Infecciones necrosantes de partes blandas atendidas en un servicio de urgencias de tercer nivel: evolución y correlación con la escala laboratory risk indicator for necrotizing fasciitis (LRINEC) / Necrotizing fasciitis attended in the Emergency Department in a tertiary Hospital: evaluation of the LRINEC scale

Objetivo. Describir la mortalidad y las complicaciones de pacientes atendidos en urgencias, con diagnóstico de infección necrosante de partes blandas (INPB) y su correlación con la escala Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC). Método. Estudio observacional retrospectivo con inclusión de pacientes con diagnóstico de INPB en urgencias de un hospital terciario durante 7 años. Los resultados se muestran como mediana, rango intercuartílico y rango absoluto para las variables cuantitativas. En el caso de las variables cualitativas, como frecuencias absoluta y relativa. La comparación se ha llevado a cabo mediante comparación post-hoc a partir de un análisis ANOVA con aproximación no paramétrica. Las comparaciones entre grupos de LRINEC en las variables cualitativas se han realizado con la prueba exacta de Fisher. Resultados. Se identificaron 24 pacientes con edad media de 51,9 años. La escala LRINEC se determinó en 21 pacientes: en 10 indicó bajo riesgo (<6), en 4 riesgo intermedio (6 o 7) y en 7 alto riesgo (≥8). La tasa de amputación en riesgos bajo, intermedio y alto fue del 10, 25 y 66%, respectivamente, con una mortalidad del 4,2%. Se observa un aumento en la estancia hospitalaria entre los niveles bajo y alto de la escala (p=0,007). Conclusiones. En general no se ha podido constatar un cambio en el pronóstico entre los niveles medio y alto de la escala LRINEC. Pero sí entre la estancia hospitalaria entre el nivel bajo y el alto, triplicando prácticamente la mediana de días de estancia hospitalaria (AU)

Aim. To describe mortality and complications of patients seen in the emergency room, diagnosed with necrotizing soft tissue infection (NSTI) and the correlation of such complications with the Laboratory Risk Indicator for Necrotizing fasciitis scale (LRINEC). Methods. Retrospective observational study including patients with a diagnosis of NSTI in the emergency room of a tertiary hospital over 7 years. The results are shown as median, interquartile range and absolute range for quantitative variables. In the case of qualitative variables, the results are shown as absolute and relative frequency. The comparison between the categories of the LRINEC scale was performed through a post-hoc comparison from a non-parametric ANOVA analysis. Comparisons between LRINEC groups in the qualitative variables were performed using Fisher's Exact test. Results. 24 patients with a mean age of 51.9 years were identified. The LRINEC scale was used on 21 patients: in 10, the value indicated low risk (<6), in 4 it indicated intermediate risk (6 or 7) and in 7 it indicated high risk (≥8). The amputation rate in patients with low, intermediate and high risk was 10%, 25% and 66% respectively with a mortality of 4.2%. There was an increase in hospital stay between the low and high level of the scale (p=0,007). Conclusions. In general, a change in the prognosis between the medium and high levels of the LRINEC scale could not be recorded, but was recorded in hospital stay between the low and the high level, practically tripling the median of days of hospital stay (AU)

Necrotizing fasciitis attended in the Emergency Department in a tertiary Hospital: Evaluation of the LRINEC scale. / Infecciones necrosantes de partes blandas atendidas en un servicio de urgencias de tercer nivel: evolución y correlación con la escala laboratory risk indicator for necrotizing fasciitis (LRINEC).

AIM: To describe mortality and complications of patients seen in the emergency room, diagnosed with necrotizing soft tissue infection (NSTI) and the correlation of such complications with the Laboratory Risk Indicator for Necrotizing fasciitis scale (LRINEC). METHODS: Retrospective observational study including patients with a diagnosis of NSTI in the emergency room of a tertiary hospital over 7 years. The results are shown as median, interquartile range and absolute range for quantitative variables. In the case of qualitative variables, the results are shown as absolute and relative frequency. The comparison between the categories of the LRINEC scale was performed through a post-hoc comparison from a non-parametric ANOVA analysis. Comparisons between LRINEC groups in the qualitative variables were performed using Fisher's Exact test. RESULTS: 24 patients with a mean age of 51.9 years were identified. The LRINEC scale was used on 21 patients: in 10, the value indicated low risk (<6), in 4 it indicated intermediate risk (6 or 7) and in 7 it indicated high risk (≥8). The amputation rate in patients with low, intermediate and high risk was 10%, 25% and 66% respectively with a mortality of 4.2%. There was an increase in hospital stay between the low and high level of the scale (p=0,007). CONCLUSIONS: In general, a change in the prognosis between the medium and high levels of the LRINEC scale could not be recorded, but was recorded in hospital stay between the low and the high level, practically tripling the median of days of hospital stay.

Abordaje anterior limitado del codo para la reducción abierta y fijación interna de las fracturas del capitellum. Técnica quirúrgica y experiencia clínica en 2casos con más de 2 años de seguimiento / The limited anterior approach of the elbow for open reduction and internal fixation of capitellum fractures. Surgical technique and clinical experience in 2 cases with more than 2 years follow-up

Objetivo. Las fracturas que afectan al capitellum pueden ser tratadas quirúrgicamente mediante escisión del fragmento, o mediante reducción y fijación interna con tornillos con o sin cabeza. El abordaje lateral de Kocher es el más usado para la reducción abierta. Creemos que el abordaje anterior limitado del codo podría ser una opción válida para tratar este tipo de fracturas, ya que no implica la desinserción de ningún grupo muscular ni de ningún ligamento y facilita la colocación anteroposterior de los tornillos, que ha demostrado ser biomecánicamente superior. Material y método. Describimos la técnica quirúrgica y evaluamos los resultados en 2casos clínicos con una fractura de tipo 1 de Bryan y Morrey (tipo 1A de Dubberley) mediante evolución clínica y radiológica. Dos cuestionarios diferentes sobre calidad de vida fueron realizados por teléfono: el EuroQol Five Dimensions Questionnaire (EQ-5D) y la porción contestada por el paciente del Liverpool Elbow Score (PAQ-LES). Resultados. Los 2pacientes presentaron una evolución clínica favorable a los 36 y 24 meses, respectivamente con un arco de movimiento de extensión/flexión de −5°/145° y −10°/145°, así como una pronosupinación de 85°/80° y de 90°/90°. Los 2pacientes presentaron consolidación radiológica sin signos de osteonecrosis, con el EQ-5D de 0,857 y 0,910 (rango: 0,36-1) y el PAQ-LES de 35 y 35 (rango: 17-36), respectivamente. Conclusiones. Creemos que el abordaje anterior limitado del codo es una opción técnica que tener en cuenta en caso de decidirse un tratamiento quirúrgico abierto de una fractura de capitellum, si bien necesitamos de estudios posteriores que demuestren su superioridad y seguridad clínica con respecto al abordaje clásico lateral de Kocher (AU)

Objective. Fractures involving the capitellum can be treated surgically by excision of the fragment, or by reduction and internal fixation with screws, with or without heads. The lateral Kocher approach is the most common approach for open reduction. We believe that the limited anterior approach of the elbow, could be a valid technique for treating these fractures, as it does not involve the detachment of any muscle group or ligament, facilitating the recovery process. Material and method. A description is presented of the surgical technique, as well as of 2cases with a Bryan-Morrey type 1 fracture (Dubberley type 1A). Two different final quality of life evaluation questionnaires were completed by telephone: the EuroQol Five Dimensions Questionnaire (EQ-5D), and the patient part of the Liverpool Elbow Score (PAQ-LES) questionnaire. Results. The 2patients showed favourable clinical progress at 36 and 24 months, respectively, with an extension/flexion movement arc of −5°/145° and −10°/145°, as well as a pronosupination of 85°/80° and 90°/90°. The 2patients showed radiological consolidation with no signs of osteonecrosis. The EQ-5D score was 0.857 and 0.910 (range: 0.36-1), and a PAQ-SLE of 35 and 35 (range: 17-36), respectively. Conclusions. We believe that the limited anterior approach of the elbow is a technical option to consider for the open surgical treatment of a capitellum fracture, although further studies are needed to demonstrate its superiority and clinical safety compared to the classical lateral Kocher approach (AU)

The limited anterior approach of the elbow for open reduction and internal fixation of capitellum fractures. Surgical technique and clinical experience in 2 cases with more than 2 years follow-up. / Abordaje anterior limitado del codo para la reducción abierta y fijación interna de las fracturas del capitellum. Técnica quirúrgica y experiencia clínica en 2casos con más de 2 años de seguimiento.

OBJECTIVE: Fractures involving the capitellum can be treated surgically by excision of the fragment, or by reduction and internal fixation with screws, with or without heads. The lateral Kocher approach is the most common approach for open reduction. We believe that the limited anterior approach of the elbow, could be a valid technique for treating these fractures, as it does not involve the detachment of any muscle group or ligament, facilitating the recovery process. MATERIAL AND METHOD: A description is presented of the surgical technique, as well as of 2cases with a Bryan-Morrey type 1 fracture (Dubberley type 1A). Two different final quality of life evaluation questionnaires were completed by telephone: the EuroQol Five Dimensions Questionnaire (EQ-5D), and the patient part of the Liverpool Elbow Score (PAQ-LES) questionnaire. RESULTS: The 2patients showed favourable clinical progress at 36 and 24 months, respectively, with an extension/flexion movement arc of -5°/145° and -10°/145°, as well as a pronosupination of 85°/80° and 90°/90°. The 2patients showed radiological consolidation with no signs of osteonecrosis. The EQ-5D score was 0.857 and 0.910 (range: 0.36-1), and a PAQ-SLE of 35 and 35 (range: 17-36), respectively. CONCLUSIONS: We believe that the limited anterior approach of the elbow is a technical option to consider for the open surgical treatment of a capitellum fracture, although further studies are needed to demonstrate its superiority and clinical safety compared to the classical lateral Kocher approach.

[What do we know about atypical fractures in patients on biphosphonates treatment? A literature review using a case series]. / ¿Qué sabemos de las fracturas atípicas en los pacientes en tratamiento con bifosfonatos? Revisión bibliográfica a raíz de una serie de casos.

AIM: Retrospective review of long term biphosphonates treated patients who sustained a subtrochanteric or diaphyseal femoral fracture with an atypical pattern. A literature review is presented as an update of the topic. MATERIAL AND METHODS: A retrospective study was conducted on 13 subtrochanteric or diaphyseal fractures in female patients treated with biphosphonates at our institution from September 2007 to March 2011. RESULTS: Four cases of subtrochanteric fractures and 13 diaphyseal fractures were detected. Four patients had bilateral fractures. All cases but one (that affected only the lateral cortex) were complete fractures. Surgically, these kinds of fractures are demanding due to the hardness of the bones. DISCUSSION: It is difficult to know if there is any relationship between bisphosphonates treatment and atypical femoral fractures. Nevertheless, current literature supports a greater benefit of their use in preventing vertebral and non-vertebral fractures. For this reason, biphosphonates continue being considered as a first choice in the prevention of osteoporotic fractures. CONCLUSIONS: Patients on long-term treatment with bisphosphonates may present atypical femoral fractures as a complication. It is considered that the maximum period for biphosphonates treatment should not exceed 5 years.

¿Qué sabemos de las fracturas atípicas en los pacientes en tratamiento con bifosfonatos? Revisión bibliográfica a raíz de una serie de casos / What do we know about atypical fractures in patients on biphosphonates treatment? A literature review using a case series

Objetivos. Realizamos una revisión retrospectiva de los pacientes en tratamiento de forma prolongada con bifosfonatos que presentaron fracturas subtrocantéreas y diafisarias de fémur de patrón atípico. Revisión de la literatura existente con el fin de realizar una actualización del tema con consideraciones de interés para el cirujano ortopeda y traumatólogo. Material y métodos. Revisión de 13 pacientes en tratamiento con bifosfonatos con fracturas subtrocantéreas y diafisarias de fémur tratadas en nuestro centro entre septiembre de 2007 y marzo de 2011. Resultados. Se detectaron 4 casos de fracturas subtrocantéreas y 13 de fracturas diafisarias. Cuatro pacientes presentaron fracturas bilaterales. Todas las fracturas eran completas salvo un caso en el que era incompleta con afectación de la cortical lateral. La intervención quirúrgica fue más demandante técnicamente por encontrarse un hueso pétreo como consecuencia de la medicación con bifosfonatos. Discusión. Existe la dificultad de establecer la relación causal directa entre el tratamiento prolongado con bifosfonatos y las fracturas atípicas femorales. No obstante, la literatura actual refiere un beneficio superior en la prevención de fracturas vertebrales y no vertebrales y, por tanto, se continua considerando a los bifosfonatos como un fármaco de primera elección en la prevención de las fracturas osteoporóticas. Conclusiones. Los pacientes con tratamiento prolongado con bifosfonatos pueden presentar fracturas atípicas femorales como complicación. Se considera que debe evaluarse en un periodo medio menor a 5 años la sustitución parcial o definitiva por otro fármaco, teniendo en cuenta el riesgo residual de fractura estimado en ese momento (AU)

Aim. Retrospective review of long term biphosphonates treated patients who sustained a subtrochanteric or diaphyseal femoral fracture with an atypical pattern. A literature review is presented as an update of the topic. Material and methods. A retrospective study was conducted on 13 subtrochanteric or diaphyseal fractures in female patients treated with biphosphonates at our institution from September 2007 to March 2011. Results. Four cases of subtrochanteric fractures and 13 diaphyseal fractures were detected. Four patients had bilateral fractures. All cases but one (that affected only the lateral cortex) were complete fractures. Surgically, these kinds of fractures are demanding due to the hardness of the bones. Discussion. It is difficult to know if there is any relationship between bisphosphonates treatment and atypical femoral fractures. Nevertheless, current literature supports a greater benefit of their use in preventing vertebral and non-vertebral fractures. For this reason, biphosphonates continue being considered as a first choice in the prevention of osteoporotic fractures. Conclusions. Patients on long-term treatment with bisphosphonates may present atypical femoral fractures as a complication. It is considered that the maximum period for biphosphonates treatment should not exceed 5 years (AU)

Tumoración bilateral de codo en paciente hemodializado / Bilateral elbow tumors in a hemodialyzed patient

Introducción. La calcinosis tumoral urémica (CTU) es una complicación infrecuente en los pacientes sometidos a hemodiálisis de larga evolución. La etiología es multifactorial, y se caracteriza por la aparición de tumoraciones calcificadas periarticulares. La alteración del metabolismo calcio-fósforo constituye el factor etiopatogénico más importante en la aparición de calcinosis tumoral en los pacientes hemodializados.Caso clínico. Se presenta el caso de un paciente de 30 años con antecedentes de insuficiencia renal crónica, en tratamiento con hemodiálisis en los últimos 9 años, remitido a nuestro servicio por la aparición de masas en ambos codos y clínica de compresión del nervio cubital en el codo izquierdo, confirmada mediante electromiograma (EMG). La extirpación quirúrgica permitió el estudio anatomopatológico que confirmó el diagnóstico de calcinosis tumoral mecánica

Introduction. Tumoral uremic calcinosis (TUC) is an uncommon complication in patients undergoing long-term hemodialysis. The origin is multifactorial and the disease is characterized by calcified periarticular tumors. Disturbance of calcium-phosphorus metabolism is the most important etiopathogenic factor in the appearance of tumoral calcinosis in hemodialyzed patients. Case report. A 30-year-old male patient with a history of chronic kidney failure and 9 years of hemodialysis was referred to our center for the presence of masses in both elbows and clinical manifestations of ulnar nerve compression in the left elbow, confirmed by EMG. Surgical excision and anatomopathologic study confirmed the diagnosis of tumoral uremic calcinosis

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