Rare Cause of Shoulder Pain / 대한스포츠의학회지

Isolated stress fracture of the first rib is quite rare cause of uncertain shoulder pain in athletes. These fractures are stress induced and precipitated by repeated traction of muscles acting on the first rib. A prompt diagnosis can shorten the time required for healing and decrease the risk of associated complication as nonunion or pseudoarthrosis. The diagnosis can be made by taking a thorough history and performing chest X-ray, computed tomography, or bone scan. Early recognition and proper management generally lead to successful outcomes and return to normal activities. Typically, they heal with conservative treatment with rest and mild analgesia. This report describes stress fractures of bilateral first rib in a weightlifter, one of which developed into a pseudoarthrosis as a result of persistent overhead activities due to missed diagnosis.

Circumferential Fusion through All-Posterior Approach in Andersson Lesion

STUDY DESIGN: Retrospective case series. PURPOSE: To assess safety and efficacy of single stage, posterior stabilisation and anterior cage reconstruction through the transforaminal or lateral extra-cavitary route for Andersson lesions. OVERVIEW OF LITERATURE: Pseudoarthrosis in ankylosing spondylitis (Andersson lesion, AL) can cause progressive kyphosis and neurological deficit. Management involves early recognition and surgical stabilisation in patients with instability. However, the need and safety of anterior reconstruction of the vertebral body defect remains unclear. METHODS: Twenty consecutive patients with AL whom presented with instability back pain and or neurological deficit were managed by single stage posterior approach with long segment pedicle screw fixation and anterior vertebral reconstruction. Radiological evaluation included- the regional kyphotic angle, measurement of anterior defect in computed tomography (CT) scan and the spinal cord status in magnetic resonance imaging. Radiological outcomes were assessed for fusion and kyphosis correction. Functional outcomes were assessed with visual analogue scale (VAS), ankylosing spondylitis quality of life (ASQoL) and Oswestry disability index (ODI). RESULTS: The mean age of the patients was 50.1 years (male, 18; female, 2). The levels affected include thoracolumbar (n=12), lower thoracic (n=5) and lumbar (n=3) regions. The mean level of fixation was 6.2±2.4 vertebrae. The mean anterior column defect was 1.6±0.6 cm. The mean surgical duration, blood loss and hospital stay were 112 minutes, 452 mL and 6.2 days, respectively. The mean followup was 2.1 years. At final follow up, VAS for back pain improved from 8.2 to 2.4 while ODI improved from 62.7 to 18.5 (p <0.05) and ASQoL improved from 14.3±2.08 to 7.90±1.48 (p <0.05). All patients had achieved radiological union at a mean 7.2±4.6 months. The mean regional kyphotic angle was 27° preoperatively, 16.7° postoperatively and 18.1° at the final follow-up. CONCLUSIONS: Posterior stabilisation and anterior reconstruction with cage through an all-posterior approach is safe and can achieve good results in Andersson lesions.

Clinical evaluation of patients submitted to osteogenic distraction in the lower limb at a university hospital / Avaliação clínica de pacientes submetidos à distração osteogênica no membro inferior em hospital universitário

ABSTRACT OBJECTIVE: To evaluate the clinical characteristics from patients submitted to osteogenic distraction to correct bone gap at a university hospital. METHODS: Retrospective transversal study, with a convenience sample, from 2000 to 2012, evaluating clinical aspects of patients treated, submitted to osteogenic distraction (bone transport) with Ilizarov's external fixation device. The chi-squared, Fisher's, and Mann-Whitney's U tests were used with a 5% level of significance (p < 0.05). RESULTS: 33 patients were studied, of whom 28 men (84.8%). The more frequent age was from 21 to 40 years. Most patients were from the metropolitan region of the capital (57.6%). The leg was the most affected limb (75.8%), and the left side was the most affected (66.7%). The most common cause was infected pseudoarthrosis (75.8%). The most common bone transportation type was bifocal (75.8%). Mean previous surgery at others institutions were 2.62 (1.93 standard deviation), and mean surgeries after treatment were 1.89 (1.29 standard deviation). Ilizarov's external fixation device was used for 1.94 years (1.34 mean deviation), from one to six years. The most common complications were pin infection (57.6%), equinus (30.3%), deep infection (24.2%), and shortening (21.2%). CONCLUSION: Osteogenic distraction for bone gaps were more frequent in young adults, men, in the leg, with bifocal transportation, after several previous surgeries, treated for a mean of two years, with many complications (infections were the most common).

RESUMO OBJETIVO: Avaliar as características clínicas dos pacientes submetidos à distração osteogênica por falha óssea em hospital universitário. MÉTODOS: Estudo transversal, retrospectivo, com amostra de conveniência, de 2000 a 2012, das características clínicas de pacientes tratados e submetidos à distração osteogênica (transporte ósseo) com uso de fixador externo circular tipo Ilizarov. Foram usados os testes de qui-quadrado, exato de Fisher e U de Mann-Whitney, com nível de significância de 5% (p < 0,05). RESULTADOS: Foram 33 casos, 28 homens (84,8%). A idade mais frequente foi entre 21 e 40 anos. A maioria dos pacientes (57,6%) era da região metropolitana. O segmento mais afetado foi a perna (75,8%) e o lado foi o esquerdo (66,7%). A causa mais frequente foi a pseudoartrose infectada (75,8%). O tipo de transporte ósseo feito foi principalmente o bifocal (75,8% dos casos). A média de procedimentos prévios em outra instituição foi de 2,62 cirurgias (desvio padrão de 1,93) e a dos feitos após o início do tratamento foi de 1,89 cirurgia (desvio padrão de 1,29). O tempo de uso de fixador externo foi de 1,94 ano (desvio padrão de 1,34), com mínimo de um ano e máximo de seis. As quatro complicações mais encontradas foram infecção de base de pinos (57,6% dos casos), equino (30,3%), infecção profunda (24,2%) e encurtamento (21,2%). CONCLUSÃO: A necessidade de distração osteogênica por falhas ósseas foi mais frequente em adultos jovens, homens, na perna, com transporte bifocal, após múltiplas cirurgias prévias, com média de aproximadamente dois anos de tratamento e com várias complicações (as infecções foram as principais).