Revisión narrativa: unidad de ortogeriatría, la propuesta para reducir los desenlaces adversos en adultos mayores con fracturas de cadera por fragilidad / Narrative review: Orthogeriatrics unit, the proposal to reduce adverse outcomes in older adults with fragility fractures

Introducción Las fracturas de cadera son un problema de salud pública debido a su asociación con altas tasas de mortalidad a un año, deterioro funcional y empeoramiento de la calidad de vida. Un enfoque multidisciplinario mejora los resultados de los pacientes adultos mayores con fracturas por fragilidad. Objetivo Realizar una revisión narrativa para evaluar la evidencia de las unidades de ortogeriatría como estrategia para reducir desenlaces adversos en adultos mayores con fracturas de cadera por fragilidad. Materiales y métodos Se realizó una búsqueda de la literatura en las siguientes bases de datos: PubMed,Cochrane y Scielo, con los términos: "hip fracture" or "fragility fracture" AND "multidisciplinary team" or "Geriatric co management" or AND "orthogeriatric" or "ortho-geriatric". Resultados El manejo por ortogeriatría reduce el tiempo de evaluación pre-quirúrgico, complicaciones postoperatorias y la estancia hospitalaria. La valoración interdisciplinaria ha demostrado ser eficaz para disminuir el deterioro funcional, la mortalidad intrahospitalaria, la mortalidad a los 30 días y el riesgo de institucionalización en comparación con otros modelos de atención. Estos factores impactan sobre la optimización de recursos disminuyendo los costos en salud. Conclusión Los servicios de ortogeriatría son el modelo ideal para tratar las fracturas de cadera por fragilidad en adultos mayores. En Colombia se deben implementar más unidades de ortogeriatría para mejorar la atención intrahospitalaria, crear programas de seguimiento y rehabilitación.

Introduction Hip fracture is a public health problem due to its association with high mortality rates at one year, functional decline and worsening of quality of life. A multidisciplinary approach improves outcomes for elderly patients with fragility fracture. Objective To carry out a narrative review to evaluate the evidence of orthogeriatric units as a strategy to reduce adverse outcomes in older adults with fragility hip fractures. Material and Methods A literature search was carried out in the following databases: PubMed, Cochrane and Scielo, with the terms: "hip fracture" or "fragility fracture" AND "multidisciplinary team" or "Geriatric co management" or AND "orthogeriatric" or "ortho-geriatric". Results Care by orthogeriatrics reduces pre-operative surgical time, postoperative complications and hospital stay. Interdisciplinary assessment has been shown to be effective in reducing functional decline, in-hospital mortality, 30-day mortality, and the risk of institutionalization compared to other models of care. These factors impact on the optimization of resources, reducing health costs. Conclusion Orthogeriatric services are the ideal model to treat fragility fractures in older adults. In Colombia, more orthogeriatric units should be implemented to improve in-hospital care, create follow-up and rehabilitation programs.

Correlación clínico-radiológica como primera ruta en el diagnóstico de síndrome de Gorham-Stout / Clinical-radiological correlation as the first route in the diagnosis of Gorham-Stout syndrome

Resumen El síndrome de Gorham-Stout constituye una rara enfermedad ósea cuya etiología sigue siendo desconocida, que se caracteriza por presentar osteólisis y proliferación anormal de canales vasculares. Se describe el caso de un paciente masculino de 47 años quien consultó por un cuadro de aproximadamente 15 días de evolución consistente en edema, dolor, eritema y secreción sero-hemática por herida quirúrgica en hombro derecho, con diagnóstico reciente de artritis séptica. Refería antecedente de síndrome de Gorham-Stout, evidenciándose al examen físico y radiografía comparativa de hombros. La presentación clínica de estos pacientes depende del área afectada y la extensión de la enfermedad, convirtiéndose su diagnóstico en un desafío en caso de que el deterioro se presente en zonas no expuestas. El principal síntoma consiste en dolor localizado, acompañado de hinchazón, debilidad y deterioro funcional de las extremidades afectadas. Estos pacientes pueden permanecer asintomáticos hasta sufrir una fractura ósea espontáneamente o después de un trauma menor

Abstract Gorham-Stout syndrome is a rare bone disease whose etiology remains unknown, characterized by osteolysis and abnormal proliferation of vascular channels. We describe the case of a 47-year-old male patient who consulted for 15 days of evolution of edema, pain, erythema and seroma expulsion from surgical wound in the right shoulder, with a recent diagnosis of septic arthritis. He referred a history of Gorham-Stout syndrome, evidenced with physical examination and comparative radiography of the shoulders. The clinical presentation of these patients depends on the affected area and the extent of the disease, making their diagnosis a challenge in case the deterioration occurs in unexposed areas. The main symptom is localized pain, accompanied by swelling, weakness and functional impairment of the affected limbs. These patients may remain asymptomatic until suffering a bone fracture spontaneously or after minor trauma

Treatment of Pathological Humerus-Shaft Tumoral Fractures with Rigid Static Interlocking Intramedullary Nail-22 Years of Experience / Tratamento de fraturas patológicas tumorais diafisárias do úmero com haste intramedular rígida bloqueada estática - Experiência de 22 anos

Abstract Objective This was a retrospective observational study in patients submitted to intramedullary nail fixation after established or impeding pathological humerus-shaft tumoral fracture in the context of disseminated tumoral disease along 22 years of experience at the same institution. Methods Sample with 82 patients and 86 humeral fixations with unreamed rigid interlocking static intramedullary nail by the antegrade or retrograde approaches. Results The most prevalent primary tumors were breast carcinoma (30.49%), multiple myeloma (24.39%), lung adenocarcinoma (8.54%), and renal cell carcinoma (6.10%). The average surgical time was 90.16 ± 42.98 minutes (40-135 minutes). All of the patients reported improvement in arm pain and the mean Musculoskeletal Tumor Society (MSTS) score rose from 26% in the preoperative period to 72.6% in the evaluation performed in patients still alive 3 months after the surgery. The overall survival was 69.50% 3 months after the surgery, 56.10% at 6 months, 26.70% at 1 year, and 11.90% at 2 years. No death was related to the surgery or its complications. There were only 4 surgery-related complications, 1 intraoperative and 3 late, corresponding to a 4.65% complication risk. Conclusion Closed unreamed static interlocking intramedullary nailing (both in the antegrade or retrograde approaches) of the humerus is a fast, safe, effective, and low morbidity procedure to treat pathological fractures of the humerus shaft, assuring a stable arm fixation and consequently improving function and quality of life in these patients during their short life expectation.

Resumo Objetivo Estudo retrospectivo observacional em pacientes submetidos à fixação com haste intramedular de fratura patológica tumoral consumada ou iminente da diáfise do úmero em contexto de doença tumoral disseminada ao longo de 22 anos na mesma instituição. Métodos Amostra com 82 pacientes e 86 fixações do úmero com haste intramedular rígida bloqueada estática não fresada anterógrada ou retrógrada. Resultados Os tumores primários mais prevalentes foram carcinoma da mama (30,49%), mieloma múltiplo (24,39%), adenocarcinoma do pulmão (8,54%) e carcinoma das células renais (6,10%). O tempo médio de intervenção cirúrgica para fixação com haste foi 90,16 ± 42,98 minutos (40-135). Todos os pacientes referiram melhoria das queixas álgicas no nível do braço e velicou-semelhoria do scoreMSTSmédio de 26% no pré-operatório para 72,6% na avaliação efetuada nos pacientes ainda vivos aos três meses de pós-operatório. A taxa de sobrevivência aos três meses após a cirurgia foi de 69,50%, 56,10% aos seis meses, 26,70% em um ano e 11,90% em dois anos. Nenhuma dasmortes decorreu da cirurgia ou de complicações dela. Apenas se registaramquatro complicações relacionadas com a cirurgia, uma intraoperatória e três tardias, corresponderam a risco de complicações de 4,65%. Conclusão O uso de haste intramedular não fresada estática bloqueada (anterógrado ou retrógrado) no úmero é um método rápido, seguro, eficaz e com baixa morbilidade no tratamento das fraturas patológicas da diáfise umeral, garante fixação estável do braço e consequentemente melhora a funcionalidade e a qualidade de vida desses pacientes durante a sua curta expectativa de vida.

Pathologic Femoral Neck Fracture Due to Fanconi Syndrome Induced by Adefovir Dipivoxil Therapy for Hepatitis B

In Fanconi syndrome, hypophosphatemic osteomalacia is caused by proximal renal tubule dysfunction which leads to impaired reabsorption of amino acids, glucose, urate, and phosphate. We present a rare case of a 43-year-old Korean male who was found to have insufficiency stress fracture of the femoral neck secondary to osteomalacia due to Fanconi syndrome. He had been receiving low-dose adefovir dipivoxil (ADV, 10 mg/day) for the treatment of chronic hepatitis B virus infection for 7 years and he subsequently developed severe hypophosphatemia and proximal renal tubule dysfunction. The incomplete femoral neck fracture was fixed with multiple cannulated screws to prevent further displacement of the initial fracture. After cessation of ADV and correction of hypophosphatemia with oral phosphorus supplementation, the patient's clinical symptoms, such as bone pain, muscle weakness, and laboratory findings improved.

Pathologic Femoral Neck Fracture Due to Fanconi Syndrome Induced by Adefovir Dipivoxil Therapy for Hepatitis B

In Fanconi syndrome, hypophosphatemic osteomalacia is caused by proximal renal tubule dysfunction which leads to impaired reabsorption of amino acids, glucose, urate, and phosphate. We present a rare case of a 43-year-old Korean male who was found to have insufficiency stress fracture of the femoral neck secondary to osteomalacia due to Fanconi syndrome. He had been receiving low-dose adefovir dipivoxil (ADV, 10 mg/day) for the treatment of chronic hepatitis B virus infection for 7 years and he subsequently developed severe hypophosphatemia and proximal renal tubule dysfunction. The incomplete femoral neck fracture was fixed with multiple cannulated screws to prevent further displacement of the initial fracture. After cessation of ADV and correction of hypophosphatemia with oral phosphorus supplementation, the patient's clinical symptoms, such as bone pain, muscle weakness, and laboratory findings improved.

An Atraumatic Fracture of the Odontoid Process in a Newly Diagnosed Rheumatoid Arthritis Patient

Rheumatoid arthritis (RA) is a systemic autoimmune disorder which can affect all of the synovial joints including the cervical spine. Cervical involvement typically begins early in the disease process and shows relatively slow progression. Fractures of the odontoid process are mainly noted after a major trauma to the cervical spine. A case of a 77-year-old woman with paresthesia of the extremities caused by spontaneous atraumatic fracture of the odontoid process, which was revealed as a manifestation of RA, is presented in this report.

Patterns of Treatment for Metastatic Pathological Fractures of the Spine: The Efficacy of Each Treatment Modality

BACKGROUND: Metastatic pathological fractures of the spine are a major problem for cancer patients; however, there is no consensus on treatment strategy. The purpose of this study was to evaluate various treatment options by analyzing their patterns for metastatic pathological fractures of the spine. METHODS: In this study, 54 patients (male:female = 36:18) who were diagnosed with metastatic pathological fractures of spine were recruited. Demographic data, origin of cancer, type of treatment, and results were obtained from electronic medical records. Treatment options were divided into radiotherapy (RT), vertebroplasty (VP) or kyphoplasty (KP), operation (OP), and other treatments. Treatment results were defined as aggravation, no response, fair response, good response, and unknown. The survival time after detection of pathologic fractures was analyzed with the Kaplan-Meier method. RESULTS: The mean age of the patients was 62.3 years. Hepatocellular carcinoma was the most common cancer of primary origin (n = 9), followed by multiple myeloma (n = 8). RT was the most common primary choice of treatment (n = 29, 53.7%), followed by OP (n = 13, 24.1%), and VP or KP (n = 10, 18.5%). Only 13 of 29 RT cases and 7 of 13 OP cases demonstrated a fair or good response. The mean survival time following detection of pathological spinal fractures was 11.1 months for 29 patients, who died during the study period. CONCLUSIONS: RT was the most common primary choice of treatment for metastatic pathological fractures of the spine. However, the response rate was suboptimal. Although OP should be considered for the relief of mechanical back pain or neurologic symptoms, care should be taken in determining the surgical indication. VP or KP could be considered for short-term control of localized pain, although the number of cases was too small to confirm the conclusion. It is difficult to determine the superiority of the treatment modalities, hence, a common guideline for the diagnosis and treatment of metastatic pathological fractures of the spine is required.

Avaliação clínica da vertebroplastia percutânea transpedicular / Evaluación clinica de la vertebroplastia transpedicular percutánea / Clinic evaluation of transpedicular percutaneous vertebroplasty

OBJETIVO: Avaliar a eficácia do efeito analgésico da vertebroplastia com polimetilmetacrilato (PMMA) e da estabilização vertebral obtida nos pacientes com fraturas vertebrais patológicas e realizar uma revisão detalhada da técnica da vertebroplastia percutânea, analisando suas indicações. MÉTODOS: Análise retrospectiva de 64 procedimentos de vertebroplastia percutânea em 46 pacientes. Foram realizadas avaliações dos prontuários e das radiografias pré e pós-operatórias e em nova consulta de rotina, na qual foi aplicado o questionário de dor (escala analógica visual da dor). RESULTADOS: Entre os 46 pacientes analisados, 37 (80,4 por cento) eram do sexo feminino e 9 (19,6 por cento) do sexo masculino, com média de idade de 71 anos (desvio-padrão +/- 9,2), variando de 50 a 90 anos. Foram operados 64 níveis, com predomínio do segmento toracolombar, sendo realizadas 17 (26,6 por cento) vertebroplastias a maioria em pedículos de T12. Trinta e um pacientes (67,4 por cento) apresentaram apenas um nível fraturado, 12 (26,1 por cento) apresentaram 02 níveis operados e três pacientes (6,5 por cento) apresentaram 03 ou mais níveis operados. O diagnóstico de osteoporose foi o mais comum (33 casos, 71,7 por cento). Quanto ao alívio da dor no pós-operatório, houve um alto índice de satisfação de 90 a 100 por cento em 37 (80 por cento) pacientes. CONCLUSÃO: A vertebroplastia demonstra ser um procedimento eficaz no tratamento da dor por fratura patológica de coluna, sendo também utilizada em investigação diagnóstica (biópsia óssea). É um procedimento seguro com baixas taxas de complicações.

OBJECTIVE: This paper evaluates the analgesic effect and obtained vertebral stability of percutaneous vertebroplasty with polymethylmethacrylate (PMMA) in patients with vertebral pathological fractures, and performs a detailed revision of this technique. METHODS: A retrospective analysis of 64 percutaneous vertebroplasty procedures in 46 patients was performed. Patients were evaluated by medical records, pre and post-operative radiographs, and by pain status (visual analog pain scale). RESULTS: 37 (80.4 percent) patients were female and 9 (19.6 percent) male, with mean age of 71 years (standard deviation + / - 9.2), ranging from 50 to 90 years. Sixty-four levels were treated, with a predominance of thoracic-lumbar segment, the majority 17 (26.6 percent) of vertebroplaties at T12 pedicle. Thirty-one patients (67.4 percent) presented only one fractured level, 12 patients (26.1 percent) presented 02 levels and three (6.5 percent) presented 03 or more treated levels. Osteoporosis was the most common diagnosis (33 cases, 71.7 percent). A high satisfaction rate of 90 to 100 percent was observed to the majority of patients when considering relief of pain postoperatively. CONCLUSIONS: Vertebroplasty has proven to be an effective procedure to treat pain caused by pathological fracture, and it is also used for diagnostic investigation (bone biopsy). The technique is secure and has provided low complications rates.

OBJETIVO: Evaluar la eficacia del efecto analgésico y estabilización vertebral de la vertebroplastia con polimetilmetacrilato (PMMA) en pacientes con fracturas patológicas de la columna vertebral, y realizar una revisión detallada de la técnica de vertebroplastia percutánea, analizando sus indicaciones. MÉTODOS: Evaluación retrospectiva de 64 fracturas tratadas en 46 pacientes sometidos a vertebroplastia percutánea en el período de enero de 2000 a diciembre de 2008. Los pacientes fueron evaluados por las historias clínicas, por las radiografías pre y postoperatorias y consultas de rutina en las cuales se realizaron encuestas de dolor (escala universal visual del dolor). RESULTADOS: 37 (80,4 por ciento) eran mujeres y 9 (19,6 por ciento) eran varones, con edad promedio de 71 años (desvío estándar de + / - 9,2), que oscila entre 50 y 90 años. 64 niveles fueron operados, con predominio de lo segmento torácico-lumbar, se realizaron 17 (26,6 por ciento) la mayoría en pedículos vertebroplastia de T12. Treinta y un pacientes (67,4 por ciento) tenían sólo un nivel de fractura, 12 pacientes (26,1 por ciento) tenían 02 niveles y 03 (6,5 por ciento) pacientes tenían 03 o más niveles de fractura. El diagnóstico de osteoporosis fue el más común (33 casos, el 71,7 por ciento). Cuanto al alivio del dolor postoperatorio, hubo un alto índice de satisfacción de 90 a 100 por ciento en 37 (80 por ciento) pacientes. CONCLUSIÓN: La vertebroplastia es un procedimiento que probó ser eficaz en el tratamiento del dolor por fractura patológica de la columna, y también se utiliza con fines de diagnóstico (biopsia de hueso). Es un procedimiento seguro y tiene bajas tasas de complicaciones.

A case of a fractured and impacted central venous chemoport in a patient with stomach cancer / 대한내과학회지

A central venous port catheter is widely used to administer fluids, chemotherapeutic agents, and parenteral nutrition; however, similar to other invasive procedures, it has numerous potential complications. Among them, distal migration of a fractured central venous port catheter is a rare complication. A 66-year-old man had a central venous port catheter implanted into the right subclavian vein for adjuvant stomach cancer chemotherapy and presented with an ulceration at the chemoport insertion site. While removing the port catheter, it fractured and the distal tip and migrated and impacted the annulus of the right atrium. The impacted port catheter was successfully removed through a femoral vein approach using a radiofrequency ablation catheter and a multi snare.