La ratio de grosor diafragmático (inspiratorio/espiratorio) como método diagnóstico de parálisis diafragmática asociada al bloqueo interescálenico / Diaphragmatic thickness ratio (inspiratory/expiratory) as a diagnostic method of diaphragmatic palsy associated with interescalene block

Introducción. La parálisis diafragmática es un efecto indeseable clásicamente asociado al bloqueo interescalénico. De forma reciente ha sido introducido en clínica el índice del grosor del músculo diafragma (grosor inspiratorio/grosor espiratorio) obtenido mediante ecografía como herramienta diagnóstica en la parálisis crónica y atrofia del músculo diafragma. Nuestro objetivo fue evaluar este índice para el diagnóstico de paresia frénica aguda asociada al bloqueo interescalénico. Pacientes y métodos. Diseñamos un estudio observacional descriptivo en 22 pacientes programados para artroscopia de hombro. Se les realizó una espirometría forzada (se consideró paresia frénica un descenso del FVC y FEV1 ≥20%), se identificó la zona de aposición en la línea axilar anterior y se evaluó el desplazamiento diafragmático en inspiración y espiración máximas (n.° de espacios intercostales; se consideró paresia frénica una reducción ≥25%) y el grosor del músculo diafragma (se consideró paresia frénica un índice<1,2). Estas determinaciones se realizaron antes y a los 20 min de realizar el bloqueo interescalénico entre C5 y C6 con 20ml de ropivacaína 0,5%. Resultados. Veintiún pacientes (95%) presentaron bloqueo del nervio frénico según alguno o varios de los métodos empleados. Un paciente no manifestó ningún síntoma ni signo sugestivo de parálisis frénica y fue excluido del análisis posterior. Todos los pacientes presentaron paresia frénica con base en el índice del grosor diafragmático, con un índice prebloqueo de 1,8±0,5 y posbloqueo de 1,05±0,06 (p<0,001). El 90% de los pacientes (19) presentó paresia frénica según la espirometría y todos los pacientes presentaron un descenso diafragmático reducido tras el bloqueo (de 1,9±0,5 espacios intercostales a 0,5±0,3; p<0,001). Conclusión. El índice del grosor diafragmático en inspiración/espiración<1,2 parece ser de utilidad en el diagnóstico de paresia frénica asociada al bloqueo interescalénico, sin que sea necesaria una evaluación basal prebloqueo (AU)

Introduction. Diaphragmatic paralysis is a side-effect associated with interscalene block. Thickness index of the diaphragm muscle (inspiratory thickness/expiratory thickness) obtained by ultrasound has recently been introduced in clinical practice for diagnosis of diaphragm muscle atrophy. Our objective was to evaluate this index for the diagnosis of acute phrenic paresis associated with interscalene block. Patients and methods. We designed an observational study in 22 patients scheduled for shoulder arthroscopy. Spirometry was performed (criteria of phrenic paresis was a decrease in FVC and FEV1 ≥20%). Ultrasound apposition zone was assessed in anterior axillary line and diaphragmatic displacement was evaluated on inspiration and expiration (number of intercostal spaces; phrenic paresis considered a reduction ≥25%) and thickness of the diaphragm muscle (a phrenic paresis was considered an index <1.2). These determinations were performed before and at 20min after interscalene block at C5-C6 with 20ml of 0.5% ropivacaine. Results. Twenty-one patients (95%) presented phrenic nerve block according to one or more of the methods used. One patient did not show any symptoms or signs suggestive of phrenic paralysis and was excluded. All the patients presented phrenic paresis based on the diaphragmatic thickness index, with the pre-block index being 1.8±0.5 and post-block of 1.05±0.06 (P<0.001). Ninety percent of the patients (19) presented phrenic paresis according to spirometry and all the patients had a reduction in diaphragmatic movement after the block (from 1.9±0.5 intercostal spaces to 0.5±0.3; P<0.001). Conclusion. The index of inspiratory / expiratory diaphragmatic thickness at cut-off <1.2 seems to be useful in the diagnosis of phrenic paresis associated with interscalene block. This index does not require a baseline pre-assessment (AU)

Diaphragmatic thickness ratio (inspiratory/expiratory) as a diagnostic method of diaphragmatic palsy associated with interescalene block. / La ratio de grosor diafragmático (inspiratorio/espiratorio) como método diagnóstico de parálisis diafragmática asociada al bloqueo interescálenico.

INTRODUCTION: Diaphragmatic paralysis is a side-effect associated with interscalene block. Thickness index of the diaphragm muscle (inspiratory thickness/expiratory thickness) obtained by ultrasound has recently been introduced in clinical practice for diagnosis of diaphragm muscle atrophy. Our objective was to evaluate this index for the diagnosis of acute phrenic paresis associated with interscalene block. PATIENTS AND METHODS: We designed an observational study in 22 patients scheduled for shoulder arthroscopy. Spirometry was performed (criteria of phrenic paresis was a decrease in FVC and FEV1 ≥20%). Ultrasound apposition zone was assessed in anterior axillary line and diaphragmatic displacement was evaluated on inspiration and expiration (number of intercostal spaces; phrenic paresis considered a reduction ≥25%) and thickness of the diaphragm muscle (a phrenic paresis was considered an index <1.2). These determinations were performed before and at 20min after interscalene block at C5-C6 with 20ml of 0.5% ropivacaine. RESULTS: Twenty-one patients (95%) presented phrenic nerve block according to one or more of the methods used. One patient did not show any symptoms or signs suggestive of phrenic paralysis and was excluded. All the patients presented phrenic paresis based on the diaphragmatic thickness index, with the pre-block index being 1.8±0.5 and post-block of 1.05±0.06 (P<0.001). Ninety percent of the patients (19) presented phrenic paresis according to spirometry and all the patients had a reduction in diaphragmatic movement after the block (from 1.9±0.5 intercostal spaces to 0.5±0.3; P<0.001). CONCLUSION: The index of inspiratory / expiratory diaphragmatic thickness at cut-off <1.2 seems to be useful in the diagnosis of phrenic paresis associated with interscalene block. This index does not require a baseline pre-assessment.

Uso de técnicas de ahorro de sangre en la artroplastia primaria de cadera y rodilla en España. Estudio FILTRO / Blood saving measures in patients undergoing primary elective hip or knee arthroplasty in Spain. The FILTRO study

Objetivo: El estudio FILTRO pretende conocer las medidas profilácticas del sangrado quirúrgico excesivo que se aplican en España y su impacto en la evolución del paciente. Material y métodos: Estudio epidemiológico retrospectivo en 1.180 pacientes intervenidos de artroplastia total primaria de cadera o rodilla entre enero y septiembre de 2010. El estudio fue aprobado por el CEIC del Hospital Clínic de Barcelona. Antes de la cirugía se administró hierro y/o eritopoyetina en un 4,1% de pacientes. Durante la cirugía, un 2,8% fue tratado con fármacos antifibrinolíticos, en un 11,8% se empleó recuperador de sangre intraoperatorio y en el 12,7% se aplicó la autotransfusión. Resultados: El valor medio de Hb en el preoperatorio fue de 13,5 g/dL, y antes del alta, de 10,6g/dL. Un 33,2% de los pacientes recibieron transfusión durante el ingreso y se asoció a la utilización de drenaje (p=0,0033) y a la autotransfusión (p=0,0002). El uso de antifibrinolíticos disminuyó la necesidad de transfusión (p=0,0025). Se registraron complicaciones tras la cirugía en el 5,5% de la muestra, sin observarse asociación con las técnicas de ahorro de sangre empleadas. Conclusión: A pesar de disponer en nuestros hospitales de procedimientos y medidas eficaces para reducir la necesidad de transfusiones de sangre alogénica, no parece que estas se apliquen de forma generalizada en la práctica clínica de los hospitales españoles (AU)

Objective: The aim of the FILTRO study was to determine which were prophylactic measures of excessive surgical bleeding that are being implemented in Spain in patients undergoing elective total primary arthroplasty of the hip or knee, and the impact of these measures on the patient outcomes in short term. Material and methods: We included 1,180 patients, underwent surgery for primary hip and knee replacement. All data were collected retrospectively. Socio-demographic and clinical data were recorded from the clinical history, including techniques and drugs administered, as well as the patient outcomes during admission and after discharge consultation. The blood-saving measures used were: before surgery, iron or erythropoietin in 4.1% of the sample; during surgery, antifibrinolytic drugs in 2.8%, a blood-recovery system in 11.8% and 12.7% used autotransfusion. 33.2% of patients received blood transfusion during hospitalization. Results: The mean value of Hb before surgery was 13.5 g/dL and before discharge was 10.6 g/dL. The need for transfusion was higher in patients using drainage (p=0.0033) and those who opted for autotransfusion (p=0.0002). The use of antifibrinolytic drugs decreased the transfusion requirements (p=0.0025). Postoperative complications were recorded in 5.5% of the sample: deep venous thrombosis in 0.7% of cases, bleeding in 1.9% and infection in 2.8%, and there was no association between these and the use or not either blood-saving method. Conclusion: Although Spanish hospitals have procedures and measures to reduce the need for allogeneic blood transfusions, it seems they are still not generally applied in clinical practice (AU)

[SECOT consensus on thromboembolisms in knee and hip replacement surgery]. / Consenso SECOT sobre tromboembolismo en la cirugía protésica de rodilla y cadera.

The purpose of this paper is to develop a professional consensus that proposes, in the light of the current scientific evidence and the clinical experience of an expert panel, some clinical recommendations directed at the Orthopaedic and Trauma Surgery (OTS) specialist and with the aim of reducing the variability in the prophylactic management of venous thromboembolic disease in knee and hip arthroplasty in clinical practice. The Delphi method was used, which consisted of two rounds of an e-mail questionnaire. Of the 55 items considered, a consensus was reached in 37 (67.2%) of them. In 31 cases there was consensus with the formulation of the item, and in 6 cases there was no agreed consensus. It was observed that there was a consensus in multiple clinical recommendations that could help OTS specialists in the making of decisions in their clinical practice.

Consenso SECOT sobre tromboembolismo en la cirugía protésica de rodilla y cadera / SECOT consensus on thromboembolisms in knee and hip replacement surgery

El objetivo de este documento es desarrollar un consenso profesional que proponga a la luz de la evidencia científica actual y de la experiencia clínica de un panel de expertos, unas recomendaciones clínicas dirigidas a especialistas COT y orientadas a reducir la variabilidad de la práctica clínica en el tratamiento de la profilaxis de la enfermedad tromboembólica venosa, en la cirugía protésica de rodilla y cadera. Se empleó el método Delphi, el cual consiste en 2 rondas de un cuestionario por correo electrónico. De los 55 ítems considerados se consiguió el consenso en 37 de ellos (67,2%). En 31 casos se consensuó según la formulación del ítem y en 6 casos se consensuó en desacuerdo. Se observa que existe un consenso en múltiples recomendaciones clínicas que pueden ayudar en la toma de decisiones del especialista de COT en su práctica clínica (AU)

The purpose of this paper is to develop a professional consensus that proposes, in the light of the current scientific evidence and the clinical experience of an expert panel, some clinical recommendations directed at the Orthopaedic and Trauma Surgery (OTS) specialist and with the aim of reducing the variability in the prophylactic management of venous thromboembolic disease in knee and hip arthroplasty in clinical practice. The Delphi method was used, which consisted of two rounds of an e-mail questionnaire. Of the 55 items considered, a consensus was reached in 37 (67.2%) of them. In 31 cases there was consensus with the formulation of the item, and in 6 cases there was no agreed consensus. It was observed that there was a consensus in multiple clinical recommendations that could help OTS specialists in the making of decisions in their clinical practice (AU)

Glomus tumor of the hallux. Review of the literature and report of two cases.

A glomus tumor is a rare and benign vascular tumor. It can originate in multiple locations on the body, although it has most frequently been found in subungeal areas of the hand. This two cases report describes a glomus tumor of the hallux, including a recurrence and a review of the related literature. We believe this case study might be of interest due to the unusual location of this tumor.

Actualización de la profilaxis tromboembólica en fractura de cadera / Update on thromboembolic prophylaxis in hip fracture

La fractura de cadera en el anciano constituye un problema sanitario de primera magnitud, con una incidencia en crecimiento exponencial. La cirugía de estas fracturas, a pesar de los avances de los últimos años en cuanto a las técnicas quirúrgicas y anestésicas, a la generalización de la profilaxis tromboembólica y a unos mejores cuidados médicos, continúa siendo un procedimiento de alto riesgo en cuanto a morbilidad y mortalidad (AU)

Hip fractures in the elderly is a health problem of first magnitude, with an incidence which is increasing exponentially. The surgery of these fractures, despite progress in recent years in terms of surgical and anesthetic techniques, the widespread use of thromboprophylaxis and better medical cares, remains a high risk procedure in terms of morbidity and mortality (AU)

Effectiveness and safety of tranexamic acid administration during total knee arthroplasty.

BACKGROUND: The administration of tranexamic acid (TA) is associated with a decrease in the number of red blood cell (RBC) units transfused. However, concerns about its safety have hindered its broader use. STUDY DESIGN AND METHODS: We evaluated the effect of TA on RBC transfusion and thromboembolic complications in total knee arthroplasty. We retrospectively studied 414 patients, 215 immediately before introducing TA treatment (control group) and after, in 199 patients without history of thromboembolic diseases (TA group). In a subgroup of patients, a lower extremities contrast venography was performed. RESULTS: Fifty-four per cent of control group patients were transfused with RBC while only 17.6% of TA group patients received RBCs. In the TA that group, those transfused received less units (2.83 vs. 1.89), showed smaller mean calculated perioperative blood loss and haemoglobin values at discharge were higher compared to control group (10.1 vs. 9.3 g/dl). Thromboembolic complications were diagnosed in 2.8% of the patients in the control group and in 1.5% in the TA group. Asymptomatic distal deep venous thrombosis was found in 54 (14.8%) of TA group patients and 54 (30.1%) of control patients. TA administration reduced the expenditure for RBC transfusion plus the cost of TA from 148.94 to 33.87 euro per patient. CONCLUSION: Routine administration of TA during total knee arthroplasty to patients without history of thromboembolic disease is associated with a 67% reduction in RBC transfusions and, in those transfused, with a reduction in the number of units administered. TA treatment was not associated with an increase in thromboembolic complications. Transfusion costs are significantly reduced.

Fractura bilateral simultánea de cadera en el anciano / Simultaneous bilateral fracture of the hip in the elderly

La producción simultánea de una fractura bilateral de cadera en el anciano es excepcional. Presentamos dos casos de fractura simultánea pertrocantérea y subtrocantérea de fémur secundarias a traumatismos de baja energía. Esta asociación comporta actuaciones distintas respecto de la fractura unilateral. De un adecuado manejo del estado general del paciente y de sus fracturas dependerá su pronóstico vital (AU)

Simultaneous bilateral hip fractures in elderly people are an exceptional occurrence. Two clinical cases of simultaneous pertrochanteric and subtrochanteric fractures of the femur due to low energy traumas are presented here. This association requires a different course of action to cases of unilateral fractures. The patients’ life prognosis will depend on appropriate handling of their general condition and of their fractures (AU)

Perioperative fracture-dislocation of the humeral head during a resurfacing hemiarthroplasty.

We report a case of perioperative fracture-dislocation of the humeral head produced during the reaming for a resurfacing replacement hemiarthroplasty (RRH) in a 79-year old woman. This is a surgical complication not previously described in the literature for this type of prosthesis design. Resurfacing humeral head implant has been noted as a useful treatment for glenohumeral arthropathies, also in elderly people, with a very low incidence of complications. However, as we report, they are possible.It is advisable that conventional stemmed implants could be available when RRH is performed.

Perioperative fracture-dislocation of the humeral head during a resurfacing hemiarthroplasty

We report a case of perioperative fracture-dislocation of the humeral head produced during the reaming for a resurfacing replacement hemiarthroplasty (RRH) in a 79-year old woman. This is a surgical complication not previously described in the literature for this type of prosthesis design. Resurfacing humeral head implant has been noted as a useful treatment for glenohumeral arthropathies; also in elderly people; with a very low incidence of complications. However; as we report; they are possible. It is advisable that conven- tional stemmed implants could be available when RRH is performed

Use of freeze-dried bone allograft with platelet-derived growth factor for revision of a glenoid component.

Glenoid replacement is technically challenging. Removal of a cemented glenoid component often results in a large osseous defect which makes the immediate introduction of a revision prosthesis almost impossible. We describe a two-stage revision procedure using a reversed shoulder prosthesis. Freeze-dried allograft with platelet-derived growth factor was used to fill the glenoid defect. Radiological incorporation of the allograft was seen and its consistency allowed the placement of a screwed glenoid component. There were no signs of new mature bone formation on histological examination. The addition of platelet-derived growth factor to the allograft seems to contribute to an increase in incorporation and hardness, but does not promote the growth of new bone.

Periosteal chondroma of the clavicle.

We report a case of periosteal chondroma of the clavicle. To our knowledge, this benign cartilaginous tumor has never been previously reported in this location. Clinical, radiographic and pathological investigations were necessary to establish the diagnosis. Marginal excision proved an effective treatment.

Avascular necrosis of the humeral head after dislocation with fracture of the greater tuberosity.

A case of posttraumatic avascular necrosis of the humeral head in a young patient was detected 3 years after an anterior dislocation with a nondisplaced greater tuberosity fracture. The evolution to degenerative joint disease is described.

Tuberculous synovitis with "rice bodies" presenting as carpal tunnel syndrome.

A 41-year-old man had typical symptoms and signs of carpal tunnel syndrome. At operation there were multiple large rice bodies along the flexor tendons with a great deal of adherent synovitis involving the index finger. Widespread surgical debridement with excision of involved synovium was done. Mycobacterium tuberculosis was cultured from the tenosynovium excised.