Análisis de sentencias judiciales relativas a negligencias médicas emitidas contra traumatólogos entre 1995 y 2011 / Analysis of judicial sentences issued against traumatologists between 1995 and 2011 as regards medical negligence

Introducción y objetivos. La Traumatología y Cirugía Ortopédica es una de las especialidades más reclamadas por su amplitud y complejidad. Nuestro objetivo es determinar las características de las reclamaciones presentadas contra médicos especialistas en Traumatología, considerando todas aquellas variables que puedan tener influencia tanto en el planteamiento de la demanda como en la resolución del proceso. Material y métodos. Se ha realizado un análisis de 303 sentencias judiciales (1995-2011) recogidas en el archivo de sentencias judiciales sanitarias de la Escuela de Medicina Legal de Madrid que se nutre de la base de datos de Westlaw Aranzazi. Resultados. La jurisdicción civil fue la más empleada. El proceso específico más reclamado fueron los trastornos osteoarticulares seguidos de las alteraciones vasculonerviosas y de las infecciones. La lesión reclamada ocurrió con más frecuencia en miembros inferiores sobre todo rodilla. La causa general de reclamación más frecuente fue el error terapéutico quirúrgico seguido del error diagnóstico. En el 14,9% fue el defecto de información. Existió condena en el 49,8% de los casos siendo la indemnización mayoritariamente menor de 50.000 euros. Conclusiones. Concluimos que la Traumatología y Cirugía Ortopédica es una especialidad proclive a las reclamaciones por mala praxis. El número de condenas a traumatólogos es elevado pero las indemnizaciones suelen ser menores de 50.000 euros. El motivo fundamental de las reclamaciones es el error terapéutico quirúrgico siendo pues el acto quirúrgico fundamental y donde se deben extremar las precauciones. Las condenas por deficiente información son elevadas siendo fundamental una adecuada comunicación médico-paciente y rellenar correctamente el consentimiento informado (AU)

Introduction and objectives. Traumatology and Orthopaedic Surgery is one of the specialities with most complaints due to its scope and complexity. The aim of this study is to determine the characteristics of the complaints made against medical specialists in Traumatology, taking into account those variables that might have an influence both on the presenting of the complaint as well as on the resolving of the process. Material and methods. An analysis was performed on 303 legal judgments (1995-2011) collected in the health legal judgements archive of the Madrid School of Medicine, which is linked to the Westlaw Aranzadi data base. Results. Civil jurisdiction was the most used. The specific processes with most complaints were bone-joint disorders followed by vascular-nerve problems and infections. The injury claimed against most was in the lower limb, particularly the knee. The most frequent general cause of complaint was surgical treatment error, followed by diagnostic error. There was lack of information in 14.9%. There was sentencing in 49.8% of the cases, with compensation mainly being less than 50,000 euros. Conclusions. Traumatology and Orthopaedic Surgery is a speciality prone to complaints due to malpractice. The number of sentences against traumatologists is high, but compensations are usually less than 50,000 euros. The main reason for sentencing is surgical treatment error; thus being the basic surgical procedure and where precautions should be maximised. The judgements due to lack of information are high, with adequate doctor-patient communication being essential as well as the correct completion of the informed consent (AU)

[Analysis of judicial sentences issued against traumatologists between 1995 and 2011 as regards medical negligence]. / Análisis de sentencias judiciales relativas a negligencias médicas emitidas contra traumatólogos entre 1995 y 2011.

INTRODUCTION AND OBJECTIVES: Traumatology and Orthopaedic Surgery is one of the specialities with most complaints due to its scope and complexity. The aim of this study is to determine the characteristics of the complaints made against medical specialists in Traumatology, taking into account those variables that might have an influence both on the presenting of the complaint as well as on the resolving of the process. MATERIAL AND METHODS: An analysis was performed on 303 legal judgments (1995-2011) collected in the health legal judgements archive of the Madrid School of Medicine, which is linked to the Westlaw Aranzadi data base. RESULTS: Civil jurisdiction was the most used. The specific processes with most complaints were bone-joint disorders followed by vascular-nerve problems and infections. The injury claimed against most was in the lower limb, particularly the knee. The most frequent general cause of complaint was surgical treatment error, followed by diagnostic error. There was lack of information in 14.9%. There was sentencing in 49.8% of the cases, with compensation mainly being less than 50,000 euros. CONCLUSIONS: Traumatology and Orthopaedic Surgery is a speciality prone to complaints due to malpractice. The number of sentences against traumatologists is high, but compensations are usually less than 50,000 euros. The main reason for sentencing is surgical treatment error; thus being the basic surgical procedure and where precautions should be maximised. The judgements due to lack of information are high, with adequate doctor-patient communication being essential as well as the correct completion of the informed consent.

Seguridad y eficacia de la cifoplastia en el tratamiento de la enfermedad tumoral de la columna vertebral / Safety and efficacy of kyphoplasty in the treatment of tumoral disease of the spine

Las fracturas vertebrales en pacientes oncológicos generan dolor e incapacidad, con limitación funcional y disminución de la calidad de vida. El objetivo del estudio es valorar la eficacia y seguridad de la cifoplastia en este tipo de fracturas vertebrales en el momento agudo. Material y métodos. Estudio descriptivo retrospectivo de 75 pacientes oncológicos consecutivos con 122 fracturas vertebrales agudas, que fueron tratados mediante cifoplastia percutánea bilateral con balón, con un seguimiento medio de 11 meses. Resultados. Se produjo mejoría del dolor en el 91% de los pacientes. La mejoría media en la Escala Visual Analógica (EVA) fue de 4,28 puntos (valor preoperatorio 7,49 [DE 1,19], postoperatorio 3,21 [DE 0,95]). Antes de la intervención necesitaban opioides mayores un 53% de los pacientes (40 casos) y al mes de la cirugía solo un 12% (9 pacientes). La calidad de vida determinada por el índice de Karnosfky mejoró de 60,2 (DE 10) a 80,7 (DE 12,1). En un 5,7% de las cifoplastias (7 casos) se encontraron fugas de cemento, todas ellas sin repercusión neurológica. Aparecieron nuevas fracturas en un 14% de las cifoplastias (11 casos). Este subgrupo presentó un empeoramiento discreto de la mejoría clínica adquirida inicialmente. No encontramos ninguna complicación neurológica ni pulmonar relacionada con la técnica quirúrgica que no estuviera justificada por la evolución de la enfermedad. Conclusiones. La cifoplastia constituye un procedimiento eficaz y seguro para el tratamiento de las fracturas vertebrales en pacientes con cáncer (AU)

Vertebral fractures in oncology patients cause significant pain and disability, with decreased quality of life. The aim of the study is to assess the efficacy and safety of kyphoplasty in this type of vertebral fracture in the acute phase. Materials and methods. A retrospective study was conducted on 75 consecutive oncology patients with 122 acute vertebral fractures, who underwent bilateral balloon kyphoplasty, with a mean follow up of 11 months. Results. Almost all (91%) of the patients improved their pain level. The mean improvement in the Visual Analogue Scale (VAS) was 4.28 points (preoperative value 7.49 [SD 1.19], postoperative 3.21 [SD 0.95]). Before surgery, 53% of patients needed major opioids (40 cases), and one month after surgery only 12% (9 patients) required them. Quality of life determined by the Karnofsky index improved from 60.2 (SD 10) to 80.7 (SD 12.1). Cement leaks were found in 5.7% (7 cases), all without neurological repercussions. New fractures appeared in 11 patients. This subgroup showed a slight worsening of the initially acquired clinical improvement. No neurological or pulmonary complications related to surgical technique were found. Conclusions. Kyphoplasty is an effective and safe for treating vertebral fractures in patients with cancer (AU)

[Safety and efficacy of kyphoplasty in the treatment of tumoral disease of the spine]. / Seguridad y eficacia de la cifoplastia en el tratamiento de la enfermedad tumoral de la columna vertebral.

UNLABELLED: Vertebral fractures in oncology patients cause significant pain and disability, with decreased quality of life. The aim of the study is to assess the efficacy and safety of kyphoplasty in this type of vertebral fracture in the acute phase. MATERIALS AND METHODS: A retrospective study was conducted on 75 consecutive oncology patients with 122 acute vertebral fractures, who underwent bilateral balloon kyphoplasty, with a mean follow up of 11 months. RESULTS: Almost all (91%) of the patients improved their pain level. The mean improvement in the Visual Analogue Scale (VAS) was 4.28 points (preoperative value 7.49 [SD 1.19], postoperative 3.21 [SD 0.95]). Before surgery, 53% of patients needed major opioids (40 cases), and one month after surgery only 12% (9 patients) required them. Quality of life determined by the Karnofsky index improved from 60.2 (SD 10) to 80.7 (SD 12.1). Cement leaks were found in 5.7% (7 cases), all without neurological repercussions. New fractures appeared in 11 patients. This subgroup showed a slight worsening of the initially acquired clinical improvement. No neurological or pulmonary complications related to surgical technique were found. CONCLUSIONS: Kyphoplasty is an effective and safe for treating vertebral fractures in patients with cancer. LEVEL OF EVIDENCE: Level IV.

Corrección del Hallux valgus en metatarso adductus / Hallux valgus correction in metatarsus adductus

Objetivo. Señalar la frecuente asociación de metatarso adductus y Hallux valgus en el adulto como causa de corrección insuficiente de éste tras la aplicación de técnicas quirúrgicas comunes. Material y método. Se han revisado retrospectivamente 16 casos en 15 pacientes operados de Hallux valgus entre los años 2006 y 2008, presentaban metatarso adductus clínico y radiológico y en los que se observaba una corrección de la deformidad inferior a 10°. Resultados. La corrección media presentada fue de 9°. La oblicuidad media de la primera articulación cuneometatarsiana fue de 65°. No apareció relación entre grado de metatarso adductus y corrección observada. Las mejores correcciones se obtuvieron con la osteotomía en Scarf. Discusión. Existe controversia en cuanto a la relación entre metatarso adductus y Hallux valgus. Aunque una inadecuada aplicación de las técnicas quirúrgicas es la causa más importante de fracaso en la corrección, la poca bibliografía existente y la comparación con resultados propios, nos pueden señalar esta asociación como una causa de dificultad en la aplicación de técnicas quirúrgicas convencionales. Conclusión. La presencia de metatarso adductus en un paciente adulto que va a ser operado de Hallux valgus debe ser detectada y consignada como una causa que dificulta la corrección. La planificación y la elección de la técnica deben tener en cuenta estos defectos angulares para evitar un resultado decepcionante para el paciente (AU)

Background. To describe the frequent association of Metatarsus adductus and Hallux valgus in the adult foot as a cause of insufficient correction after application of common surgical techniques. Method and material A retrospective review was made of 16 cases in 15 patients with clinical and radiologic metatarsus adductus operated by Hallux valgus from 2006 to 2008. In all cases, a correction of the deformity lower than 10° was observed. Results. The mean postoperative correction was 9°. The mean inclination of first cuneometatarsal joint was 65°. We did not find any relationship between Metatarsus adductus magnitude and postoperative Hallux valgus correction. The best results were observed with Scarf Osteotomy. Discussion. There is controversy on the Metatarsus adductus and Hallux valgus relationship. Although poor application of the surgical techniques is the most important cause of correction failure, the limited literature references and the comparison with similar results, may show this association as a cause of the difficulty in the application of conventional surgical techniques. Poor performance of these techniques is an important cause of correction failure and must be evaluated. Conclusion. Metatarsus adductus in the adult foot with Hallux valgus to be operated must be detected and seen as a deformity that is difficult to correct. Preoperative planning and choice of surgical technique must assess these angular deformities to avoid a poor result for the patient (AU)

Early lymphocyte activation in the synovial microenvironment in patients with osteoarthritis: comparison with rheumatoid arthritis patients and healthy controls.

Osteoarthritis (OA) is largely considered to be a non-inflammatory disease, although there is compelling evidence that subclinical inflammation is a common event, even in the absence of acute inflammatory flares. In this study we analyze, by means of CD5 and CD69 expression, the infiltration and early activation of CD5+cells, mostly lymphocytes, in both synovial membrane and synovial fluid from advanced OA patients and compare them with samples from patients with rheumatoid arthritis and healthy controls. The number of infiltrating CD5+ cells in both synovial membrane and synovial fluid from patients with advanced OA was significantly reduced as compared with rheumatoid arthritis patients. However, synovial membrane and synovial fluid CD5+ cells on OA exhibited a phenotype with evidence of recent activation comparable to that observed in RA.

Differential proteome of bone marrow mesenchymal stem cells from osteoarthritis patients.

OBJECTIVE: Adult mesenchymal stem cells (MSCs) are multipotent cells whose primary reservoir is bone marrow (BM). Following situations of extensive tissue damage, MSCs are mobilized and migrate to the site of injury. Osteoarthritis (OA) is a condition that involves extensive cartilage and bone damage. To gain insight into the pathogenesis of OA, we have analyzed the differential BM-MSCs proteome of OA patients. METHODS: MSCs protein extracts were prepared from BM aspirates from six patients with OA and from six hip fracture subjects without OA, and analyzed by Two-dimensional gels, using the differential in-gel electrophoresis approach. Differentially expressed proteins were identified by mass spectrometry. In addition, the chemotactic responses of OA and control MSCs were assessed. RESULTS: The majority of proteins that changed at least 1.5-fold (P<0.05) belonged to the following three categories: metabolic enzymes (14 proteins, 36%), cytoskeleton/motility (12 proteins, 32%), and transporters (three proteins, 8%). In OA MSCs, a high percentage of metabolic enzymes (n=8, 57%) were up-regulated and most of the proteins related to cytoskeleton/motility (n=9, 75%) were down-regulated. There was a significant increase in the migration response of OA MSCs to platelet-derived growth factor-BB (chemotaxis index CI: 5.13+/-1.19 vs 3.35+/-0.42, P=0.043). CONCLUSIONS: In this study, we have described the differential proteome of BM-MSCs from OA patients together with an increased chemotactic response of these cells in the context of OA. These results could indicate an activation of OA BM-MSCs in response to chemotactic signals sent by the altered subchondral bone in an attempt to heal damaged tissue.

Tratamiento de las fracturas vertebrales mediante cifoplastia / Treatment of vertebral fractures by kyphoplasty

Objetivo. Análisis retrospectivo clínico y radiológico sobre los primeros casos intervenidos mediante cifoplastia en un centro de la Comunidad de Madrid. Material y método. Se revisaron 30 pacientes (43 vértebras) intervenidos entre diciembre 2002 y mayo 2005. La distribución etiológica fue: 24 pacientes con fractura osteoporótica y 6 con implantes tumorales líticos (1 caso de cáncer de pulmón, 2 de mama, un hipernefroma y 2 mielomas). El seguimiento medio fue de 13,2 meses. Se valoró la escala analógica visual (EAV), el índice de Karnosfky y la analgesia empleada antes del proceso y tras el seguimiento. También se midió el porcentaje de aplastamiento, el ángulo de Cobb local y la corrección de ambos. Resultados. El 93,2% de los pacientes mejoraron. La media de la EAV aumentó 5 puntos (p < 0,05). El índice de Karnosfky pasó de 70,63 a 90 puntos (p < 0,05). El 53% usaba opiáceos mayores antes de la cirugía, pasando el porcentaje después de la cirugía al 6,6% (p < 0,05). Veinte casos (46,5%) mejoraron radiológicamente. Excluyendo aquellas vértebras que no se corrigieron, la mejora obtenida fue de 21,7% de aplastamiento (rango 5-70%) y 13,86° de corrección ángulo de Cobb (rango 3-30°) respectivamente. Hubo 6 extravasaciones anterolaterales, todas asintomáticas. Se detectaron 2 fracturas adyacentes (ambas en los tres primeros meses tras la cirugía), una con repercusión clínica. En el subgrupo de pacientes tumorales los resultados finales fueron comparables a la serie general. Conclusiones. La mayoría de los casos mejoran sustancialmente sin complicaciones asociadas. La cifoplastia es una técnica de baja morbilidad y alta eficacia

Purpose. To conduct a retrospective clinical and radiological study of the first few cases operated by kyphoplasty at one center of Madrid. Materials and methods. Thirty patients were reviewed (43 vertebrae) who were operated between December 2002 and May 2005. The etiological distribution was as follows: 24 patients with an osteoporotic fracture and 6 with osteolytic tumors (lung cancer, 1 case; breast cancer, 2; hypernephroma, 1; and myeloma, 2). Mean follow-up was 13.2 months. Pain reduction was assessed by means of the Visual Analog Scale (VAS), the Karnosfky score and the amount of analgesia used before the procedure and during follow-up. Pre- and postoperative endplate angles were measured to assess the restoration of the sagittal alignment. Results. A 93.2% of patients improved. Mean VAS increased by 5 points (p < 0.05). Karnosfky score went from 70.63 to 90 points (p < 005). Patients using major opioids went from 53% befofre surgery to 6.6% postoperatively (p < 0.05). 20 cases (46.5%) showed radiological improvement. If we exclude uncorrected vertebrae, the improvement obtained was 21.7% as regards crushing (range: 5-70%) and 13.86° as regards Cobb's angle (range: 3-30°). There were 6 instances of anterolateral cement extravasation, all of them asymptomatic. Two adjoining fractures were detected (both in the first three months post-op), one of them with clinical repercussions. In the group of patients with tumors, final results were comparable to the general series. Conclusions. Most cases show a significant improvement with no associated complications. Kyphoplasty is a highly effective minimally invasive technique with a low degree of morbidity

Artrodesis mediocarpiana con placa Spider® / Midcarpal Spider® plate arthrodesis

Objetivo. Con este estudio pretendemos valorar la efectividad de la placa Spider® en la artrodesis mediocarpiana. Material y método. Hemos estudiado 11 pacientes intervenidos de artrodesis mediocarpiana con placa Spider® que presentaban un proceso degenerativo avanzado del carpo estadio II o III. El seguimiento medio ha sido de 15 meses (7 a 25 meses). Resultados. Se observa una importante disminución del dolor en todos los casos, manteniéndose una flexión postquirúrgica de 33° (12° a 37°); una extensión de 29° (12° a 33°); una desviación radial postoperatoria de 12° (0° y 16°) y una desviación cubital de 17° (0° a 20°). Se apreció un aumento de la fuerza de prensión después de la cirugía. Se observó la consolidación de la artrodesis en todos los casos, con una pequeña disminución del índice de la altura del carpo. Conclusiones. Esta técnica quirúrgica nos ha permitido obtener buenos resultados clínico-radiológicos y una movilización precoz tras la cirugía

Purpose. The aim of this study was to assess the effectiveness of SpiderTM plates in midcarpal arthrodesis. Materials and methods. We studied 11 patients with advanced stage II and III degenerative process of the carpus treated by midcarpal arthrodesis with SpiderTM plates. Mean followup was 15 months (7-25 months). Results. A significant decrease in pain was seen in all cases. Postoperative flexion was 33° (12º-37º); extension 29° (12°-33°); there was one postoperative radius deviation of 12° (0°­16°) and one ulnar deviation of 17° (0°-20°). After surgery an increase in grasping strength was seen. Arthrodesis healing was seen in all cases, with a small decrease in the carpal height index. Conclusions. This surgical technique has allowed us to obtain good clinical and radiological results and early postoperative mobilization (AU)

Human parvovirus B19, varicella zoster virus, and human herpesvirus-6 in mesenchymal stem cells of patients with osteoarthritis: analysis with quantitative real-time polymerase chain reaction.

OBJECTIVE: To investigate whether there is a possible viral transmission using mesenchymal stem cells (MSCs) in autologous or allogeneic transplantation in the context of osteoarthritis (OA) patients. The presence of parvovirus B19 (B19), varicella zoster virus (VZV), and human herpesvirus-6 (HHV-6) was studied in MSCs from bone marrow of patients with OA and healthy controls. METHODS: MSCs were prepared from bone marrow aspirates obtained from 18 patients undergoing joint replacement as a result of OA and from 10 healthy controls. DNA was extracted from primary MSCs' culture established from these cells and quantitative real-time polymerase chain reaction was performed to analyse the prevalence and viral load of B19, VZV and HHV-6. RESULTS: The prevalence of total viral DNA among patients with OA was 16.7% (3/18), with a mean viral load of 29.7 copies/microg of DNA. One out of 18 was positive for B19 (viral load, 61.2 copies/microg of DNA), two for VZV (mean viral load, 14.4 copies/microg of DNA), and none for HHV-6. The prevalence of total viral DNA in the control group was 20% (2/10), with a mean viral load of 13.4 copies/microg of DNA. Both positive results were of B19 parvoviruses. There were no statistically significant differences among patients and controls. CONCLUSIONS: This first approach to the viral prevalence in MSCs of bone marrow in OA patients and healthy controls seems to show a very low risk of viral transmission or reactivation in a possible MSCs' transplantation.

Retrograde nailing of femur: surgical technique with tibial traction.

A modified surgical technique for femoral retrograde nailing is described. A tibial skeletal traction in the proximal metaphysis is placed to obtain fracture reduction during surgery. This technique enables fracture control during the procedure, avoiding the need of an assistant.

Necrosis of the femoral head after fixation of trochanteric fractures with Gamma Locking Nail. A cause of late mechanical failure.

Cut-out of the lag screw after fixation of trochanteric fractures with intramedullary devices like the Gamma Locking Nail is a well documented cause of late mechanical failure. Avascular necrosis of the femoral head after trochanteric fractures is an uncommon complication and several causes have been described. As far as we know, the relation of the mechanical failure of fracture fixation and avascular necrosis of the femoral head in trochanteric fractures has never been described. We present a study of six consecutive patients who underwent arthroplasty after cut-out of the lag screw fixation of a trochanteric fracture with Gamma Locking Nail. All six femoral heads were studied histologically and a clinical retrospective study was also performed. In all cases, we found homogeneous avascular necrosis of the femoral head; in all but one, revascularisation was present in every area examined. We suggest that after fixation of these trochanteric fractures with the Gamma Locking Nail, there is a transitory ischaemia, if the revascularisation is not enough to provide a strong support for the lag screw, it may result in late mechanical failure in these fractures.

A modified technique of four-bone fusion for advanced carpal collapse (SLAC/SNAC wrist).

This study reports the outcome of 16 patients treated with a modified four-bone fusion for symptomatic stage II and III advanced carpal collapse. The technique is based on fusion of the capitate, lunate, hamate and triquetrum using an autogenous corticocancellous bone-graft fixed with screws. The void left behind after scaphoid excision was filled with an extensor carpi radialis longus anchovy. After an average follow up of 3 years; there were 13 excellent and three good outcomes. In every patient pain relief was achieved with preservation of joint motion and grip strength. All the patients were able to return to their previous activities and jobs. Radiographic evaluation showed bone fusion in all 16 patients with a slight decrease in carpal height but a well preserved radiolunate joint space. In conclusion, this technique provides immediate stable fixation and early mobilization and assures bone fusion.

Unreamed intramedullary locking nailing for open tibial fractures.

We reviewed the results of the treatment of 24 cases of open tibial fractures using unreamed intramedullary locking nailing. The fractures were classified, following the Gustilo system as grade I-7, grade II-7 and grade III-10. The average time to achieve bony union was 22 weeks with a 26% incidence of pseudoarthrosis. There were no cases of deep infection. Five cases healed with shortening of over 1 cm, but we did not observe angular deformity in any of the patients. In 2 fractures with associated articular lesions, joint motion was limited at final follow up. The nail broke in 2 cases and the screws in 5. The surgical procedure is well tolerated by patients, allows good management of soft tissue lesions and rehabilitation with low rate of infection and malunion. The main disadvantages have been the relative high incidence of nonunion and breakage of metal.

Cardiopulmonary and haemodynamic changes during total hip arthroplasty.

We report a prospective study of 30 patients who underwent total hip arthroplasty for osteoarthrosis in order to investigate the haemodynamic and respiratory changes which occur during operation. Cement was used in 17 cases and the implants were not cemented in 13. Pulmonary and cardiac function, blood levels of methylmethacrylate monomer, intramedullary pressure and transoesophageal echocardiography were recorded. Two well differentiated echogenic patterns appeared consistently during the operation. The intramedullary pressure became raised as the cement was inserted. The following changes occurred within seconds and continued for some minutes: elevation of mean arterial pressure and mean pulmonary artery pressure; decrease of arterial oxygen tension and of mixed venous PO2, and greater tissue consumption of oxygen. Although we recorded raised concentration of methylmethacrylate monomer in venous blood after the cement was inserted, there is no evidence that the monomer is responsible for the haemodynamic changes which take place.

Bilateral Smith fracture of the radius caused by airbag deployment.

A passenger-side occupant of a car involved in a collision suffered bilateral Smith's fracture after extending both arms for protection and being hit by the deploying airbag.

Bilateral sacroiliac dislocation with intrapelvic intrusion of the lumbosacral spine. A case report.

A patient sustained bilateral sacroiliac dislocation in which the proximal part of the sacrum was displaced 10 cm anteriorly and 6 cm inferiorly into the pelvis. Stabilisation was initially obtained with an external fixator. Operation was carried out later: reduction was achieved by overhead skeletal traction using sublaminar wires; two screws were inserted through each sacroiliac joint and the two fragments of the sacrum were wired in place.

Osteochondral allografts for osteochondritis dissecans and osteonecrosis of the femoral condyles.

Osteochondral allografts were used in 11 patients with osteochondritis dissecans and 4 with osteonecrosis of the femoral condyles. The lesions were mainly in the medial condyle in 13 cases, and in the weightbearing area in 10. The grafts had a mean size of 6 cm2; 8 were kept in hypothermia at 4 degrees C for less than 24 h and 7 were stored at -80 degrees C with cryoprotection. After an average follow up of 3.2 years, only 2 patients needed a further operation, one for nonunion and the other for a fracture of the graft. The others had improved clinically and showed radiological union of the graft with preservation of the joint space.

Hombro doloroso: evaluación del tratamiento con infiltraciones de orgoteína / Painful shoulder treated by subacromial orgoteine infiltration: assessment of treatment

El hombro doloroso es la tercera causa de consulta por dolor en la práctica médica general, por detrás de la cefalea y el dolor de espalda. El objeto de este trabajo es sentar las bases para la terapéutica de este síndrome mediante infiltraciones locales con orgoteína. Se han seguido 48 pacientes con hombro doloroso. El seguimiento se extiende desde enero de 1989 a diciembre de 1990, con una media de 17 meses. La media de edad entre los pacientes fue de 33 años con un limite entre 19 y 61 años. De los 48 pacientes, 16 eran hombres y 32 mujeres. Tras un estudio protocolizado prospectivo se pudo apreciar cómo todos los pacientes mejoraron su sintomatología y en períodos muy similares: el dolor nocturno desapareció en la segunda semana, mientras que el diurno lo hizo a la tercera semana. La rigidez matutina era de 10 minutos de duración ya a la primera semana y desapareció a partir de entonces. La movilidad en abducción alcanzó los 90-100 grados hacia la sexta semana del tratamiento. La orgoteína como sustancia aplicada en infiltración local cumple su misión de disminución de radicales libres de oxígeno contribuyendo a la acción antiflogística y en definitiva aliviando los síntomas generales del hombro doloroso.