[Hip fracture due to osteomalacia secondary to celiac disease] / Fractura de cadera debida a osteomalacia secundaria a enfermedad celíaca

Background: Hip fracture in the young patient is uncommon, but it can have devastating consequences. This pathology in the context of minimal trauma obliges us to carry out a study on calcium metabolism to determine the primary cause. Material and methods: We present a clinical case about an 18-year-old male patient who suffered a subcapital fracture of the left hip due to minimal trauma while playing football. The patient was treated urgently by means of closed reduction and internal fixation with two spongy screws. Subsequently, the metabolism study showed a severe vitamin D deficiency (27.1 nmol/L - normal above 75 nmol/L) and high levels of anti-transglutaminase IgA antibodies (2502.40 U/mL). The digestive biopsy confirmed the diagnosis of celiac disease and was treated with a gluten-free diet and calcium and vitamin D supplements. Results: After two years of follow-up, the patient is pain free, with complete hip mobility. There have been no complications (failure of osteosynthesis, avascular necrosis or pseudoarthrosis) and serum levels of vitamin D as well as IgA antibodies against transglutaminase have normalized. Conclusion: In young patients with low energy trauma fractures, vitamin D deficiency must be considered as a possible etiology and the reason for such osteomalacia, such as celiac disease, must be identified.

Antecedentes: La fractura de cadera en el paciente joven es infrecuente, pero puede tener unas consecuencias devastadoras. Esta patología en el contexto de un traumatismo mínimo nos obliga a realizar un estudio sobre el metabolismo del calcio para filiar la causa primaria. Material y método: Presentamos un caso clínico sobre un paciente varón de 18 años que sufrió una fractura subcapital de cadera izquierda debido a un traumatismo mínimo mientras jugaba al fútbol. El paciente fue tratado quirúrgicamente de urgencia mediante reducción cerrada y fijación interna con dos tornillos de esponjosa. Posteriormente, el estudio del metabolismo mostró una deficiencia grave de vitamina D (27.1 nmol/L ­ normal por encima de 75 nmol/L) y altos niveles de anticuerpos IgA antitransglutaminasa (2502.40 U/mL). La biopsia digestiva confirmó el diagnóstico de enfermedad celíaca por lo que fue tratado con una dieta libre de gluten y suplementos de calcio y vitamina D. Resultados: Tras dos años de seguimiento, el paciente está libre de dolor, con movilidad completa de la cadera. No ha habido complicaciones (fracaso de la osteosíntesis, necrosis avascular o pseudoartrosis) y los niveles séricos de vitamina D así como de los anticuerpos IgA antitransglutaminasa se han normalizado. Conclusión: En pacientes jóvenes que presentan fracturas por traumatismos de baja energía, se ha de tener en cuenta la deficiencia de vitamina D como posible etiología y se debe identificar el motivo de dicha osteomalacia, como es la enfermedad celíaca. Conclusión: En pacientes jóvenes que presentan fracturas por traumatismos de baja energía, se ha de tener en cuenta la deficiencia de vitamina D como posible etiología y se debe identificar el motivo de dicha osteomalacia, como es la enfermedad celíaca.

Acute rupture of distal biceps: Repair using a single anterior approach and cortical anchoring device / [Rotura aguda de bíceps distal: reparación mediante abordaje único anterior y dispositivo de anclaje cortical]

Background: Rupture of the distal tendon of the biceps is a pathology with an increasing incidence, which can cause important functional alterations. When the rupture is complete and the patient is active, surgical treatment is of choice. Material and method: 47-year-old man with sudden and intense pain in the left antecubital fossa while lifting weight. On examination, impotence for flexion and active supination of the left arm with loss of the biceps silhouette. Ultrasonography confirms the diagnosis of complete rupture of the distal biceps tendon. Surgical treatment was decided, performing a single anterior approach and reinserting the tendon in its radial footprint with the help of a cortical anchorage device. Results: At 12 months, the patient presented flexo-extension and complete prone supination, without encountering difficulties in carrying out the activities of his daily and work life, with a score of 100 points in the Mayo Elbow Performance Score (MEPS). Conclusion: Rupture of the distal biceps is a typical injury in active patients with an increasing incidence. Although there have been no significant differences between the different repair options, in our experience the use of cortical anchorage devices with a single anterior approach provides very satisfactory results.

Antecedentes: La rotura del tendón distal del bíceps braquial es una patología con una incidencia creciente, que puede ocasionar importantes alteraciones funcionales. Cuando la rotura es completa y el paciente activo, el tratamiento quirúrgico es de elección. Resultados: A los 12 meses, el paciente presenta flexo-extensión y prono-supinación completa, sin encontrar dificultades para realizar las actividades de su vida diaria y laboral, con puntación de 100 puntos en el Mayo Elbow Performance Score (MEPS). Material y método: Varón de 47 años con dolor intenso y súbito en la fosa antecubital izquierda mientras levantaba peso. A la exploración, impotencia para la flexión y supinación activa del brazo izquierdo con pérdida de la silueta del bíceps braquial. La ecografía confirma el diagnóstico de rotura completa del tendón distal del bíceps braquial. Se decide tratamiento quirúrgico, realizando un abordaje único anterior  y reinsertando el tendón en su "footprint" radial con ayuda de un dispositivo de anclaje cortical. Conclusión: La rotura del bíceps distal es una lesión típica de pacientes activos con una incidencia creciente. Aunque no se han evidenciado diferencias significativas entre las distintas opciones de reparación, en nuestra experiencia la utilización de dispositivos de anclaje cortical con un abordaje único anterior aporta unos resultados muy satisfactorios.

Surgical clavicle reconstruction after aneurysmal bone cyst resection in a child: A simple method.

The clavicle is an infrequent location for primary tumors in general, and aneurysmal bone cyst (ABC) of the clavicle is particularly rare. The challenge of the functional and esthetic result in the treatment of these lesions in the pediatric population is high when considering the reconstruction of critical bone defects. In this article, we present the case of a seven-year-old boy with an ABC in the middle third of the clavicle, treated by resection and reconstruction with free autograft of the fibula stabilized by using an intramedullary titanium nail. We offer a description of the used technique, considerations about treatment options in children, and a follow-up of more than two-and-a-half years.

On the relevance of preoperative haemoglobin optimisation within a Patient Blood Management programme for elective hip arthroplasty surgery.

BACKGROUND: Preoperative anaemia is highly prevalent among patients scheduled for total hip arthroplasty (THA), and is the main risk factor for perioperative red blood cell transfusion (RBCT). This retrospective cohort study aimed at assessing whether preoperative haemoglobin (Hb) optimisation reduced RBCT rates and improved outcome in this patient population. MATERIALS AND METHODS: All patients entered a Patient Blood Management (PBM) programme consisting of in-hospital erythropoiesis stimulation, tranexamic acid administration, and a restrictive RBCT policy. Data from preoperatively anaemic patients (Hb <13 g/dL) who underwent THA, before (2015-2016, control group, n=75) or after (2017-2018, study group, n=70) the incorporation of a preoperative Hb optimisation protocol (Ferric carboxymaltose IV, 1,000 mg ± epoetin-α, 40,000 IU; administered 4 weeks prior to surgery) to the PBM programme underwent a comparative analysis. RESULTS: Haemoglobin concentrations at preoperative assessment were similar (12.1±0.7 g/dL vs 12.2±0.7 g/dL, for study and control groups, respectively; p=0.129). At hospital admission, significantly higher Hb were observed in the study group (13.4±0.8 g/dL vs 12.2±0.7 g/dL, respectively; p=0.001), with anaemia being corrected in 79% of cases. Compared to the control group, reduced perioperative RBCT rate (4% vs 24%, respectively; p=0.001), shorter length of hospital stay (6 [range 5-7] days vs 7 [5-8 days], respectively; p=0.002), and increased proportion of patients being discharged directly to their home (74% vs 47%, respectively; p=0.01) were observed in the study group. No treatment-related side-effects were witnessed. DISCUSSION: Within a PBM programme for THA, preoperative Hb optimisation was efficacious at correcting anaemia and minimising RBCT requirements, thus contributing to an improvement in postoperative outcomes.

[Transfusion trend in total hip arthroplasty following the implementation of a Patient Blood Management protocol.] / Tendencia transfusional en la artroplastia total de cadera tras la implantación de un protocolo de "Patient Blood Management".

Introduction: Total hip arthroplasty is a successful and safe surgical procedure, but it involves an associated blood loss. When this surgery is carried out on a scheduled basis, the implantation of a multimodal approach of Patient Blood Management (PBM) will significantly reduce transfusion needs. Objective: To present the clinical-analytical results and the transfusion incidence after the implantation of a PBM protocol in those patients who are going to undergo prosthetic hip surgery. Materials and methods: Restrospective, unicentric, observational and analytical study, among those patients undergoing primary elective hip arthroplasty between January 2017 and February 2019. In all of them, a PBM protocol has been applied, focused on the development of an optimization program of preoperative anemia, the use of topical tranexamic acid and the adoption of a restrictive transfusion policy. Results: The study included a total of 384 patients, where only 9 required allogeneic blood transfusion (transfusion rate: 2.34%). In the analysis of transfused patients, they were found to have a longer hospital stay (8 ± 2.9 Vs 5.3 ± 2.9 days; p = 0.007) and a higher rate of complications (22.2% vs. 3, 9%; p = 0.017), with respect to those who avoided the TSA. Conclusion: The application of an adequate multimodal protocol of PBM, brings us closer to the utopia of bloodless surgery in prosthetic surgery, resulting in a cost-effective model that significantly reduces the TSA in primary hip arthroplasty.

Introducción: La artroplastia total de cadera es un procedimiento quirúrgico exitoso y seguro, pero que conlleva una inherente perdida sanguínea asociada. Cuando esta cirugía se lleva a cabo de forma programada, la implantación de un abordaje multimodal de Patient Blood Management (PBM), permitirá reducir significativamente las necesidades transfusionales. Objetivo: Presentar los resultados clínico-analíticos y la incidencia transfusional tras la implantación de un protocolo de PBM en aquellos pacientes que van a someterse a una cirugía protésica de cadera. Materiales y métodos: Estudio restrospectivo, unicentrico, observacional y analítico, entre aquellos pacientes sometidos a una artroplastia primaria de cadera electiva entre enero de 2017 y Febrero de 2019. En todos ellos, se ha aplicado un protocolo de PBM, centrado en el desarrollo de un programa de optimización de la anemia preoperatoria, la utilización de ácido tranexámico tópico y la adopción de una política transfusional restrictiva. Resultados: El estudio incluyó un total de 384 pacientes, donde únicamente 9 precisaron transfusión de sangre alogénica (Tasa transfusional: 2,34%). En el análisis de los pacientes transfundidos, se encontró que presentaban una mayor estancia hospitalaria (8 ±2,9 Vs 5,3 ±2,9 días; p=0,007) y un mayor índice de complicaciones (22,2% vs 3,9%; p=0,017), respecto a aquellos que eludieron la TSA. Conclusión: La aplicación de un adecuado protocolo multimodal de PBM, nos acerca a la utopía de una cirugía sin sangre en la cirugía protésica, resultando un modelo costo-efectivo que permite reducir de forma significativa la TSA en la artroplastia primaria de cadera.

Effective surgical solution to a complete rupture of the pectoralis major. / [Eficaz solución quirúrgica a una rotura completa del pectoral mayor.]

Background: The rupture of the pectoralis major muscle is rare, occurring typically in young male athletes. When the break is complete and the patient active, surgical treatment is the choice. Clinical case: 48-year-old man with severe pain in left shoulder after lifting weights. He presents impotence to adduction and internal rotation of the shoulder with thinning of the axillary fold. MRI confirms the diagnosis of complete rupture of the pectoralis major. Surgical treatment was decided, performing a deltopectoral approach and reinserting the pectoralis major tendon with three cortical buttons. Conclusion: The rupture of the pectoralis major is a typical lesion of active young patients with an increasing incidence. Although there have been no significant differences between the different repair options, in our experience the use of cortical buttons provides very satisfactory results.

Antecedentes: La rotura del músculo pectoral mayor es una entidad poco frecuente, aconteciendo típicamente en varones jóvenes deportistas. Cuando la rotura es completa y el paciente activo, el tratamiento quirúrgico es de elección. Caso clínico: Varón de 48 años con dolor intenso en hombro izquierdo tras levantamiento de pesas. A la exploración, impotencia a la aducción y rotación interna del hombro con adelgazamiento del pliegue axilar. La RMN confirma el diagnóstico de rotura completa del pectoral mayor. Se decide tratamiento quirúrgico, realizando un abordaje deltopectoral y reinsertando el tendón del pectoral mayor con tres dispositivos de anclaje endocortical. Conclusión: La rotura del pectoral mayor es una lesión típica de pacientes jóvenes activos con una incidencia creciente. Aunque no se han evidenciado diferencias significativas entre las distintas opciones de reparación, en nuestra experiencia la utilización de dispositivos de anclaje endocortical aporta unos resultados muy satisfactorios.

Metaphyseal sleeves as the primary implant for the management of bone defects in total knee arthroplasty after post-traumatic knee arthritis.

BACKGROUND: Implantation of a prosthesis after post-traumatic knee arthritis poses challenges derived from the bone defects and soft tissue damage. The objective of this study was to evaluate the clinical and radiological results of the use of metaphyseal sleeves in primary total knee arthroplasty surgery after post-traumatic arthritis. METHODS: Clinical and radiological results of 25 patients undergoing surgery for post-traumatic knee arthritis were prospectively evaluated. A semi-constrained, mobile platform prosthesis with metaphyseal sleeves was implanted. American Knee Society scales, Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the Short Form 12 Health Survey were used. Patients were evaluated at the baseline and at postoperative months three, 12, and annually until final follow-up. RESULTS: The mean follow-up was 79 months with a maximum of 10 years. Mean Knee Society Score (KSS) increased from 29 to 78, and functional KSS from 42 to 81. The average WOMAC pain index changed from 12 to three; average WOMAC stiffness improved from four to one, and WOMAC function score improved from 44 to 16. The mean physical SF12 varied from 30 to 46, while mental SF-12 varied from 45 to 55. Radiological osseointegration of the implants was considered optimal in all cases, with a survival of 100%. CONCLUSIONS: Metaphyseal sleeves in combination with varus-valgus constrained (VVC) components and a rotating platform, have shown good clinical and radiological results in patients with post-traumatic knee arthritis and constitute a reliable alternative for treatment of this disease when the epiphyseal zone is deteriorated and has bone defects.