Latin America trauma systems-Mexico and Brazil.

In this brief review, the authors describe the main characteristics of trauma systems in Latin America's 2 most populous countries, Mexico and Brazil. Trauma is a common health problem and the major cause of death in the young populations in both countries. Mexico and Brazil have well-organized systems based on system designation and prehospital triage. The highest level trauma hospitals are only available in the biggest cities, with residents of the smaller cities having less access to quality care. Both countries can provide adequate musculoskeletal trauma and polytrauma care, but the systems are not universally equal and, therefore, not ideal. The lack of consistency and standardization of the systems across each country must be addressed to improve patient outcomes across each country.

FACTORS ASSOCIATED WITH COMPLEX REGIONAL PAIN SYNDROME IN SURGICALLY TREATED DISTAL RADIUS FRACTURE.

OBJECTIVE: The aim of this study was to identify factors associated with developing complex regional pain syndrome (CRPS) after surgical treatment for distal radius fracture (DRF). METHODS: This case-control study analyzed patients seen from January 2014 to January 2016. Results: In our sample of 249 patients, 4% developed CRPS. Associated factors were economic compensation via work disability (odds ratio [OR] 14.3), age (OR 9.38), associated fracture (OR 12.94), and level of impact (OR 6.46), as well as psychiatric history (OR 7.21). CONCLUSIONS: Economically-productive aged patients with a history of high-impact trauma and patients with a history of psychiatric disorders have greater risk of developing CRPS after DRF. Level of Evidence III, Case-Control Study.

OBJETIVO: Este estudo tem como objetivo identificar fatores de risco associados ao desenvolvimento de síndrome de dor regional complexa (CRPS) após o tratamento cirúrgico da fratura distal do rádio (DRF). MÉTODOS: Este estudo de caso/controle analisou pacientes atendidos de janeiro de 2014 a janeiro de 2016. Resultados: Em nossa amostra de 249 pacientes, 4% desenvolveram CRPS. Os fatores associados foram compensação econômica (razão de chances [RC] 14,3), idade (RC 9,38), fratura associada (RC 12,94) e nível de impacto (RC 6,46), bem como história psiquiátrica (RC 7,21). CONCLUSÕES: Os pacientes com idade produtiva e história de trauma de alto impacto e os com história de transtornos psiquiátrico têm maior risco de desenvolver CRPS depois de DRF. Nível de Evidência III, Estudo de Caso Controle.

Factors associated with complex regional pain syndrome in surgically treated distal radius fracture / Fatores associados à síndrome de dor regional complexa em fratura do distal do rádio tratada cirurgicamente

ABSTRACT Objective: The aim of this study was to identify factors associated with developing complex regional pain syndrome (CRPS) after surgical treatment for distal radius fracture (DRF). Methods: This case-control study analyzed patients seen from January 2014 to January 2016. Results: In our sample of 249 patients, 4% developed CRPS. Associated factors were economic compensation via work disability (odds ratio [OR] 14.3), age (OR 9.38), associated fracture (OR 12.94), and level of impact (OR 6.46), as well as psychiatric history (OR 7.21). Conclusions: Economically-productive aged patients with a history of high-impact trauma and patients with a history of psychiatric disorders have greater risk of developing CRPS after DRF. Level of Evidence III, Case-Control Study.

RESUMO Objetivo: Este estudo tem como objetivo identificar fatores de risco associados ao desenvolvimento de síndrome de dor regional complexa (CRPS) após o tratamento cirúrgico da fratura distal do rádio (DRF). Métodos: Este estudo de caso/controle analisou pacientes atendidos de janeiro de 2014 a janeiro de 2016. Resultados: Em nossa amostra de 249 pacientes, 4% desenvolveram CRPS. Os fatores associados foram compensação econômica (razão de chances [RC] 14,3), idade (RC 9,38), fratura associada (RC 12,94) e nível de impacto (RC 6,46), bem como história psiquiátrica (RC 7,21). Conclusões: Os pacientes com idade produtiva e história de trauma de alto impacto e os com história de transtornos psiquiátrico têm maior risco de desenvolver CRPS depois de DRF. Nível de Evidência III, Estudo de Caso Controle.

Risk factors for amputation in periprosthetic knee infection.

Treatment for prosthetic knee replacement is becoming more common. Infection is an arthroplasty-related complication leading to prolonged hospitalization, multiple surgical procedures, permanent loss of the implant, impaired function, impaired quality of life and even amputation of the limb. Previous studies have evaluated the risk factors associated with periprosthetic knee infection, but scarce information related to risk factors associated with amputation in this group of patients is available. The purpose of this study was to identify risk factors for amputation in periprosthetic infected knee through a case-control study, analyzing patients treated from January 2012 to November 2016 in a hospital with a high incidence of this diagnosis. We included 183 patients with periprosthetic knee infection; 23 required amputation as definitive management (cases). We found that patients with surgical time >120 min (p = 0.01), surgical risk higher than two points according to the American Society of Anesthesiology score (p = 0.00), smokers (p = 0.04), obesity and diabetes mellitus (p = 0.00) had an increased risk of amputation.

[Evidence and recommendation of empirical antimicrobial treatment in pyogenic spondylodiscitis: systematic review]. / Evidencia y recomendación del tratamiento antimicrobiano empírico en espondilodiscitis piógena: revisión sistemática.

BACKGROUND: Pyogenic spondylodiscitis is the infectious process that affects the vertebral body and the intervertebral disc. It has an incidence between 2 and 7%. To prescribe antibiotic treatment, it is required to identify the causative organism on the basis of the epidemiology of the etiologic agent, as well as the ability of the antibiotic to penetrate the bone tissue and the intervertebral disc. The objective was to identify the level of evidence and the grade of recommendation for the empiric initial treatment. METHODS: A systematic review was conducted based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria. PubMed articles were evaluated to assess their level of evidence and the grade of recommendation according to the Jadad scale and the classification of Sackett. On the basis of those two scales, it was analyzed the agreement by two observers and a Kappa value of 0.750 (p = 0.0001) was considered statistically significant. RESULTS: 642 studies were analyzed, out of which only 19 met the inclusion criteria. In these it was identified a level of evidence 4 and a degree of recommendation C for the use of fluoroquinolones in association with rifampicin in the empirical treatment of pyogenic spondylodiscitis and the use of vancomycin for the treatment of methicillin-resistant strains. CONCLUSION: There is not enough information concerning the use of empiric antibiotics in pyogenic spondylodiscitis; however, the existing information is favorable, even though it is not conclusive.

Introducción: la espondilodiscitis piógena es el proceso infeccioso que afecta al cuerpo vertebral y al disco intervertebral, con una incidencia de 2 a 7% de todas las osteomielitis. Para indicar tratamiento antibiótico se requiere identificar el germen causal a partir de la epidemiología del agente etiológico y de la capacidad del antibiótico de penetrar en el tejido óseo y en el disco intervertebral. El objetivo fue identificar el nivel de evidencia y el grado de recomendación del tratamiento antibiótico empírico inicial. Métodos: se hizo una revisión sistemática con base en los criterios PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Se evaluó en las publicaciones de PubMed el nivel de evidencia y el grado de acuerdo respecto a la escala de Jadad y a la clasificación de Sackett. Se analizó la concordancia entre los evaluadores y hubo significación estadística en los valores de Kappa de 0.750 con valor de p = 0.0001. Resultados: se analizaron 642 artículos, de los cuales solo 19 cumplieron con los criterios de selección. En estos últimos se identificó un nivel de evidencia 4 y un grado de recomendación C para la utilización de fluoroquinolonas en asociación con rifampicina en el tratamiento empírico de la espondilodiscitis piógena y el uso de vancomicina en caso de cepas resistentes a la meticilina. Conclusión: no existe información suficiente al respecto, pero la información existente es favorable, aunque no concluyente, para el uso de antibióticos empíricos en los casos de espondilodiscitis piógena.

Caracterizacion histopatologica y bacteriologica de las membranas periprotesicas de cadera

Criterios de Morawietz

Parameters of nuclear magnetic resonance in patients with congenital narrowing of the lumbar spinal canal / Parâmetros de ressonância magnética em pacientes com estreitamento congênito do canal vertebral lombar / Parámetros de resonancia magnética en pacientes con estrechamiento congénito del conducto lumbar

ABSTRACT Objective: To compare the morphological parameters of magnetic resonance in patients with congenital narrowing of the lumbar spinal canal with patients with low back pain. Methods: A descriptive, retrospective, observational study was conducted with measurements in the axial and sagittal magnetic resonance sections of the vertebral body and canal of the lumbar spine of 64 patients with diagnosis of low back pain, which were compared with resonance images taken from 31 Mexican patients with congenital narrowing of the lumbar spinal canal. Results: The results show that patients with congenital narrowing of the lumbar spinal canal in the axial sections have a difference in diameters, being L2<13.9 mm, L3<13.3 mm, L4<12.9 mm, L5<13.1 mm, compared with controls L2<20.5 mm, L3<20.5 mm, L4<19.3 mm, L5<18.1 mm with p = 0.000. Conclusions: We found different measurements in the Mexican population compared to those found by similar studies. With the parameters obtained, it would be possible to make the proper diagnosis, surgical planning, and treatment.

RESUMO Objetivo: Comparar os parâmetros morfológicos de ressonância magnética de pacientes com estreitamento congênito do canal lombar com os pacientes com lombalgia. Métodos: Foi realizado um estudo descritivo, retrospectivo, observacional, com medições nos cortes axiais e sagitais de ressonância magnética do corpo e do canal vertebral da coluna lombar de 64 pacientes com diagnóstico de lombalgia, os quais foram comparados com ressonâncias feitas em 31 pacientes com diagnóstico de estreitamento congênito de canal vertebral lombar na população mexicana. Resultados: Os resultados obtidos mostram que os pacientes com estreitamento congênito do canal vertebral lombar apresentam, nos cortes axiais, uma diferença com relação aos diâmetros, sendo em L2 < 13,9 mm, L3 < 13,3 mm, L4 < 12,9 mm, L5 < 13,1 mm, em comparação com os controles L2 < 20,5 mm, L3 < 20,5 mm, L4 < 19,3 mm, L5 < 18,1 mm com p = 0,000. Conclusões: Foram encontradas distintas medições na população mexicana em comparação com outros estudos similares. Com os parâmetros obtidos será possível realizar o diagnóstico adequado, planejamento cirúrgico e tratamento.

RESUMEN Objetivo: Comparar parámetros morfológicos en resonancia magnética nuclear de pacientes con estrechamiento congénito del conducto lumbar con pacientes con lumbalgia. Métodos: Se realizó un estudio descriptivo, retrospectivo, observacional, con mediciones en cortes axiales y sagitales del cuerpo y conducto vertebral en resonancias magnéticas de columna lumbar de 64 pacientes con diagnóstico de lumbalgia y se comparó con resonancias magnéticas de 31 pacientes diagnosticados con estrechamiento congénito del conducto lumbar en población mexicana. Resultados: Los resultados obtenidos demuestran que los pacientes con estenosis lumbar congénita presentan, en cortes axiales, una diferencia en cuanto a los diámetros, siendo en L2 < 13,9 mm, L3 < 13,3 mm, L4 < 12,9 mm, L5 < 13,1 mm en comparación a los controles L2 < 20,5 mm, L3 < 20,5 mm, L4 < 19,3 mm, L5 < 18,1 mm con una p = 0,000. Conclusiones: Encontramos distintas mediciones en población mexicana comparado a otros estudios similares. Con estos parámetros obtenidos se podrá realizar un adecuado diagnóstico, planeación quirúrgica y tratamiento.

[Mixed knee arthrodesis a rescue alternative in knee periprosthetic joint infection]. / Artrodesis mixta de rodilla: una alternativa de salvamento en infecciones periprotésicas de rodilla.

BACKGROUND: Knee arthrodesis is a rescue procedure for patients with knee periprosthetic joint infection who are not candidates for a revision surgery. The actual methods present a high complication rate with only moderate efectivity. METHODS: We retrospectively analyzed 17 cases, of patients with knee periprosthetic joint infection and bone loss treated by intramedular expandable nail and monoplanar external fixator with a mínimum evolution of 1 year, evaluating the medical records and digitalized X-rays by 2 sub specialized doctors in osteoarticular rescue surgery. RESULTS: From the 17 patients, 88.2% were classified as Anderson Orthopaedic Research Institute classification grade (III) and the 11.2% IIB. We obtained fusion in 82.5%, staged Hammer (I-II) in a mean time of 6.33 months. Achieving independent gait was reported in 88.2%. Our complication rate was 47.1%, most of them minor complications except for a supracondylar amputation. Our infection recurrence rate was 35.4%. Mean intervention rate was 2.47 surgeries, all without any operative room complication. CONCLUSIONS: We achieved a fusion rate similar to other available knee arthrodesis methods in a similar treatment time; with lower complication rate, making it a suitable rescue alternative for knee arthrodesis in patients with significant bone loss and knee periprosthetic joint infection.

Introducción: la artrodesis es una cirugía de salvamento para la infección periprotésica de rodilla; este procedimiento reporta moderada efectividad, alto índice de complicaciones y es la última alternativa antes de la amputación. El objetivo de este estudio fue identificar si la artrodesis de rodilla con clavo expandible y fijador externo es un tratamiento seguro y efectivo. Métodos: estudio observacional, retrospectivo, en 17 pacientes con infección periprotésica y pérdida ósea importante, tratados mediante artrodesis con clavo centro-medular expandible autobloqueante y fijador externo monoplanar con evolución mínima de 1 año; la información se obtuvo del expediente clínico e imágenes de rayos X, siendo estas evaluadas por 2 ortopedistas especializados en rescate osteoarticular. Resultados: de 17 pacientes, con una pérdida ósea grado III en un 88.2% de los casos, se obtuvo una fusión en el 82.5%. Logrando la deambulación independiente en el 88.2%. Con un promedio de 2.4 intervenciones quirúrgicas por paciente. Sin complicaciones transquirúrgicas reportadas. Con un índice de complicaciones global del 47.1% incluyendo una amputación por sepsis. La evaluación inter-observador tuvo un valor de Kappa del 0.90 y la muestra alcanzó un poder estadístico del 60%. Conclusiones: se obtuvo una consolidación similar a otros métodos, en un tiempo promedio de 6.3 meses, con un menor índice de complicaciones al reportado con otras técnicas. Siendo esta una alternativa de salvamento para la realización de artrodesis de rodilla, antes de considerar la amputación de la extremidad.

[Sensitivity and antibiotic resistance in infections of the musculoskeletal system]. / Sensibilidad y resistencia antibiótica en infecciones de sistema musculoesquelético.

BACKGROUND: Infections of the musculoskeletal system are a devastating complication for patients, due to it's long rehabilitation process and even sometimes the removal of the implant, the chronicity of infection, is often due to lack of coverage in empirical antibiotics. METHODS: A retrospective, observational, descriptive cohort study was performed. All cultures form musculoskeletal system infected patients reported of sensitivity and resistance of germs isolated were analyzed. RESULTS: A total of 143 positive results were included. Reported more frequent germ Staphylococcus aureus accounted for 75 positive cases, followed by Escherichia coli with 31 positive results. Antibiotics with better sensitivity according to the type of microorganisms were trimethoprim-sulfamethoxazole and vancomycin, levofloxacin and linezolid, gentamicin, erythromycin and amikacin. Regarding antibiotic resistance, those reported with the highest percentage were penicillin G, amoxicillin with clavulanic acid and ampicillin. CONCLUSIONS: We recommend using empirical treatments in musculoskeletal system infections, trimethoprim-sulfamethoxazole are the best choice because they have the same sensitivity compare with vancomycin and a resistance rate of 7.6%. Betalactamics have a high percentage of resistance and low sensitivity so we must consider alternatives.

Introducción: las infecciones de sistema musculoesquelético son una complicación grave para el paciente, debido a que prolongan el tiempo de recuperación y pueden llegar al retiro del implante o a la cronicidad de la infección con gasto excesivo para la institución y desgaste para el paciente y su familia. Métodos: estudio observacional en cirugías limpias programadas por patología crónicadegenerativa en el 2015. Se seleccionaron 225, que fueron reportadas como infectadas, a las que se les realizó cultivo. Se revisó la sensibilidad y resistencia de los microorganismos aislados con mayor frecuencia. Resultados: se incluyeron los cultivos y antibiogramas realizados a 225 pacientes, cumpliendo criterios de selección 143 resultados positivos. Se reportó Staphylococcus aureus, y Escherichia coli. Los antibióticos con mejor sensibilidad de acuerdo al tipo de microorganismos fueron trimetoprim-sulfametoxazol y vancomicina, levofloxacino y linezolid, gentamicina, eritromicina y amikacina. Respecto a la resistencia antibiótica, los de mayor porcentaje fueron la penicilina, amoxicilina con ácido clavulánico y ampicilina. Conclusiones: en las infecciones del sistema musculoesquelético estudiadas con cultivo y antibiograma, los dos microorganismos con mayor incidencia fueron S. aureus y E. coli, mostrando una mayor sensibilidad antibiótica para el trimetoprim-sulfametoxazol, muy similar a la vancomicina, así también el TMP-SMX mostró una resistencia baja. Los betalactámicos mostraron un alto porcentaje de resistencia y baja sensibilidad.

Guidelines for treatment of degenerative lumbar spondylolisthesis / Diretrizes para tratamento de espondilolistese lombar degenerativa / Guía de tratamiento de la espondilolistesis lumbar degenerativa

ABSTRACT Objectives: To determine the standard of treatment of degenerative lumbar spondylolisthesis in its different clinical presentations in UMAE Dr. Victorio de la Fuente Narváez. Methods: Six cases found in the literature were presented to 36 experts in spine surgery, along with treatment options, to thereby obtain a standard prescription for the treatment of degenerative lumbar spondylolisthesis. Analytical observational cross-sectional descriptive study. Results: It was found that the treatment of choice in cases of degenerative lumbar spondylolisthesis with axial symptoms is conservative. The surgical treatment of choice for both stable and unstable patients with radiculopathy and/or claudication is decompression + posterolateral graft + transpedicular instrumentation + discectomy (graft). Conclusions: We managed to define the degenerative lumbar spondylolisthesis treatment guidelines in our unit, which can serve as a basis for the development of a clinical practice guide.

RESUMO Objetivos: Determinar o padrão de tratamento de espondilolistese lombar degenerativa em suas diversas apresentações clínicas em UMAE Dr. Victorio de la Fuente Narváez. Métodos: Seis casos encontrados na literatura foram apresentados a 36 médicos especialistas em cirurgia de coluna, juntamente com opções de tratamento, para assim, obter um padrão de prescrição para o tratamento de espondilolistese degenerativa lombar. Estudo descritivo transversal observacional analítico. Resultados: Verificou-se que o tratamento de escolha para os casos de espondilolistese lombar degenerativa com sintomas axiais são conservadores. O tratamento cirúrgico de escolha para casos estáveis ou instáveis com radiculopatia e/ou claudicação é descompressão + enxerto posterolateral + instrumentação transpedicular + discectomia (enxerto). Conclusões: Foi possível definir as diretrizes de tratamento de espondilolistese lombar degenerativa em nossa unidade, que pode servir de base para o desenvolvimento de um guia de prática clínica.

RESUMEN Objetivos: Conocer el patrón de tratamiento de la espondilolistesis lumbar degenerativa en sus diferentes presentaciones clínicas en la UMAE Dr. Victorio de la Fuente Narváez. Métodos: Se presentaron a 36 médicos expertos en cirugía de columna 6 casos basados en la literatura, junto con las posibilidades de tratamiento, para obtener de este modo un patrón de prescripción para el tratamiento de espondilolistesis lumbar degenerativa. Estudio observacional descriptivo transversal analítico. Resultados: Se encontró que el tratamiento de elección para los casos de espondilolistesis lumbar degenerativa con sintomatología axial es conservador. El tratamiento quirúrgico de elección para los casos estables o inestables con radiculopatía y/o claudicación es la descompresión + injerto posterolateral + instrumentación transpedicular + discectomía (injerto). Conclusiones: Se logró definir la guía de tratamiento de espondilolistesis lumbar degenerativa en nuestra unidad, lo que puede servir como fundamento en la elaboración de una guía de práctica clínica.

The regensburg protocol for spinal metastases / Protocolo de regensburg para metástases da coluna / Protocolo de regensburg para metástasis de columna

Metastases to the vertebrae are a common problem in the practice of a spine surgeon. Therapeutic intervention can alleviate pain, preserve or improve neurologic function, achieve mechanical stability, optimize local tumor control, and improve quality of life. Treatment options available for metastatic spine tumors include radiation therapy, chemotherapy and surgery. This article is focused on the decision making for spine surgeons and shows the protocol to treat spinal metastases at the University Hospital of Regensburg, Germany.

As metástases nas vértebras são um problema comum na prática do cirurgião de coluna. A intervenção terapêutica pode aliviar a dor, preservar ou melhorar a função neurológica, obter a estabilidade mecânica, otimizar o controle local do tumor e melhorar a qualidade de vida. As opções de tratamento disponíveis para os tumores metastáticos da coluna vertebral incluem radioterapia, quimioterapia e cirurgia. O foco deste artigo é a tomada de decisão para cirurgiões de coluna, e mostra o protocolo de tratamento de metástases da coluna vertebral no Hospital Universitário de Regensburg, Alemanha.

Las metástasis en las vértebras son un problema común en la práctica de un cirujano de columna. La intervención terapéutica puede aliviar el dolor, mantener o mejorar la función neurológica, lograr la estabilidad mecánica, optimizar el control local del tumor y mejorar la calidad de vida. Las opciones de tratamiento para los tumores de la columna vertebral metastáticos son la radioterapia, la quimioterapia y la cirugía. Este artículo se centra en la toma de decisiones para los cirujanos de columna y muestra el protocolo de manejo de las metástasis vertebrales en el Hospital Universitario de Regensburg, Alemania.