Screening complications in the postoperative period of orthopedic surgeries by video arthroscopy

To analyze the prevalence and characteristics of late postoperative complications of orthopedic surgeries by video arthroscopy.This was a descriptive cross-sectional study that evaluated, through its own instrument, local and systemic postoperative complications of patients undergoing orthopedic surgeries by video arthroscopy. The study included 270 patients, who were evaluated on days 30(without prosthesis) and 90(with prosthesis placement) of the postoperative period, by telephone service. The selection of participants occurred sequentially and population-based, within the data collection period, from February to July 2020, in a large hospital for medium and high complexity surgeries. Of the 270 procedures performed in the period, 4.4% (n = 12) presented late postoperative infection. The most frequent complications were erythema (83%), edema (75%) and secretion (67%) in the surgical wound. Most used antibiotic therapy (92%) and anti-inflammatory drugs (67%). Hospital readmission was not necessary concerning the complications. Only 50% required medical evaluation before the scheduled time.The need for practices that ensure the quality of perioperative care and improve the active search to assess surgical outcomes is reinforced.

Avaliação ortopédica e ultrassonográfica da estabilidade dos quadris de recém-nascidos encaminhados por pediatras, com suspeita de Displasia Típica do Desenvolvimento / Orthopedic and ultrasound assessment of hip stability of newborns referred by pediatricians with suspected Developmental Dysplasia

RESUMO Objetivo: avaliar recém-nascidos com suspeita de instabilidade do quadril, encaminhados por pediatras a um serviço ortopédico terciário. Métodos: recém-nascidos de uma maternidade pública universitária, com suspeita de instabilidade ou fatores de risco para displasia do quadril, eram encaminhados ao Departamento de Ortopedia e Anestesiologia, Ribeirão Preto/SP, onde eram avaliados clinicamente e através de exames ultrassonográficos dos quadris. Constatada a displasia, iniciava-se o tratamento, e em casos em que havia apenas imaturidade do quadril e exame clínico normal, procedia-se à observação e re-exame clinico e ultrassonográfico com dois ou três meses de vida. Resultados: foram examinados 448 recém-nascidos, com predominância feminina e média de idade na primeira avaliação de 27 dias. A principal causa do encaminhamento foi apresentação pélvica. Em 8% havia sinal de Ortolani positivo e em 12,5% estalido no quadril. No exame ortopédico, 405 (90,5%) pacientes eram normais, 8,5% apresentavam estalido no quadril e 1,1% apresentavam teste de Ortolani positivo. À ultrassonografia, 368 (89,5%) apresentavam imaturidade, 26 (6,3%) tinham displasia moderada e em 17 (4,1%) pacientes os quadris eram francamente displásicos. Todos os casos com sinal de Ortolani positivo apresentavam quadro ultrassonográfico de displasia. Conclusão: houve excesso de diagnóstico de instabilidade do quadril na avaliação do pediatra, o que, no entanto, permitiu ao paciente uma segunda avaliação, em ambiente mais especializado e com mais recursos tecnológicos.

ABSTRACT Objective: to evaluate newborns with suspected hip instability, referred by pediatricians to a tertiary orthopedic service. Methods: newborns from a public university maternity hospital, with suspected instability or risk factors for hip dysplasia, were referred to the Department of Orthopedics and Anesthesiology, Ribeirão Preto/SP, where we evaluated them clinically and through ultrasound examinations of the hips. Once we found dysplasia, we initiated treatment, and in cases in which there was only hip immaturity and normal clinical examination, we performed clinical and ultrasound observation and review at two or three months of age. Results: we examined 448 newborns, with female predominance and average age at first evaluation of 27 days. The main cause of referral was pelvic presentation at delivery. In 8% there was a positive Ortolani sign and in 12.5%,. At orthopedic examination, 405 (90.5%) patients were normal, 8.5% had hip click and 1.1% had positive Ortolani test. At ultrasound, 368 (89.5%) had immaturity, 26 (6.3%) had moderate dysplasia and in 17 (4.1%) patients the hips were frankly dysplastic. All cases with positive Ortolani sign showed dysplasia at ultrasound. Conclusion: there was an excess diagnosis of hip instability in the pediatrician evaluation, which, however, allowed the patient a second assessment, in a more specialized environment and with more technological resources.

Foot drop: an iatrogenic complication of spinal anesthesia / Pé caído: uma complicação iatrogênica da anestesia espinhal

Abstract Background and objectives Foot drop in postoperative period is very rare after spinal anesthesia. Early clinical assessment and diagnostic interventions is of prime importance to establish the etiology and to start appropriate management. Close follow-up is warranted in early postoperative period in cases when patient complain paresthesia or pain during needle insertion or drug injection. Case report A 22-year-old male was undergone lower limb orthopedic surgery in spinal anesthesia. During shifting from postoperative ward footdrop was suspected during routine assessment of regression of spinal level. Immediately the patient was referred to a neurologist and magnetic resonance imaging was done, which was inconclusive. Conservative management was started and nerve conduction study was done on the 4th postoperative day that confirmed pure motor neuropathy of right peroneal nerve. Patient was discharged with ankle splint and physiotherapy after slight improvement in motor power (2/5). Conclusions Foot drop is very rare after spinal anesthesia. Any suspected patient must undergo emergent neurological consultation and magnetic resonance imaging to exclude major finding and need for early surgical intervention.

Resumo Justificativa e objetivos Pé caído no período pós-operatório é muito raro após a anestesia espinhal. Avaliação clínica e intervenções diagnósticas precoces são de primordial importância para estabelecer a etiologia e iniciar o tratamento adequado. Um acompanhamento atento é justificado no pós-operatório imediato nos casos em que o paciente se queixa de parestesia ou dor durante a inserção da agulha ou da injeção de fármacos. Relato de caso Paciente do sexo masculino, 22 anos, submetido a cirurgia ortopédica de membros inferiores sob anestesia espinhal. Durante a transferência para a sala de recuperação pós-operatória, houve suspeita de pé caído durante a avaliação rotineira da regressão do nível espinhal. O paciente foi imediatamente enviado ao neurologista e uma ressonância magnética foi feita, mas não foi conclusiva. O manejo conservador foi iniciado e o estudo de condução nervosa foi feito no 4° dia de pós-operatório, o que confirmou a neuropatia motora pura do nervo fibular direito. O paciente foi dispensado com imobilizador de tornozelo e fisioterapia após ligeira melhoria da força motora (2/5). Conclusões Pé caído é muito raro após a anestesia espinhal. Qualquer paciente suspeito deve ser submetido à consulta neurológica de emergência e ressonância magnética para excluir o principal achado e a necessidade de intervenção cirúrgica precoce.

Tratamiento quirúrgico de las dismetrías y deformidades angulares de miembros inferiores mediante epifisiodesis con tornillos transfisarios (técnica de Metaizeau) / Surgical treatment of lower limb length discrepancy and angular deformity by epiphysiodesis with transphyseal screw (Metaizeau technique) / Tratamento cirúrgico das dismetrias e deformidades angulares de membros inferiores mediante epifisiodese com parafusos transfisários (técnica de Metaizeau)

Evaluamos los niños con dismetrías y deformidades angulares operados mediante la Técnica de Metaizeau en el período 2010-2014, mediante un estudio retrospectivo de 11 pacientes, analizados en 2 Grupos. Grupo 1 (Dismetrías), formado por 5 pacientes, de los cuales 3 fueron operados solamente mediante esta técnica, mientras que 2 requirieron adicionalmente procedimientos de alargamiento femoral, valoramos dismetría inicial, dismetría por predicción para el último control y para el final de la madurez, y dismetría final. Grupo 2 (Deformidades Angulares), formado por 6 pacientes, de los cuales 1 presentaba genu varo, 4 genu valgo y 1 valgo de tobillo, valoramos el ángulo femorotibial anatómico, ángulo femoral distal lateral anatómico, ángulo tibial proximal medial, y ángulo tibioastragalino. En ambos Grupos se valoraron las complicaciones. El seguimiento promedio fue de 2 años y 5 meses. En el Grupo 1 obtuvimos dismetría promedio inicial 7,64 cm., dismetría promedio por predicción para el último control 8,54 cm., dismetría promedio final 7,62 cm., corrección promedio lograda 0,91 cm. En el Grupo 2 el promedio de corrección del ángulo femorotibial anatómico 16,85˚, promedio de corrección del ángulo femoral distal lateral anatómico 16,85˚, promedio de corrección del ángulo tibial proximal medial 7,62˚. No detectamos complicaciones en ningún paciente. En 8 (72,72%) pacientes la Técnica fue efectiva, mientras que en 3 (27,27%) los resultados fueron malos por errores técnicos o error en la predicción. La Técnica de Metaizeau, respetando los detalles quirúrgicos y realizando una adecuada predicción, es una buena opción para el tratamiento de dismetrías y deformidades angulares.

We evaluated children with lower limb length discrepancy and angular deformity operated by the Metaizeau technique in the 2010-2014 period through a retrospective study of 11 patients analyzed in 2 groups. Group 1 (Lower limb length discrepancy), consisted of 5 patients, among whom 3 were operated only by Metaizeau technique, whereas the other 2 additionally required procedures for femoral elongation. We evaluated initial discrepancy, predicted discrepancy for ultimate control and at maturity, and final discrepancy. Group 2 (Angular deformity), consisted of 6 patients, among whom 1 had genu varum, 4 genu valgum and, 1 ankle valgus. We evaluated anatomic femorotibial angle, anatomic lateral distal femoral angle, medial proximal tibial angle, and tibio talar angle. In both groups the complications were assessed. The average follow-up was 2 years and 5 months. In Group 1 we obtained the following values: average initial discrepancy, 7.64 cm; average discrepancy predicted for ultimate control, 8.54 cm; average final discrepancy, 7.62 cm and average correction achieved, 0.91 cm. In Group 2 the values were: average correction anatomic femorotibial angle, 16.85˚; average correction anatomic lateral distal femoral angle, 16.85˚ and average correction medial proximal tibial angle, 7.62˚. We found no complications in any patient. In 8 patients (72.72%) the technique was effective, while in 3 (27.27%) the results were poor due to technical errors or prediction errors . Metaizeau Technique, respecting the surgical details and making an accurate prediction is an effective, simple and uncomplicated procedure.

Avaliamos as crianças com dismetrias e deformidades angulares operadas pela técnica de Metaizeau no período de 2010 até 2014, mediante um estudo retrospectivo de 11 pacientes analisados em dois grupos. Grupo 1 (Dismetrias), constituído por cinco pacientes, dos quais 3 foram operados apenas por esta técnica, enquanto que os outros dois precisaram de procedimentos adicionais de alongamento femoral. Avaliamos a dismetria inicial, a dismetria por predição para o último controle e para o final da maturação, e a dismetria final. Grupo 2 (deformidades angulares), constituído por 6 pacientes, entre os quais um apresentava genu varo, 4 genu valgo e um, valgo do tornozelo. Avaliamos o ângulo femorotibial anatômico, o ângulo femoral distal anatômico o ângulo femoral distal lateral anatômico, o ângulo tibial proximal medial, e o ângulo tibioastragalino. Em ambos os grupos foram avaliadas as complicações. O seguimento médio foi de 2 anos e 5 meses. No Grupo 1, obtivemos dismetría inicial média de 7,64 cm, dismetria média por previsão para o último controle de 8,54 cm, dismetría final média de 7,62 cm e correcção média atingida de 0,91 cm. No Grupo 2, a correção de ângulo tibiofemoral anatómica média 16,85˚, correção média do ângulo femoral distal lateral anatómico 16,85˚, e correção média de ângulo tibial proximal medial de 7,62˚. Não detectamos complicações em nenhum paciente. A técnica foi efetiva em 8 (72,72%) pacientes, mas em 3 (27,27%) os resultados foram insatisfatórios por erros técnicos ou na predicção. A técnica de Metaizeau, desde que sejam respeitados os detalhes cirúrgicos e seja feita uma predicção adequada, é uma boa escolha para o tratamento de dismetrías e deformidades angulares.

The development and evaluation of individualized templates to assist transoral C2 articular mass or transpedicular screw placement in TARP-IV procedures: adult cadaver specimen study

OBJECTIVES: The transoral atlantoaxial reduction plate system treats irreducible atlantoaxial dislocation from transoral atlantoaxial reduction plate-I to transoral atlantoaxial reduction plate-III. However, this system has demonstrated problems associated with screw loosening, atlantoaxial fixation and concealed or manifest neurovascular injuries. This study sought to design a set of individualized templates to improve the accuracy of anterior C2 screw placement in the transoral atlantoaxial reduction plate-IV procedure. METHODS: A set of individualized templates was designed according to thin-slice computed tomography data obtained from 10 human cadavers. The templates contained cubic modules and drill guides to facilitate transoral atlantoaxial reduction plate positioning and anterior C2 screw placement. We performed 2 stages of cadaveric experiments with 2 cadavers in stage one and 8 in stage two. Finally, guided C2 screw placement was evaluated by reading postoperative computed tomography images and comparing the planned and inserted screw trajectories. RESULTS: There were two cortical breaching screws in stage one and three in stage two, but only the cortical breaching screws in stage one were ranked critical. In stage two, the planned entry points and the transverse angles of the anterior C2 screws could be simulated, whereas the declination angles could not be simulated due to intraoperative blockage of the drill bit and screwdriver by the upper teeth. CONCLUSIONS: It was feasible to use individualized templates to guide transoral C2 screw placement. Thus, these drill templates combined with transoral atlantoaxial reduction plate-IV, may improve the accuracy of transoral C2 screw placement and reduce related neurovascular complications. .

Calidad de vida de la luxación acromioclavicular / Quality of life of patients with acromioclavicular dislocation

Objetivo: Comparar la calidad de vida en pacientes con luxación acromioclavicular tipo III de Tossy tratados mediante técnica RAFI de placa gancho, técnica Weaver Dunn y técnica Bosworth. Material y métodos: Se realizó una encuesta transversal, analítica, de Enero de 2012 a Abril 2013, en pacientes con diagnóstico de luxación acromioclavicular tipo III de Tossy intervenidos con la técnica de RAFI con placa gancho, técnica Weaver y Dunn y técnica de Bosworth. Se incluyeron a los pacientes con edades de entre 18 y 70 años y cirugía realizada dentro de las primeras tres semanas del diagnóstico. El grado de calidad de vida fue evaluado mediante el cuestionario de DASH heteroadministrado, previo consentimiento informado. Resultados: Se operaron 47 pacientes divididos en 3 grupos, técnica RAFI placa gancho 26 pacientes, técnica Weaver y Dunn 11 pacientes y la técnica de Bosworth, 10 pacientes. El sexo y la edad fueron similares en los tres grupos con una p = 0.137 y p = 0.252 respectivamente. El tiempo de evolución de la cirugía fue similar en los tres grupos, con una p = 0.051. La técnica, RAFI placa gancho fue la más empleada con 26 cirugías; 96.4% de pacientes mostró discapacidad leve y síntomas leves con técnica RAFI placa gancho y 100% en la técnica Bosworth y Weaver y Dunn. Conclusiones: La calidad de vida fue similar con las tres técnicas quirúrgicas con una discapacidad y síntomas leves. La técnica RAFI placa gancho fue la más utilizada.

To compare quality of life in patients with Tossy type III acromioclavicular dislocation treated with the hook-plate ORIF technique, the Weaver & Dunn technique and the Bosworth technique. Material and methods: A cross-sectional analytical survey was conducted from January 2012 to April 2013 in patients with a diagnosis of Tossy type III acromioclavicular dislocation treated surgically with the hook-plate ORIF technique, the Weaver & Dunn technique, and the Bosworth technique. We included patients ages 18 to 70 years old, operated within three weeks after the diagnosis. Quality of life was assessed using the hetero-administered DASH questionnaire once the informed consent was obtained. Results: Forty-seven patients were operated on. They were divided into 3 groups: hook-plate ORIF technique, with 26 patients: Weaver & Dunn technique, 11 patients; and Bosworth technique, 10 patients. Sex and age distribution were similar in all 3 groups, with p = 0.137 and p = 0.252, respectively. Time elapsed after surgery was similar in all 3 groups, with p = 0.051. The hook-plate ORIF technique was the most frequently used one, in 26 surgeries. 96.4% of patients had mild disability and symptoms with the hook-plate ORIF technique, and 100% with the Bosworth and Weaver & Dunn techniques. Conclusions: Quality of life was similar with all 3 surgical techniques and involved mild disability and symptoms. The hook-plate ORIF technique was the most frequently used technique.

Usage of a Curved Chisel When Resecting Osteochondroma in the Long Bone

No abstract available.

Anatomical Study of Position of the Rib Head for Placing Anterior Vertebral Body Screws in a Chinese Population / Estudio Anatómico de la Posición de la Cabeza de la Costilla para Colocar Tornillos en la Zona Anterior del Cuerpo Vertebral en una Población China

Instrumentation of anterior vertebral body screws has become an important approach for treatment of unstable fracture or curvature of the spine, but little attention has been paid to the starting point of placing the screws and variability of the rib head position. We analyzed the variability of rib head position in a Chinese population in terms of the spinal canal and vertebral body using computed tomography (CT). Images from transverse CT scan of the T4-T12 vertebral bodies of 30 normal individuals were 3D reconstructed, and analyzed for measurement of parameters, which included: 1) distance between the left (or right) anterior border of the rib head and the posterior (or anterior) margin of the vertebral body [L(R )ARHP(A)VB], 2) left (or right) transverse dimension [L(R)TD], 3) left (or right) posterior (or anterior) safe angle [L(R)P(A)SA], and 4) distance between the inferior border of the left (or right) rib head and the superior (or inferior) end-plate in the sagittal plane [IL(R)RHS(I)EP]. The ARHPVB, PSA, and IRHIEP gradually decrease, but ARHAVB, TD, ASA, and IRHSEP gradually increase from T4 to T12, indicating that the position of the rib head changes from a more anterior position to a more posterior position and from a more superior position to a more inferior position as the number of the vertebra increases. Our study has provided comprehensive reference guide for accurate and safe instrumentation of vertebral body screws in treating related spine diseases.

La instrumentación del cuerpo anterior vertebral con tornillos ha sido una vía importante para el tratamiento de las fracturas inestables y curvaturas de la columna, pero se ha prestado poca atención a la zona de colocación de los tornillos y la variabilidad de la posición de la cabeza costal. Se analizó la variabilidad de la posición de la cabeza de la costilla en una población de China en relación al canal vertebral y cuerpo vertebral mediante tomografía computarizada (TC). Imágenes de cortes transversales de TC correspondientes a los cuerpos vertebrales T4-T12 de 30 individuos normales fueron reconstruidos tridimensionalmente, y se analizó la medida de algunos parámetros: 1) la distancia entre el margen anterior izquierdo (o derecho) de la cabeza de la costilla y el margen posterior (o anterior) del cuerpo vertebral [L(R)ARHP(A)VB], 2) Dimensión transversa izquierda (o derecha) [L(R)TD], 3) ángulo de seguridad izquierdo (o derecho) posterior (o anterior) [L(R)P(A)SA], y 4) la distancia entre el margen inferior de la cabeza de la costilla izquierda (o derecha) y la placa terminal superior (o inferior) en el plano sagital [IL(R)RHS(I)EP]. El ARHPVB, PSA, y IRHIEP disminuyeron gradualmente, pero ARHAVB, TD, ASA, y IRHSEP aumentaron gradualmente de T4 a T12, lo que indica que la posición de la cabeza de la costilla cambia desde una posición más anterior a una posición más posterior y de una posición más superior a una posición más inferior a medida que aumenta el número de vértebras. Nuestro estudio ha proporcionado completa guía de referencia para la instrumentación precisa y segura de tornillos en el cuerpo vertebral para el tratamiento de enfermedades relacionadas con la columna vertebral.

Pedicle Screw Instrumentation for Adolescent Idiopathic Scoliosis: The Insertion Technique, the Fusion Levels and Direct Vertebral Rotation

The pedicle is a power nucleus of the vertebra and offers a secure grip of all 3 columns. Pedicle screw instrumentation has advantages of rigid fixation with improved three-dimensional (3D) correction and it is accepted as a reliable method with a high margin of safety. Accurate placement of the pedicle screws is important to reduce possible irreversible complications. Many methods of screw insertion have been reported. The author has been using the K-wire method coupled with the intraoperative single posteroanterior and lateral radiographs, which is the most safe, accurate and fast method. Identification of the curve patterns and determining the fusion levels are very important. The ideal classification of adolescent idiopathic scoliosis should address the all patterns, predict the extent of accurate fusion and have good inter/intraobserver reliability. My classification system matches with the ideal classification system, and it is simple and easy to learn; and my classification system has only 4 structural curve patterns and each curve has 2 types. Scoliosis is a 3D deformity; the coronal and sagittal curves can be corrected with rod rotation, and rotational deformity has to be corrected with direct vertebral rotation (DVR). Rod derotation and DVR are true methods of 3D deformity correction with shorter fusion and improved correction of both the fused and unfused curves, and this is accomplished using pedicle screw fixation. The direction of DVR is very important and it should be opposite to the direction of the rotational deformity of the vertebra. A rigid rod has to be used to prevent rod bend-out during the derotation and DVR.

Evolução clínica e funcional dos pacientes com infecção após artrodese de coluna lombar / Evolución clínica y funcional de los pacientes con infección post-artrodesis de columna lumbar / Clinical and functional outcome of patients with deep wound infection after spinal lumbar fusion

Descrever a experiência dos autores no manejo da infecção após instrumentação da coluna lombar e suas consequências futuras. Métodos: estudo de coorte prospectivo com pacientes portadores de infecção profunda pós-operatória, realizado entre janeiro de 1997 e janeiro de 2009. Todos os pacientes foram submetidos à revisão cirúrgica, coleta de material para exame microbiológico, lavagem exaustiva da região, debridamento dos tecidos desvitalizados, colocação de sistema de lavagem contínua, sutura primária e antibioticoterapia. Manteve-se a instrumentação em todos os pacientes. Os pacientes foram avaliados durante o seguimento por imagens radiográficas, estado clínico e funcional. Utilizaram-se a escala numérica da dor e o índice de incapacidade Oswestry. Os resultados numéricos foram submetidos a análises pareadas pelo teste de Wilcoxon. Resultados: a incidência de infecção foi de 3,1 por cento (15/485). O agente etiológico mais prevalente foi o Staphylococcus aureus. Todos os casos lograram consolidação. Em um seguimento médio de 47,6 meses, observaram-se mudanças nos escores da escala numérica da dor (p=0,001) e índice de incapacidade Oswestry (p=0,017). Na avaliação final, 64,2 por cento dos pacientes (9/14) apresentaram incapacidade mínima e 35,8 por cento (5/14), incapacidade moderada. Conclusão: o tratamento agressivo das infecções pós-operatórias de artrodese de coluna lombar permite evitar a retirada da instrumentação e manter a estabilidade vertebral. A despeito da complicação, os pacientes apresentaram melhoras em relação à dor e capacidade funcional pré-operatórias.

To describe the authors' experience in managing deep wound infection after surgical procedure on the lumbar spine, as well as to evaluate the clinical and functional long-term course of these patients. Methods: prospective cohort study, comprising patients who presented deep infection of the surgical wound between, carried out in January 1997 till January 2009. All the patients were submitted to surgical revision, collection of material for a microbiological examination, exhaustive washing, debridement, implementation of a continuous washing system, primary suturing of the wound and treatment with antibiotics. The instrumentation was not removed from any patient. The patients were evaluated radiologically, clinically and functionally during the follow-up. Paired analyses were performed by means of Wilcoxon test. Results: the incidence of infection was 3.1 percent (15/485). The most prevalent etiological agent was Staphylococcus aureus. All surgical procedures obtained consolidation. In a mean follow-up of 47.6 months, changes were seen in the numerical scale pain scores (p=0.001), Oswestry Disability Index (p=0.017) and physical component of SF-36 (p=0.036). In the final evaluation, 64.2 percent of the patients (9/14) presented minimal disability, and 35.8 percent (5/14), moderate disability. Conclusion: Aggressive treatment of postoperative infections after spinal lumbar fusion avoids removal of the instrumentation and allows the maintenance of the vertebral stability. Despite the complications, the patients presented improvement with regard to pain, functional capacity and preoperative quality of life.

Describir la experiencia de los autores en el manejo de la infección post-instrumentación de la columna lumbar, bien como analizar sus consecuencias futuras. Métodos: estudio de cohorte prospectivo con los pacientes que presentaron infección profunda de herida operatoria entre Enero de 1997 y Enero de 2009. Todos los pacientes fueron sometidos a la revisión quirúrgica, colecta de material para análisis microbiológico, lavado exhaustivo, desbridamiento de los tejidos desvitalizados, colocación de sistema de lavado continuo, sutura primaria de la herida y antibióticoterapia. No se retiró la instrumentación en ningún paciente. Los pacientes fueron evaluados radiológicamente, clínicamente y funcionalmente en el seguimiento. Se realizaron análisis pareados con la prueba de Wilcoxon. Resultados: la incidencia de infección fue del 3.1 por ciento (15/485). El agente etiológico más prevaleciente fue el Staphylococcus aureus. Si logro consolidación en todos los pacientes. En un seguimiento promedio de 47.6 meses, se observaron alteraciones en los scores de la escala numérica del dolor (p=0.001), índice de incapacidad Oswestry (p=0.017) y componente físico del SF-36 (p=0.036). En la evaluación final, un 64.2 por ciento de los pacientes (9/14) presentaron incapacidad mínima y un 35.8 por ciento (5/14), incapacidad moderada. Conclusión: el tratamiento agresivo de las infecciones postoperatorias de artrodesis de columna lumbar permite evitar la retirada de la instrumentación y mantener la estabilidad vertebral. A pesar de la complicación, los pacientes presentaron mejorías con relación al dolor, a la capacidad funcional y a la calidad de vida preoperatorias.

Mini-open transforaminal lumbar interbody fusion.

OBJECTIVE: To demonstrate the surgical technique and advantages of the mini-open transforaminal approach for lumbar interbody fusion (TLIF) combined with transpedicular screw fixation. Clinical and radiographic results were assessed to determine the clinical outcomes in twelve consecutive patients selected for minimally invasive access (mini-open technique) for TLIF in Prasat Neurological Institute. MATERIAL AND METHOD: A retrospective analysis was performed on 12 patients (age range, 38-74 yr; mean, 54. 8 yr) who underwent mini-open transforaminal approach for lumbar interbody fusion (TLIF) combined with transpedicular screw fixation between September 2006 and June 2008. The titanium pedicle screws were introduced bilaterally through the 3.5 cm length, skin incisions with Spine Classics MLD- system retractor, autologous bone graft were inserted to perform TLIF in all patients. Eight patients were augmented anterior column support with titanium interbody cage, unilateral cage insertion in four patients and the others were inserted bilaterally interbody cages. Six patients presented with low back pain and associated radiculopathy, and six presented with low back pain only. Transforaminal lumbar interbody fusion was performed at L3-L4 in two patients, L4-L5 in four patients, L5-S1 in five patients, and two levels fusion in one patient. RESULTS: All patients were able to ambulate after spinal fusion. The patients were able to walk within 1.4 days (range 1-2 days). The hospital stay averaged 4.4 days (range 3-7 days). Periodic follow-up took place 1 to 21 months after surgery (mean, 7.4 months). The radiological fusion was archived in all nine patients who were operated on more than two months age. The other three patients who had been follow-up less than two months were probably fusion on the 1-month followed-up radiological examination. CONCLUSIONS: The use of mini-open technique for pedicle screw instrumentation with spinal fusion procedure provides excellent clinical results and may be an operation of choice for lumbar spinal fusion in selected patients.

Results of Charité artificial lumbar disc replacement: experience in 43 Thais.

OBJECTIVE: To demonstrate the results of artificial lumbar disc replacement in Thai patients with degenerative disc disease. MATERIAL AND METHOD: A prospective study had been conducted to evaluate the efficacy and safety of artificial lumbar disc replacement in patients from October 2004 to December 2007. Oswestry disability index (ODI) score and visual analogic scale (VAS) for pain had been used to assess the clinical result before and after surgery. RESULTS: Forty three patients diagnosed as degenerative lumbar disc disease underwent 50 artificial lumbar disc replacement. All patients markedly improved in both ODI and VAS. The mean ODI score decreased from 60.9% preoperative to only 9.8% postoperative. The VAS score also decreased from 7.44 to 1.3 at the final follow up period. No serious complication found from this procedure. CONCLUSION: We demonstrated a good short term, a critical outcome of Charité artificial lumbar disc replacement in Thai patient with degenerative lumbar disc disease.

Surgical treatment of isthmic spondylolisthesis with radicular pain in adults.

A common consensus has not yet been reached on surgical management of isthmic Spondylolisthesis especially regarding the optimal surgical procedure. This prospective study was carried to see the outcome of Posterolateral fusion with instrumentation without decompression. Eight consecutive patients, aged between 43 to 55 years, underwent primary surgery for isolated L4, L5 lumbar isthmic Spondylolisthesis of less than grade II that presented with radicular pain and exhibited instability on dynamic radiograph. The surgical procedure consisted of instrumentation with pedicle screws and rods (Moss Miami System) and posterolateral fusion in situ by placement of autogeneous bone graft, harvested from posterior iliac crest. Postoperatively Clinical and Radiological status were assessed and were graded according to Stauffer and Coventry method. The patients were followed up for one to three years. Radiological evidence of fusion was clearly evident by six months in all cases. Symptomatically all were relieved of radicular pain completely. One patient had recurrent backache due to causes unrelated to the illness of surgical procedure requiring occasional analgesic. No serious complication was encountered. This lead to conclusion that in adults of our population with low grade isthmic spondylolisthesis and radicular pain Instrumentation with Posterolateral fusion without decompression was sufficient to relieve symptoms.

Achieving distal locking without an image intensifier.

The tibia is commonly fractured bone frequently caused by high energy trauma leading to the complications and major disabilities. Different types of intramedullary nails have been employed by surgeons over 500 years. Today, the intramedullary interlocking tibial nailing is the leading modality of treatment because of its biomechanical advantage over the other modalities. This procedure is done in the advanced centers under the C-arm image intensifier. Yet, there is no facility of C- arm image intensifier in the operation theatre at the tertiary level public hospitals in Nepal. Most of the peripheral hospitals do not have portable X- ray facility. The purpose of this study was to study the success rate of distal locking in the intramedullary nailing of tibial shaft fractures with the aid of distal aiming device (DAD). The distal locking were done in 65 tibial shaft fractures. In this technique the distal hole was directly visualized after proper drilling. All the distal locking could be done without image intensifier. So this technique can be useful where the imaging facilities are not available and even in the advanced centers to avoid radiation hazards.

The results of percutaneous release of trigger digits by using full handle knife 15 degrees: an anatomical hand surface landmark and clinical study.

OBJECTIVE: Know the results of percutaneous release of trigger digits by using full handle knife 15 degrees. MATERIAL AND METHOD: The author identified 510 cadaveric digits to find the anatomical landmark of Al pulley that relates to the knuckle and measurements of A1 pulley lengths. The proximal margin of the Al pulleys on the perpendicular line from the knuckle to the palm was in the same line in 327 (64.1%) digits, while 464 (91.0%) digits were < or =1 mm and 509 (99.8%) were < or =2 mm. The average lengths of A1 pulleys in each digit were as follows: thumb; 5.30, index finger; 6.32, middle finger; 6.58, ring finger; 6.32, and little finger 5.30 mm. The average lengths of all fingers were 6.13 mm. A further 338 digits of trigger digit in 248 patients were treated by percutaneous release by using full handle knife 15 degrees with these landmarks. RESULTS: Three hundred and thirty-eight trigger digits were treated. There was a complete resolution of symptoms in 314 digits (92.90%) when followed up 6 weeks after operation. One digit, an index finger had residual grade 1 after 3 weeks and complete resolution in 8 weeks. Three digits (0.89%), which were one thumb and two index fingers, underwent local steroid injection because of painful scar. Nineteen digits (5.62%) were stiff at proximal interphalangeal joint because of grade 4 triggering and osteoarthritis of the proximal interphalangeal joint but they increased the range of motion after 6 months. A case (0.30%) had numbness of the radial tip of the thumb, which may have been caused by injury to the radial digital nerve ofthe thumb. No one had open release of A1 pulley. CONCLUSION: This technique was a safe and effective out patient procedure on 248 patients and had a complete resolution of symptoms 92.90%.

Instrumentos de avaliação funcional de idosos submetidos à cirurgia ortopédica: revisão integrativa da literatura / Instruments of functional assessment of elderly submitted to orthopedic surgery: an integrative review of literature

Doenças musculoesqueléticas constituem causa de dano funcional no idoso, mas não são conseqüências inevitáveis da idade, portanto, todas as dimensões de saúde têm que ser contempladas na sua avaliação. Objetivo: Analisar artigos científicos que avaliaram o estado funcional do idoso submetido à cirurgia ortopédica. Metodologia: Revisão bibliográfica de artigos on-line indexados nas bases: www.bireme.br, www.scopus.com, www.ncbi.nlm.nih.gov/pubmed e www.embase.com, durante o período de 1996 a 2006. Utilizou-se a terminologia DeCS/Bireme e MeSH/PubMed, com os descritores: idoso, atividades cotidianas, cirurgia ortopédica ou procedimentos ortopédicos, pós-operatório e reabilitação. A busca foi realizada em abril/2006. Critério de inclusão: sujeitos com 60 anos ou mais, submetidos a qualquer procedimento cirúrgico ortopédico, e texto completo disponível on-line. Referências armazenadas e analisadas pelo Software Epilnfo versão 3.3.2. Variáveis: título, ano e país de publicação do periódico; categoria profissional dos autores; país de origem do estudo; objetivos da pesquisa; número e tipos de instrumentos de avaliação e sítio da cirurgia. Resultados: Foram selecionados 44 resumos e acessados 29 textos na íntegra. O "Journal of the American Geriatric Society" foi o periódico com mais publicações e os Estados Unidos com mais estudos. A categoria médica publicou 75,0%; 79,3% dos estudos são descritivos; 69% das cirurgias foram no quadril e 27,6% das pesquisas utilizaram apenas um instrumento de avaliação. Das dimensões avaliadas destacam-se: funcional com 43,6% e mental com 30,8%. Considerações finais: A dimensão funcional foi a mais investigada e a social não foi contemplada. Apesar das publicações estarem aumentando nos últimos anos, faz-se necessário que os serviços de saúde especializados incorporem o paradigma da avaliação funcional da saúde do idoso.

Illnesses from muscles and skeleton, constitute the cause of functional damage of elderly. Nevertheless they are not inevitable consequences of age and they should be approached as specific illnesses rather then being regarded as result of aging. All aspects of health must be accounted for the measurement of the elderly health (Full Geriatric Assessment). Objective: To review the scientific publication dealing with the functional condition of elderly after subjected to orthopedic surgery. Material and Method: Bibliographic research on articles as per listing in the following databases www.bireme.br, www.ncbi.nlm.nih.gov/pubmed, www.scopus.com and www.embase.com covering a period from 1996 to 2006. It has been adopted the terminology as per Science of Health (DeCs/Birene) and at Medical Subject Headings (MeSH/PubMed) that identified the key-words: elderly, daily activity, orthopedic surgery or orthopedic procedures, post-surgery and rehabilitation. The search was carried out on April 2006 and the inclusion criterion was that the test subjects should be older than 60 and subjected to any orthopedic surgery procedure. The references meeting this criterion were listed and analyzed in EpiInfo version 3.3.2. The variables were: title, year and country of publication, professional categories of the authors, country of origin of the study, objective of the research, number of assessment tools, types of assessment tools, site of the surgery, full report available on line. Results: 44 abstracts have been selected among of which 29 were available as full reports. The Journal of the American Geriatric Society was the one that has published the largest number of articles dealing with this issue and the US was the country that has issued the greatest number of publication. 75% of the articles fitted within medical category, 79.3% of the studies are descriptive, 69% of the surgeries were on the hips and 27.6% of the searches employed only one assessment tool. Among the dimensions that have been evaluated 43.6% dealt with functional status while 30.8% were about mental status. Final Notes: The functional dimension was the most investigated while the social dimension was not contemplated. Although the number of publication is increasing in the last years, it?s necessary that health service starts to incorporate the new paradigm of functional evaluation of the elderly health.

Raquianestesia para cirurgia ortopédica de urgência em paciente portadora de doença de Von Recklinghausen: relato de caso / Spinal anesthesia for emergency orthopedic surgery in a patient with Von Recklinghausen disease: case report

JUSTIFICATIVA E OBJETIVOS: A doença de Von Recklinghausen é uma doença neurogenética causada por uma anomalia no cromossomo 17. O objetivo deste relato foi descrever a conduta anestésica em paciente com doença de Von Recklinghausen submetida à cirurgia ortopédica de urgência. RELATO DO CASO: Paciente do sexo feminino, 28 anos, portadora da doença de Von Recklinghausen, submetida à cirurgia ortopédica em hospital de emergência sob raquianestesia. Não apresentou complicações no período intra-operatório, nem na sala de recuperação pós-anestésica. Teve alta hospitalar no 4° dia de pós-operatório. CONCLUSÕES: No caso relatado foi possível a realização da raquianestesia sem haver necessidade de manuseio da via aérea.

Positioning of femoral tunnel in anterior cruciate ligament reconstruction using femoral aimer guide.

OBJECTIVES: Anterior Cruciate Ligament (ACL) reconstruction is one of the common procedures. A larger number of ACL injury patients seek treatment to return to preinjury level. Many factors affect the result of reconstruction. Femoral position is one of the important factors. Nowadays, Femoral Aimer Guide is used in to find the proper position of the femoral tunnel but Grontvedt, et al reported the technique was unsatisfactory. Some studies show it is impossible to use the device via transtibial technique for anatomical attachment at femoral site. The authors studied the femoral entry point by using the Femoral Aimer Guide both through transtibial tunnel and medial arthrotomy approach. MATERIAL AND METHOD: The authors dissected 37 cadaveric knees, removed the ACL and identified the center of the ACL attachment at the femoral side. Used the Femoral Aimer Guide in assisted to find the position of the femoral entry point at 90 degrees position. Right knee by transtibial technique and left knee by medial arthrotomy technique. Both positions were compared RESULTS: All positions from the Femoral Aimer Guide entry point did not coincide with isometric point. They tended to move more superior and posterior positions. Some of the aimer positions were far more posterior, and caused the posterior cortex to be thinner than 5 mm. CONCLUSION: The Femoral Aimer Guide couldn't find the proper position of graft attachment at the femoral side by the standard technique.

Raquianestesia unilateral com baixa dose de bupivacaína a 0, 5 por cento hiperbárica / Unilateral spinal anesthesia with low 0. 5 percent hyperbaric bupivacaine dose

JUSTIFICATIVA E OBJETIVOS: A raquianestesia unilateral pode apresentar vantagens, principalmente em pacientes ambulatoriais. Baixas doses da solução anestésica, agulhas ponta de lápis ou ponta cortante, lenta velocidade de injeção e a posição lateral têm sido relatados como facilitadores da produção de raquianestesia unilateral. O presente estudo longitudinal investiga o grau de raquianestesia unilateral utilizando 5 mg de bupivacaína a 0,5 por cento hiperbárica injetada através de agulha 27G tipo Quincke no paciente em decúbito lateral, com membro a ser operado voltado para baixo. MÉTODO: Raquianestesia com bupivacaína a 0,5 por cento foi realizada através da agulha 27G Quincke em 30 pacientes estado físico ASA I e II, submetidos à cirurgias ortopédicas. A punção subaracnóidea foi realizada com o paciente previamente colocado com o lado a ser operado voltado para baixo e foram injetados 5 mg de bupivacaína a 0,5 por cento hiperbárica na velocidade de 1 ml.15s-1. Bloqueios sensitivo e motor (picada de agulha e escala de 0 a 3) foram comparados entre os lados a ser operado e o contralateral. RESULTADOS: Os bloqueios motor e sensitivo entre o lado operado e o contralateral foram significativamente diferentes em todos os momentos. Raquianestesia unilateral foi obtida em 85,7 por cento dos pacientes. Estabilidade hemodinâmica foi observada em todos os pacientes. Nenhum paciente desenvolveu cefaléia pós-raquianestesia. CONCLUSÕES: Nas condições deste estudo a bupivacaína hiperbárica a 0,5 por cento (5 mg) proporcionou um predominante bloqueio unilateral. Vinte minutos foram suficientes para a instalação do bloqueio. As principais vantagens da raquianestesia unilateral são a estabilidade hemodinâmica, a satisfação do paciente e recuperação mais rápida da anestesia.

Analgesia pós-operatória em cirurgia ortopédica: estudo comparativo entre o bloqueio do plexo lombar por via perivascular inguinal (3 em 1) com ropivacaína e a analgesia subaracnóidea com morfina / Postoperative analgesia following orthopedic surgery: a study comparing perivascular lumbar plexus inguinal block with ropivacaine (3 in 1) and spinal anesthesia with morphine

JUSTIFICATIVA E OBJETIVOS: O bloqueio do plexo lombar pelo acesso perivascular inguinal, chamado de bloqueio 3 em 1, tem sido utilizado para analgesia pós-operatória. O objetivo deste estudo foi comparar a analgesia pós-operatória do bloqueio 3 em 1 a da morfina subaracnóidea em pacientes submetidos a cirurgias ortopédicas em membro inferior (MI). MÉTODO: Foram estudados 40 pacientes escalados para cirurgia ortopédica de MI, de ambos os sexos, estado físico ASA I e II, com idades entre 15 e 75 anos, distribuídos em 2 grupos (M e BPL). Foi realizada anestesia subaracnóidea em todos os pacientes, em L3-L4 ou L4-L5, com 20 mg de bupivacaína isobárica a 0,5 por cento. No grupo M (n = 20) foi associado 50 æg de morfina ao anestésico local. No grupo BPL (n = 20) foi realizado o bloqueio 3 em 1 ao término da cirurgia, utilizando 200 mg de ropivacaína a 0,5 por cento. Avaliou-se a analgesia e a intensidade da dor às 4, 8, 12, 14, 16, 20 e 24 horas após o término da cirurgia, o nível do bloqueio subaracnóideo, o tempo cirúrgico e as complicaçöes. RESULTADOS: A duraçäo da analgesia no grupo BPL foi de 13,1 ± 2,47, enquanto no grupo M todos os pacientes referiam dor e ausência de bloqueio motor no primeiro instante avaliado (4 horas). Houve falha do bloqueio de um dos 3 nervos em 3 pacientes. A incidência de náusea e prurido foi significativamente maior no grupo M. Quanto à retençäo urinária, näo houve diferença significante entre os grupos. Näo houve depressäo respiratória, hipotensäo arterial ou bradicardia. A analgesia pós-operatória foi mais efetiva no grupo BPL, comparada ao grupo M às 4, 8, 12,14 e 16 horas. As 20 e 24 horas näo houve diferença significante entre os grupos. CONCLUSÖES: A analgesia pós-operatória proporcionada pelo bloqueio 3 em 1 apresentou efeitos colaterais inferiores à morfina subaracnóidea com tempo de analgesia semelhante