Tumores benignos que producen fracturas en niños / Benign tumors that cause fractures in children

Resumen: Introducción: Se define fractura patológica a la que se produce a través de un hueso anormal. Cada año se diagnostican aproximadamente 20,000 neoplasias benignas del sistema musculoesquelético. A menudo, el dolor de la fractura es el primer síntoma de un proceso patológico en el hueso. El sitio, la edad y la apariencia radiográfica crean un diagnóstico diferencial para las fracturas patológicas que sigue siendo amplio. El examen clínico evalúa la condición de la piel, palpar cualquier masa de tejido y determinar si hay signos inflamatorios locales como eritema, calor o edema. La toma de biopsia es muy recomendable para confirmar el diagnóstico de una fractura patológica. Objetivo: Determinar qué tumores óseos benignos y qué lesiones seudotumorales producen fracturas en huesos de niños con mayor frecuencia en nuestro hospital. Material y métodos: Estudio retrospectivo transversal, se revisaron expedientes de pacientes con diagnóstico de fractura en terreno patológico, atendidos en el período de Marzo de 2013 a Marzo de 2017. Resultados: Los tumores benignos que ocasionaron fracturas en terreno previamente dañado fueron: quiste óseo aneurismático 13, encondroma cinco, osteoma osteoide tres, tumor de células gigantes dos. Conclusión: En nuestra institución, los quistes óseos aneurismáticos fueron los tumores benignos que con mayor frecuencia producen fracturas patológicas en niños, con predominio en el sexo masculino.

Abstract: Introduction: A pathological fracture is defined as that which occurs through an abnormal bone. Approximately 20,000 benign neoplasms of the musculoskeletal system are diagnosed each year. Often the pain of the fracture is the first symptom of a pathological process in the bone. The site, age and radiographic appearance create a differential diagnosis for pathological fractures that remains broad. The clinical examination evaluates the condition of the skin, palpating any tissue mass and determining if there are local inflammatory signs such as erythema, heat or edema. The biopsy is highly recommended to confirm the diagnosis of a pathological fracture. Objective: To determine which benign bone tumors and pseudotumoral lesions produce fractures in children's bones more frequently in our institution. Material and methods: Cross-sectional retrospective study, review of records of patients with diagnosis of pathological fracture, attended in the period from March 2013 to March 2017, were reviewed. Results: The benign tumors that caused fractures in previously damaged areas were: aneurysmal bone cyst 13, enchondroma 5, osteoid osteoma 3, giant cell tumor 2. Conclusion: At our institution, aneurysmal bone cysts were the benign tumors that most frequently produce pathological fractures in children, with predominance in males.

Picnodisostosis familiar, reporte de un caso tras 10 años de seguimiento / Family picnodisostosis, report of a case after 10 years of follow-up

Resumen: Introducción: La picnodisostosis es una rara enfermedad secundaria en una mutación en el gen 1q21 que codifica la catepsina K, enzima implicada en el metabolismo de osteonectina, osteopontina y colágeno I. La incidencia mundial es de 1-1.7 casos por millón, sin prevalencia por género, se caracteriza clínicamente por talla baja, deformidades craneales, «cara de pájaro¼ y fragilidad ósea con tendencia a fracturas patológicas, que afectan predominantemente los huesos largos y ocasionalmente en los pedículos vertebrales. Radiológicamente es característica la presencia de osteoesclerosis con canales medulares permeables. Aunque existen numerosos reportes de casos clínicos en la literatura, pocos son los que describen familias con más de un individuo afectado y el seguimiento suele ser a corto plazo. Objetivo: Analizar la evolución clínica de los pacientes afectados. Material y métodos: Se realizó estudio retrospectivo, descriptivo, observacional de tres pacientes con diagnóstico de picnodisostosis, en el período de Julio 2006 a Marzo de 2016. Resultados: Se observaron diferentes formas de afectación de la picnodisostosis, algunas de ellas atípicas como la espondilólisis y una fractura de escápula en una paciente. Conclusiones: El presente estudio podría ser el análisis longitudinal más extenso del que se tenga registro. Conocer la variedad de manifestaciones y complicaciones presentadas permitirá al lector seleccionar el mejor método de tratamiento para cada caso.

Abstract: Introduction: Pycnodysostosis is a rare disease secondary to a mutation in gen 1q21 that codifies the cathepsin K, proteolitic enzyme implicated in the metabolism of osteonectin, osteopontin and type I colagen. Its global incidence is around 1-1.7 cases per million, without genre prevalences, it is clinically caracterized by short stature, craneal deformities, «bird's face¼ and bone fragility with pathological fractures tendency predominantly affecting long bones and occasionally vertebral pedicles. Radiologically is characterized by sclerous bones with permeable medular cannel. Despite there are numerous clinical reports on medical literature, just a litlle describe families with more than one afected member and its followship is usually short-term. Objective: To analize clinical evolution of these afected patients. Material and methods: A retrospective, descriptive, observational study was reelized in three patients with diagnosis of pycnodisostosis, between July 2006 and March 2016. Results: different affection forms of pycnodisostosis where observed, some of them, atipical, as for example spondilolisis and a escapule fracture in one patien. Conclusions: The present study could be the longest longitudinal report ever registered. By knowing the presented variety of manifestations and complications, the reader could select the best treatment method for each case.

Características clínicas e padrão de fraturas no momento do diagnóstico de osteogênese imperfeita em crianças / Clinical features and pattern of fractures at the time of diagnosis of osteogenesis imperfecta in children

RESUMO Objetivo: Caracterizar o padrão de fraturas e a história clínica no momento do diagnóstico de osteogênese imperfeita. Métodos: Neste estudo retrospectivo, foram incluídos todos os pacientes com osteogênese imperfeita de ambos os sexos, com idades entre 0 e 18 anos, que realizaram tratamento entre 2002 e 2014. Os prontuários médicos foram revisados para coleta de dados clínicos, incluindo presença de escleras azuladas, dentinogênese imperfeita, história familiar positiva para a doença e locais das fraturas, além de achados radiográficos no momento do diagnóstico. Resultados: Foram incluídos no estudo 76 pacientes (42 do sexo feminino), com idade, no momento do diagnóstico, entre 0 e 114 meses [mediana (p25-p75) de idade de 38 (6-96) meses]. Escleras azuladas estavam presentes em 93,4% dos pacientes, dentinogênese imperfeita foi observada em 27,6% e ossos wormianos em 29,4%. O número de fraturas ao diagnóstico variou entre 0 e 17, com uma mediana de 3 (2-8) fraturas. Em 40 (57%) pacientes, as fraturas eram de membros superiores e inferiores no momento do diagnóstico e, em 9 pacientes também havia fratura vertebral. O diagnóstico foi realizado ao nascimento em 85,7% dos pacientes com o tipo 3 e em 39,3% daqueles com tipo 4/5 da doença. Conclusões: Osteogênese imperfeita é uma doença genética com características clínicas distintas, tais como fragilidade óssea, fraturas recorrentes, escleras azuladas e dentinogênese imperfeita. É importante saber identificar essas características, facilitando o diagnóstico, otimizando o tratamento e diferenciando de outras doenças que também podem causar fraturas.

ABSTRACT Objective: To characterize the fracture pattern and the clinical history at the time of diagnosis of osteogenesis imperfecta. Methods: In this retrospective study, all patients with osteogenesis imperfecta, of both genders, aged 0-18 years, who were treated between 2002 and 2014 were included. Medical records were assessed to collect clinical data, including the presence of blue sclerae, dentinogenesis imperfecta, positive familial history of osteogenesis imperfecta, and the site of the fractures. In addition, radiographic findings at the time of the diagnosis were reviewed. Results: Seventy-six patients (42 females) were included in the study. Individuals' age ranged from 0 to 114 months, with a median (interquartile range) age of 38 (6-96) months. Blue sclerae were present in 93.4% of patients, dentinogenesis imperfecta was observed in 27.6% of patients, and wormian bones in 29.4% of them. The number of fractures at diagnosis ranged from 0 to 17, with a median of 3 (2-8) fractures. Forty (57%) patients had fractures of the upper and lower extremities, and 9 patients also had spinal fractures. The diagnosis was performed at birth in 85.7% of patients with type 3, and 39.3% of those with type 4/5 of the disorder. Conclusions: Osteogenesis imperfecta is a genetic disorder with distinctive clinical features such as bone fragility, recurrent fractures, blue sclerae, and dentinogenesis imperfecta. It is important to know how to identify these characteristics in order to facilitate the diagnosis, optimize the treatment, and differentiate osteogenesis imperfecta from other disorders that also can lead to fractures.

Incidencia de fracturas patológicas por metástasis en el fémur proximal en un hospital de concentración / Incidence of proximal femur pathologic fractures secondary to metastasis in a national reference orthopedic hospital

Resumen: Objetivo: Reportar la incidencia de fracturas en terreno patológico secundarias a metástasis que se presentaron en un hospital de referencia nacional en un período de cinco años. Métodos: Se registraron los ingresos totales a nuestro centro, así como los pacientes que satisficieran la condición de presentar una fractura de fémur proximal en terreno patológico. Con base en información oficial, se calculó el tamaño de población derechohabiente potencial de acuerdo al área de influencia. Con base en los datos se hizo el cálculo de la incidencia anual y de la densidad de incidencia. Resultados: Se identificaron 98 fracturas en 95 individuos. El cálculo de la densidad de incidencia fue de 0.70/100,000 personas durante el período de observación. Se incluyeron 54 sujetos femeninos y 41 masculinos con un promedio de edad de 65.3 años, aunque el rango fue muy variable (de 18 a 90 años). La mayor parte de las personas presentó metástasis por tumores sólidos. De los casos, 29% fue tratado de manera conservadora y el resto requirió tratamiento quirúrgico que incluyó desde osteosíntesis hasta artroplastía protésica. El promedio de estancia hospitalaria fue ligeramente mayor a una semana. Conclusiones: La incidencia reportada es relativamente baja. Encontramos una gran variedad de orígenes y localizaciones anatómicas. No se puede, al momento, generalizar tratamientos o predecir supervivencia.

Abstract: Objective: To report the incidence of pathological fractures secondary to metastasis at a national referral hospital during a 5-year period. Methods: Total admissions to our center were recorded, together with the patients who met the requirement of having a proximal femur fracture in a pathological area. The potential number of beneficiaries was estimated based on official figures and the hospital's area of influence. The annual incidence rate and the incidence density were calculated using the latter data. Results: 98 fractures were identified in 95 patients. The calculated incidence density was 0.70/100,000 population during the observation period. Fifty-four female patients and 41 male patients were included. Mean age was 65.3 years, with a very wide age range (18-90 years). Most patients had metastasis of solid tumors. Twenty-nine percent of patients were treated conservatively and the rest of them required surgery that included from osteosynthesis to prosthetic arthroplasty. The mean length of stay was over one week. Conclusions: The reported incidence of this type of fractures is relatively low. We found a wide variety of anatomical origins and locations. As of now, it is not possible to generalize the treatment or predict the survival.

Osteomielitis causante de fractura patológica: reporte de un caso / Pathological fracture resulting from osteomyelitis: report of a case

Las fracturas patológicas mandibulares son poco comunes, representanel 1 a 2% de todas las fracturas. Pueden ser defi nidas como fracturasque ocurren en regiones donde el hueso ha sido debilitado bajo un procesopatológico. Los factores de causa más comunes incluyen procesosquirúrgicos tales como extracciones de terceros molares, colocación deimplantes, osteonecrosis relacionada con bifosfonatos, osteorradionecrosisde la mandíbula, osteomielitis, infecciones, tumores o lesionesquísticas. La osteomielitis es una condición infl amatoria del hueso; estapatología es uno de los factores que puede determinar el debilitamientodel hueso mandibular y causar una subsecuente fractura patológica. Laosteomielitis mandibular se puede desarrollar si una infección primaria noes manejada adecuadamente. El tratamiento de las fracturas patológicaspuede representar un reto para el profesional de la salud y difi ere segúnla etiología de la misma. Se presenta un caso de una paciente de 54 añosde edad, con una fractura mandibular patológica causada por osteomielitis,la cual fue tratada con antibioticoterapia e intervención quirúrgica.

Pathological mandibular fractures are rare, accounting for between1 and 2% of all fractures. They can be defi ned as fractures thatoccur in regions where the bone has become weakened as a result of a pathological process. Common causal factors include surgicalprocedures such as third molar removal, implant placement, bisphosphonate-related osteonecrosis, osteoradionecrosis of the jaw,osteomyelitis, infections, tumors, and cystic lesions. Osteomyelitisis an infl ammatory condition of the bone; this pathology is one ofthe factors that may prompt weakening of the mandibular boneand cause subsequent pathological fracture. Osteomyelitis of themandible may develop if a primary infection is not properly treated.Treatment of pathological mandibular fractures can be challengingand varies according to their etiology. This article looks at the caseof a 54-year-old woman with a pathological mandibular fracture caused by osteomyelitis, which was treated by means of antibioticotherapy and surgical intervention.

Brown tumors of the femur and pelvis secondary to a parathyroid carcinoma: Report of one case / Tumores pardos de fémur y pelvis secundarios a carcinoma de paratiroides: Informe de un caso

Brown tumors result from excess osteoclast activity and consist of collections of osteoclasts intermixed with fibrous tissue and poorly mineralized woven bone. They are secondary to hyperparathyroidism (HPT). Their incidence is higher in primary than in secondary hyperparathyroidism. We report a 69 years-old male, admitted in a state of confusion, lethargy and bedridden, with a pathological fracture of the femur caused by a brown tumor. The laboratory examination revealed a hypercalcemia (8.85 mEq/L), with high levels of ionized Ca (5.48mEq/L), serum alkaline phosphatases (416 U/L) and serum parathormone (120 pg/mL). Ultrasound examination of the neck showed a large parathyroid tumor, probably corresponding to a carcinoma. A primary HPT was diagnosed. The patient was hydrated and high doses of diuretics and bisphosphonates were administered. After correction of serum calcium and neurologic symptoms, the patient was operated, performing an extensive resection of the tumor. The pathology report confirmed the diagnosis of parathyroid carcinoma.

Los tumores pardos son una consecuencia de una actividad osteoclástica excesiva y consisten en osteoclastos mezclados con tejido fibroso y tejido óseo mal mineralizado. Son secundarios a hiperparatiroidismo y más comunes en hiperparatiroidismo primario. Informamos de un hombre de 69 años que ingresa confuso y letárgico con una fractura patológica del fémur causada por un tumor pardo. El laboratorio mostró hipercalcemia de 8,85 mEq/L, fosfatasas alcalinas de 416 U/L y parathormona de 120 pg/mL. La ecografía del cuello mostró un tumor paratiroideo sospechoso de carcinoma. Se diagnosticó un hiperparatiroidismo primario. El paciente se hidrató y estabilizó con diuréticos y bifosfonatos. Una vez estabilizado, se operó efectuando una extensa resección del tumor. El estudio anatomopatológico confirmó el diagnóstico de cáncer de paratiroides.

Locking Compression Plate in Musculoskeletal Oncology 'a Friend in Need'

BACKGROUND: We are presenting our experience in the use of locking compression plate (LCP) after juxta-articular oncological resections in addition to its use in pathologic fracture. METHODS: A retrospective audit of skeletal reconstruction using LCP in 25 cases of long bone tumors was performed from 2008 to 2010. Reconstruction following limb salvage surgery was done in 17 patients and internal fixation of pathological fracture was done in 8 patients. All patients were available for > 12 months of follow-up, and thus assessed for union at the resected ends. RESULTS: There were 8 males and 17 females in the study. The average age at the time of surgery was 30 years (range, 9 to 66 years). The minimum follow-up was 12 months (range, 12 to 32 months). All patients except three went on to heal successfully. Complications occurred in those three patients: wound infection in one, nonunion in another, and periprosthetic fracture in the other patient. In the remaining patients, union was achieved at an average of 6.5 months after reconstruction in curative resection and 4.75 months after fixation of pathological fractures. CONCLUSIONS: Joint sparing limb salvage surgery was made successfully possible after sekeletal reconstruction with LCP. Its use was also quite effective in pathological fractures with poor bone quality. Use of locking plates for musculoskeletal oncological reconstruction resulted in a good and predictable rate of union.

Distal renal tubular acidosis, hypokalemic paralysis, nephrocalcinosis, primary hypothyroidism, growth retardation, osteomalacia and osteoporosis leading to pathological fracture: a case report

Renal tubular acidosis [RTA] is a constellation of syndromes arising from different derangements of tubular acid transport. Recent advances in the biology of urinary acidification have allowed us to discern various molecular mechanisms responsible for these syndromes. RTA often presents as renal stone disease with nephrocalcinosis, ricket/osteomalacia and growth retardation in children with ultimate short stature in adulthood. The case reported here has features of distal renal tubular acidosis [dRTA], hypokalemic paralysis, primary hypothyroidism, growth retardation, osteomalacia and osteopenia leading to stress fracture. All these features presenting in a single case [as in our case] is a rare occurrence, so far other cases of distal renal tubular acidosis [dRTA] have been reported

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.

Estado del funcionamiento renal de pacientes con osteoporosis primaria (tipo 2) / Renal function status in patients with primary osteoporosis (type 2)

Introducción: Diversos estudios han corroborado la relación entre la insuficiencia renal crónica y la disminución de la densidad mineral ósea; sin embargo, no se ha determinado la misma en presencia de función renal levemente disminuida. El objetivo de esta investigación fue valuar el estado de la función renal en pacientes con osteoporosis primaria y su relación con la densidad mineral ósea. Material y métodos: Estudio prospectivo, transversal, descriptivo, en pacientes con osteoporosis primaria determinada mediante densitometría central (cadera y columna). Se calculó la función renal con la fórmula MRDR (modification of diet in renal disease) en base a la creatinina sérica. Los resultados se clasificaron utilizando las categorías recomendadas por The National Kidney Foundation. Se analizó la relación entre el grado de alteración del funcionamiento renal y la densidad mineral ósea. Resultados: 120 mujeres con edad promedio de 67.9 ± 6.56 años. Se encontró correlación entre valores menores de densidad mineral ósea de columna (T score) y afección moderada de la función renal (F = 4.860, p = 0.009). No hubo relación entre la densitometría de cadera con la función renal ni entre la función renal y el antecedente de fractura (p = 0.223). Conclusiones: Existe relación significativa entre la disminución de la densidad mineral ósea de columna y el deterioro de la función renal de las pacientes con osteoporosis primaria. No fue significativa la relación de la función renal con la incidencia de fracturas en esta población.

BACKGROUND: Several studies correlate renal function with lower bone mineral density (BMD); however, the relationship between early stages of renal dysfunction and BMD has not been clearly defined. Our objective was to determine renal function in patients with primary osteoporosis (type 2) and its relationship with BMD. METHODS: Patients with primary osteoporosis diagnosed using DEXA were evaluated in this cross-sectional analysis. Renal function was estimated according to the modification of diet in renal disease (MDRD) equation and classified according to the National Kidney Foundation for chronic kidney disease (CKD). The relationship between renal function and BMD was analyzed. RESULTS: Included in the study were 120 women with a mean age 67.9 + or - 6.56 years. There was a positive relationship between spine BMD and moderate affection of renal function (F = 4.860, p = 0.009). No relationship was found between hip BMD or fracture with renal function (p = 0.223). CONCLUSIONS: Although women with poor renal function have significantly lower spine BMD, no relationship between early stages of CKD and low BMD has been demonstrated.

Percutaneous vertebroplasty: a comparison between the procedure using the traditional and the new side-opening cannula for osteoporotic vertebral fracture / Vertebroplastia percutânea: uma comparação entre o procedimento usando a cânula tradicional e a nova cânula de orifício lateral para fratura vertebral osteoporótica

A total of 47 percutaneous vertebroplasties (PVs) were performed for osteoporotic vertebral fractures in 31 patients, 25 PVs were performed using the frontal-opening cannula (FOC) and 22 using the new side-opening cannula (SOC), randomly distributed. The incidence of cement extrusion was 27 percent with the SOC, and 68 percent with the FOC, all asymptomatic (p<0.01). The pain control was similar for both groups, with good improvement of pain in most of the patients, and there were no clinical relevant complications. The cement leakage can be significantly reduced with this new SOC, which allows for a better cement injection toward the center of the vertebral body, increasing the safety of the procedure, with no increase in cost.

Um total de 47 vertebroplastias percutâneas (VP) foram realizadas para fraturas vertebrais osteoporóticas em 31 pacientes, 25 VP foram realizadas usando-se a cânula de orifício frontal (COF) e 22 com a nova cânula de orifício lateral (COL), distribuídos randomicamente. A incidência de extrusão de cimento ortopédico ocorreu em 27 por cento com a COL, e 68 por cento com a COF, todas assintomáticas (p<0,01). O controle da dor foi similar em ambos os grupos, com boa melhora da dor na maioria dos pacientes, sem complicações clínicas relevantes. A extrusão do cimento pode ser significativamente reduzida com esta nova COL, que permite uma melhor injeção do cimento para o centro do corpo vertebral, aumentando a segurança do procedimento, sem aumento no seu custo.

Quantitative ultrasound for the detection and management of osteoporosis: [review] / Ultrasonido cuantitativo para la detección y manejo de osteoporosis: [revisión]

Quantitative ultrasound (QUS) appears to be developing into an acceptable, low-cost and readily-accessible alternative to dual X-ray absorptiometry (DXA) measurements of bone mineral density (BMD) in the detection and management of osteoporosis. Perhaps the major difficulty with their widespread use is that many different QUS devices exist that differ substantially from each other, in terms of the parameters they measure and the strength of empirical evidence supporting their use. But another problem is that virtually no data exist outside of Caucasian or Asian populations. In general, heel QUS appears to be most tested and most effective. Some, but not all heel QUS devices are effective assessing fracture risk in some, but not all populations, the evidence being strongest for Caucasian females > 55 years old, though some evidence exists for Asian females > 55 and for Caucasian and Asian males > 70. Certain devices may allow to estimate the likelihood of osteoporosis, but very limited evidence exists supporting QUS use during the initiation or monitoring of osteoporosis treatment. Likely, QUS is most effective when combined with an assessment of clinical risk factors (CRF); with DXA reserved for individuals who are not identified as either high or low risk using QUS and CRF. However, monitoring and maintenance of test and instrument accuracy, precision and reproducibility are essential if QUS devices are to be used in clinical practice; and further scientific research in non-Caucasian, non-Asian populations clearly is compulsory to validate this tool for more widespread use.

El ultrasonido cuantitativo (QUS) es una alternativa para la detección y manejo de la osteoporosis de bajo costo y uso práctico, si se compara con las densitometrías de rayos X de doble haz de baja energía (DXA) que determinan densidad mineral ósea (BMD). La mayor dificultad para el uso generalizado del QUS por un lado es que existen muchos instrumentos que son significativamente diferentes uno del otro y por otro en la calidad de la evidencia en que se justifica su empleo, que generalmente es insuficiente y/o poco sistematizada. Otro problema importante del QUS, es que prácticamente no existe información que no sea la generada en poblaciones asiáticas o caucásicas. En general, los estudios de calcáneo realizados con QUS son los más utilizados y mejor validados para evaluar el riesgo de fracturas en algunas poblaciones. La evidencia más grande de su efectividad se conoce para las mujeres caucásicas y asiáticas mayores de 55 años e incluso para los hombres asiáticos mayores de 70 años. Varios instrumentos cuentan con buen sustento científico, que los vuelve confiables para establecer un pronóstico preciso e identificar el riesgo individual de sufrir fracturas por osteoporosis, sin embargo, existe poca evidencia que respalde su uso para iniciar y monitorear el resultado del tratamiento de la osteoporosis. El QUS mejora su efectividad diagnóstica cuando se combina con los resultados de un cuestionario que identifica riesgos clínicos. En un escenario ideal, el DXA se debe reservar solo para aquellos individuos que no puedan ser identificados de manera confiable usando QUS y el cuestionario de riesgos clínicos. Si se quiere aceptar a los instrumentos QUS en la práctica clínica, para el monitoreo es indispensable asegurar y mantener la exactitud, precisión y reproducibilidad de los instrumentos y de los técnicos que los utilizan. Se requieren más estudios científicos de poblaciones no caucásicas o asiáticas para validar el uso generalizado del QUS.

A case of pathological rib fractures: focal osteolysis or osteoporosis? / Un caso de fracturas patológicas de costillas: osteólisis focal u osteoporosis focal?

This paper reports on a unique, previously unreported, successful outcome in the case of a patient with focal osteolytic lesions of the ribs as a first sign of osteoporosis. The lesions were detected by chance after acute cough-induced rib fractures were seen on plain chest radiographs. The diagnosis had to be approached as a diagnosis of exclusion since known causes of the osteolytic process had to be eliminated. The authors describe multiple focal osteolytic lesions with rib fractures appearing in a pattern that could be confused with metastases. Laboratory results were normal. Final diagnosis was based on plain radiography, bone scan and bone densitometry. Pharmacomedical treatments for osteoporosis were applied. The patient was observed between the year 2000 and 2005. Five years later, radiological and bone scintigraphy revealed resolution of the lesion. We conclude that osteoporosis should be included in the differential diagnosis of asymptomatic focal osteolysis of the ribs with rib fractures as a complication of acute cough. The case suggests that focal osteolytic lesions of the ribs may regress over time and become scintigraphically inactive.

Este trabajo presenta la evolución clínica exitosa, única, y no reportada con anterioridad, del caso de un paciente con lesiones osteolíticas focales en las costillas, como primera señal de osteoporosis. Las lesiones fueron detectadas por casualidad, luego que en unas radiografías simples de tórax, se observaran fracturas de las costillas inducidas por tos aguda. El diagnóstico tuvo que ser abordado como diagnóstico de exclusión, ya que las causas conocidas del proceso osteolítico tenían que ser descartadas. Los autores describen las lesiones osteolíticas focales múltiples con fracturas de costilla presentes en un patrón que podría confundirse con metástasis. Los resultados de laboratorio fueron normales. El diagnóstico final se basó en la radiografía simple, escaneo óseo y densitometría ósea. Se aplicaron tratamientos fármaco-médicos para la osteoporosis. El paciente estuvo sujeto a observación entre el año 2000 y el 2005. Cinco años más tarde, la centellografía ósea y radiológica reveló la resolución de la lesión. Concluimos que la osteoporosis debía incluirse en el diagnóstico diferencial de la osteólisis focal asintomática de las costillas con fracturas de costillas, como complicación de la tos aguda. El caso sugiere que las lesiones osteolíticas focales de las costillas pueden experimentar una regresión con el tiempo y hacerse centellográficamente inactivas.

Short-term Efficacy of Monthly Pamidronate Infusion in Patients with Osteogenesis Imperfecta

We evaluated the efficacy of a monthly infusion of pamidronate on the frequency of fractures, biochemical effects, and bone mineral density in children with osteogenesis imperfecta. Eleven patients from 0.9 to 13.8 yr of age were included in this study. The patients were administered pamidronate intravenously (30 mg/m2) over a 4-hr period monthly for a period ranging from 6 to 37 months. Height and weight Z-scores did not change significantly. The frequency of fractures was decreased from 2.3+/-1.01 times per year before treatment to 0.6+/-0.69 times per year during treatment. There were no long-term changes in biochemical markers during pamidronate therapy. The mean bone mineral density of the spine and femur increased significantly. Monthly intravenous pamidronate therapy decreased frequencies of fracture and increased bone mineral density without significant adverse events in Korean patients with osteogenesis imperfecta.

Skeletal manifestations and role of dexa study in 32 patients with multiple myeloma

To discuss skeletal manifestation of patients with multiple myeloma and the role of double energy X-ray photometry study in the management of those patients. During period from the 1st of April 2004 to 1St of January 2005 we collected 32 patients who fulfilled the criteria of diagnosis of multiple myeloma. .All our patients have detailed history and physical examination including: Age, Sex, Bone pain, pathological fracture, Localized tenderness and Bone swelling. Pathological fracture found in [14] [43.75%], [10] were males [50%] of total males and [4] were females [33.3%] of total females.Serum Alkaline Phosphatase ranging between [30-135KAU/L], mean [75.218KAU/L], patients who got serum alkaline phosphatase level>80 KAU/L are[13][40.62%],[1 lX84.6%] of them got localized tenderness and [11] [84.6%] of them got pathological fracture, but those who got serum alkaline phosphatase >100 KAU/IL all of them got pathological fracture. DEXA study found to be significant in [24] [75%] and insignificant in [8] [25%].All the studied patients with pathological fracture got significant DEXA. Significant DEXA found in [12] [75%] of patients with positive skull X-ray, [1 7X80.9%] with a positive spine X-ray,[10] [71.42%] with apositive pelvic X-ray and [8] [80%] with apositive longe bone X-ray. Significant DEXA found in [11] [91.66%] patients with S.Calcium >2.6mmol/L and those who got S.Calciuin >3.3 mmol/Lall got significant DEXA. The most common presenting feature is bone pain. Pathological fractures were more common in males than females, all patients with serum alkaline phosphatase > 100KAU/L got pathological fractures and there is no relationship between localized tenderness and pathological fracture. here is no patient with pathological fracture with insignificant DEXA. The more advanced changes in DEXA study had higher risk of pathological fracture and needed close observations and treatment to improve bone T condition

Prognostic factors in pathologic fractures secondary to metastatic tumors

OBJETIVO: As fraturas patológicas por metástase óssea determinam uma queda abrupta na qualidade de vida dos pacientes com neoplasias malignas e também aumentam sua mortalidade. Os avanços ortopédicos de osteossíntese e endopróteses têm beneficiado a prevenção e tratamento dessas fraturas. O objetivo de nosso estudo é determinar quais são os fatores prognósticos dessas fraturas patológicas tratadas no nosso serviço. CASUÍSTICA E MÉTODOS: Foram estudados 112 pacientes tratados com fraturas patológicas secundárias a tumores metastáticos entre abril de 1994 e dezembro de 2004, no nosso serviço.Os pacientes foram analisados quanto ao sexo, idade, local de metástase óssea, metástases viscerais, origem do tumor primário, tipo de tratamento, hemoglobina sérica e sobrevida. RESULTADOS: O local mais acometido foi o fêmur (44%), o tumor primário mais freqüente foi o câncer de mama (25%), o tratamento cirúrgico mais realizado foi a endoprótese não convencional (66%). As variáveis sexo, idade, tumor primário, local acometido, mestástase não-óssea e tratamento clínico versus cirúrgico não são bons preditores para sobrevida. Os pacientes operados com endoprótese (21,6 meses) apresentaram pior prognóstico que os pacientes submetidos à osteossíntese (47,8 meses). DISCUSSÃO E CONCLUSÃO: Os pacientes submetidos à osteossíntese, com uma técnica cirúrgica menos mórbida e de reabilitação mais precoce, apresentaram maior sobrevida em relação aos pacientes submetidos à endopróteses. Observamos que nossa casuística é semelhante à internacional, na qual aparece como tumor primário mais freqüente o de mama, os de origem indeterminada, próstata e pulmão.