Anatomical and biomechanical factors of osteoporotic vertebral fracture and the occurrence of cascade fractures. / Factores anatómicos y biomecánicos de la fractura vertebral osteoporótica y la aparición de las fracturas en cascada.

Osteoporosis weakens the structural strength of bone to such an extent that normal daily activity may exceed the capacity of the vertebra to bear this load. Vertebral fracture and deformity is a hallmark of osteoporosis. The detriment of trabecular bone properties alone cannot explain the occurrence of osteoporotic vertebral fracture. The ability of the spine to bear and resist loads depends on the structural capacity of the vertebrae, but also on loading conditions arising from activities of daily living or low-energy trauma. This review describes the mechanical properties of the vertebral bone, the structural load-bearing capacity of the various elements forming the spine, the neuromuscular control of the trunk, as well as the biomechanics of the loads to which the spine is subjected in relation to the presence of osteoporosis and the risk of vertebral fracture. A better understanding of biomechanical factors may help to explain both the high incidence of osteoporotic vertebral fractures and their mechanism of production. Consideration of these issues may be important in the development of prevention and management strategies.

Potential risks of using cement-augmented screws for spinal fusion in patients with low bone quality.

BACKGROUND CONTEXT: Dramatic increases in the average life expectancy have led to increases in the variety of degenerative changes and deformities observed in the aging spine. The elderly population can present challenges for spine surgeons, not only because of increased comorbidities, but also because of the quality of their bones. Pedicle screws are the implants used most commonly in spinal surgery for fixation, but their efficacy depends directly on bone quality. Although polymethyl methacrylate (PMMA)-augmented screws represent an alternative for patients with osteoporotic vertebrae, their use has raised some concerns because of the possible association between cement leakages (CLs) and other morbidities. PURPOSE: To analyze potential complications related to the use of cement-augmented screws for spinal fusion and to investigate the effectiveness of using these screws in the treatment of patients with low bone quality. STUDY DESIGN: A retrospective single-center study. PATIENT SAMPLE: This study included 313 consecutive patients who underwent spinal fusion using a total of 1,780 cement-augmented screws. METHODS AND OUTCOME MEASURES: We analyzed potential complications related to the use of cement-augmented screws, including CL, vascular injury, infection, screw extraction problems, revision surgery, and instrument failure. There are no financial conflicts of interest to report. RESULTS: A total of 1,043 vertebrae were instrumented. Cement leakage was observed in 650 vertebrae (62.3%). There were no major clinical complications related to CL, but two patients (0.6%) had radicular pain related to CL at the S1 foramina. Of the 13 patients (4.1%) who developed deep infections requiring surgical debridement, two with chronic infections had possible spondylitis that required instrument removal. All patients responded well to antibiotic therapy. Revision surgery was performed in 56 patients (17.9%), most of whom had long construction. A total of 180 screws were removed as a result of revision. There were no problems with screw extraction. CONCLUSIONS: These results demonstrate the efficacy and safety of cement-augmented screws for the treatment of patients with low bone mineral density.

Resultado a los cinco años del tratamiento quirúrgico de las fracturas desplazadas de tobillo en los pacientes mayores de 65 años / Open reduction and internal fixation of displaced ankle fractures in patients older than 65 years of age. analysis of results at five-year follow-up

Objetivo. Evaluar el resultado a largo plazo del tratamiento quirúrgico mediante reducción abierta y fijación interna de las fracturas de tobillo en los mayores de 65 años, y determinar la influencia de la edad y enfermedades previas en la aparición de complicaciones. Material y método. Estudio descriptivo retrospectivo sobre 40 pacientes, con una edad media de 72,7 años (rango: 65-88) intervenidos mediante reducción abierta y fijación interna por presentar fractura de tobillo desplazada. Los pacientes fueron valorados según criterios de la AOFAS, que valora el resultado funcional del tratamiento. También fueron evaluadas la presencia de comorbilidades, parámetros radiográficos, complicaciones y valoración subjetiva del paciente. Seguimiento medio de 5,73 años. Resultados. Al final del seguimiento, según criterios de la AOFAS se obtuvieron excelentes/buenos resultados en el 75% de los pacientes (n = 30); 38 pacientes refirieron estar bastante/muy contentos con el resultado. Las complicaciones más frecuentes fueron la migración del material de osteosíntesis y los problemas cutáneos de la herida. No se pudo demostrar relación estadísticamente significativa entre una mayor edad o un mayor número de enfermedades previas y una mayor frecuencia en la aparición de complicaciones (p > 0,05). Únicamente 3 pacientes necesitaron tratamiento de rehabilitación postoperatoria; el 95% de los pacientes (n = 38) refirieron haber regresado a sus actividades de vida diaria con normalidad. Conclusiones. El tratamiento quirúrgico de las fracturas desplazadas de tobillo en el paciente anciano facilita la pronta reanudación de las actividades de la vida diaria. Nivel de evidencia IV (AU)

Objective. The aim of this study was to evaluate the long term outcome of surgical treatment for displaced ankle fractures in patients over 65 years of age, and determine the influence of age and comorbidity in the occurrence of complications. Material and method. Retrospective descriptive study on 40 patients, with a mean age of 72.7 years (range: 65-88), who underwent open reduction and internal fixation for the treatment of a displaced ankle fracture. The patients were clinically evaluated according to the AOFAS criteria (functional outcome). Data collection also included the presence of comorbidities, radiographic evaluation, the occurrence of postoperative complications, and a questionnaire on satisfaction with treatment received. The mean follow-up was 5.73 years. Results. At the end of the follow-up, according to the AOFAS criteria, excellent/good results were obtained in 75% of the patients (n = 30), with 38 patients referring to be quite/very happy with the result. Wound skin problems and metal work migration were the most common post-operative complications. No statistically significant relationship was found between increased age or a high number of comorbidities and an increased occurrence of postoperative complications (p > .05). Only 3 patients needed postoperative rehabilitation, and 95% of the patients (n = 38) returned to their activities of normal daily living. Conclusions. Surgical treatment of displaced ankle fractures in the elderly patient facilitates the early resumption of the activities of daily living (AU)

[Open reduction and internal fixation of displaced ankle fractures in patients older than 65 years of age. Analysis of results at five-year follow-up]. / Resultado a los cinco años del tratamiento quirúrgico de las fracturas desplazadas de tobillo en los pacientes mayores de 65 años.

OBJECTIVE: The aim of this study was to evaluate the long term outcome of surgical treatment for displaced ankle fractures in patients over 65 years of age, and determine the influence of age and comorbidity in the occurrence of complications. MATERIAL AND METHOD: Retrospective descriptive study on 40 patients, with a mean age of 72.7 years (range: 65-88), who underwent open reduction and internal fixation for the treatment of a displaced ankle fracture. The patients were clinically evaluated according to the AOFAS criteria (functional outcome). Data collection also included the presence of comorbidities, radiographic evaluation, the occurrence of postoperative complications, and a questionnaire on satisfaction with treatment received. The mean follow-up was 5.73 years. RESULTS: At the end of the follow-up, according to the AOFAS criteria, excellent/good results were obtained in 75% of the patients (n=30), with 38 patients referring to be quite/very happy with the result. Wound skin problems and metal work migration were the most common post-operative complications. No statistically significant relationship was found between increased age or a high number of comorbidities and an increased occurrence of postoperative complications (p>.05). Only 3 patients needed postoperative rehabilitation, and 95% of the patients (n=38) returned to their activities of normal daily living. CONCLUSIONS: Surgical treatment of displaced ankle fractures in the elderly patient facilitates the early resumption of the activities of daily living.

Infiltración esteroidea epidural por vía caudal en el tratamiento del dolor lumbar crónico de origen discal. Estudio comparativo, prospectivo y aleatorizado / Caudal epidural steroid injection in the treatment of chronic discogenic low back pain. Comparative, prospective and randomized study

Objetivo. La literatura no ofrece consenso para el tratamiento del dolor lumbar crónico de origen discal. La infiltración esteroidea epidural por vía caudal (IEEC) ofrece resultados contradictorios en los pocos estudios prospectivos y aleatorizados realizados acerca de su efectividad. El objetivo de nuestro estudio es evaluar la eficacia del tratamiento mediante IEEC para reducir el dolor y mejorar la discapacidad asociada. Material y método. Estudio comparativo, prospectivo y aleatorizado de 46 pacientes con dolor lumbar crónico de origen discal. Pacientes asignados de forma aleatoria para recibir IEEC guiada por fluoroscopia (grupo IEEC), o antiinflamatorios no esteroideos por vía oral (grupo AINE). Pacientes valorados según indicaciones de la Sociedad Española para el Estudio de las Enfermedades del Raquis (GEER). Evaluación a las 4, 12 y 24 semanas. Resultados. Durante el seguimiento, el dolor lumbar medido mediante la escala analógica visual (EAV), y el cuestionario Oswestry de discapacidad (ODI) no experimentaron mejoría significativa en ninguno de los 2 grupos del estudio (p > 0,05). El grupo IEEC presentó una tendencia hacia mejores resultados en pacientes de menor edad, en mujeres, en pacientes con menor tiempo de evolución, actividades laborales sedentarias, sin clínica sobre miembros inferiores y que practicaban deporte, pero sin significación estadística (p > 0,05). Conclusiones. El presente estudio no ha demostrado superioridad de la IEEC frente a los AINE, en el tratamiento del dolor lumbar crónico de origen discal. A pesar de que la IEEC pueda presentar alguna mejoría en los pacientes con afección discal lumbar degenerativa, consideramos que debiera ser empleado con cautela, informando al paciente de las expectativas reales del tratamiento (AU)

Objective: There is no consensus on the treatment of chronic low back pain of disc origin in the medical literature. The few prospective, randomized, controlled studies evaluating the effectiveness of caudal epidural steroid injections (CESI) have obtained contradictory results. The aim of this study is to evaluate the efficacy of CEI in reducing pain and improving the associated disability. Material and method: This is a prospective, randomized, case-control study of a group of 46 patients with chronic low back disc pain. Patients were randomly allocated into 2 groups to either receive fluoroscopy guided CESI (CESI-group), or oral non-steroidal anti-inflammatory drugs (NSAID-group). All patients were clinically evaluated at 4, 12, and 24 weeks, and according to the indications of the Spanish Society for Study of Diseases of the Spine (GEER). Results: Lumbar pain, measured by the visual analog scale (VAS) and the Oswestry Low Back Pain Disability Questionnaire (ODQ), did not improve significantly during follow-up in any of the two study groups (P>.05). Younger patients, women, patients with shorter duration of symptoms, low physical job demand, without leg pain, and sport-active, included in CESI-group showed a trend towards better results, but none reached statistical significance (P>.05). Conclusions: The present study has not demonstrated the superiority of CESI over NSAIDs in treating chronic low back pain of disc origin. While CESI could show some improvement in patients with degenerative lumbar disc disease, we consider it should be used with caution, informing patients about realistic expectations on the success of treatment (AU)

[Caudal epidural steroid injection in the treatment of chronic discogenic low back pain. Comparative, prospective and randomized study]. / Infiltración esteroidea epidural por vía caudal en el tratamiento del dolor lumbar crónico de origen discal. Estudio comparativo, prospectivo y aleatorizado.

OBJECTIVE: There is no consensus on the treatment of chronic low back pain of disc origin in the medical literature. The few prospective, randomized, controlled studies evaluating the effectiveness of caudal epidural steroid injections (CESI) have obtained contradictory results. The aim of this study is to evaluate the efficacy of CEI in reducing pain and improving the associated disability. MATERIAL AND METHOD: This is a prospective, randomized, case-control study of a group of 46 patients with chronic low back disc pain. Patients were randomly allocated into 2 groups to either receive fluoroscopy guided CESI (CESI-group), or oral non-steroidal anti-inflammatory drugs (NSAID-group). All patients were clinically evaluated at 4, 12, and 24 weeks, and according to the indications of the Spanish Society for Study of Diseases of the Spine (GEER). RESULTS: Lumbar pain, measured by the visual analog scale (VAS) and the Oswestry Low Back Pain Disability Questionnaire (ODQ), did not improve significantly during follow-up in any of the two study groups (P>.05). Younger patients, women, patients with shorter duration of symptoms, low physical job demand, without leg pain, and sport-active, included in CESI-group showed a trend towards better results, but none reached statistical significance (P>.05). CONCLUSIONS: The present study has not demonstrated the superiority of CESI over NSAIDs in treating chronic low back pain of disc origin. While CESI could show some improvement in patients with degenerative lumbar disc disease, we consider it should be used with caution, informing patients about realistic expectations on the success of treatment.

Conceptos actuales sobre la enfermedad de Scheuermann: presentación clínica, diagnóstico y controversias sobre su tratamiento / Current concepts on Scheuermann kyphosis: clinical presentation, diagnosis and controversies around treatment

La cifosis de Scheuermann es una deformidad estructural de la columna torácica o toracolumbar, que aparece antes de la pubertad y empeora durante la adolescencia. Aunque generalmente de curso benigno, la información disponible acerca de su historia natural es muy escasa. En casos de enfermedad grave, la cifosis puede progresar durante la etapa adulta y ser causa de deformidad significativa y dolor incapacitante. El tratamiento conservador mediante rehabilitación y ortesis carece de evidencia científica. Se debe considerar el tratamiento quirúrgico ante la presencia de una cifosis progresiva y dolorosa, la aparición de compromiso neurológico, o deformidad inaceptable. Este conlleva un elevado riesgo de complicaciones graves que deben ser discutidas con el paciente y sus familiares. Hoy en día, gracias al desarrollo de modernas técnicas de instrumentación, la corrección de la deformidad es posible mediante un abordaje posterior único con menor incidencia de complicaciones. El acortamiento simultáneo de la columna posterior en los niveles apicales, y la monitorización espinal intraoperatoria reducen los riesgos de lesión neurológica (AU)

Scheuermann kyphosis is a structural deformity of the thoracic or thoracolumbar spine that develops prior to puberty and deteriorates during adolescence. There is limited information on its natural history but many patients are expected to have a benign course. Severe kyphosis can progress into adult life and cause significant deformity and debilitating back pain. Conservative treatment includes bracing and physical therapy, but although widely prescribed they have not been scientifically validated. Surgical treatment may be considered in the presence of a progressive kyphosis producing severe pain resistant to conservative measures, neurological compromise, or unacceptable deformity. This is associated with significant risks of major complications that should be discussed with the patients and their families. Modern techniques allow better correction of the deformity through posterior-only surgery with lower complication rates. Simultaneous shortening of the posterior vertebral column across the apical levels, along with spinal cord monitoring, reduces the risk of neurological deficits (AU)

Revisión de los resultados a los 10 años del tratamiento quirúrgico de las fracturas supracondíleas de húmero en el niño, tratadas mediante reducción abierta y fijación interna / Open reduction and internal fixation of supracondylar fractures of the humerus in children. Analysis of results at ten-year of follow-up

Objetivo. Evaluar el resultado a largo plazo del tratamiento quirúrgico mediante reducción abierta y fijación interna de las fracturas supracondíleas de húmero desplazadas en la edad pediátrica. Pacientes y metodología. Estudio descriptivo retrospectivo sobre 21 pacientes, con una edad media de 5,8 años, intervenidos mediante reducción abierta y fijación interna entre los años 1996-2003 por presentar fractura supracondílea de húmero desplazada según clasificación de Gartland, no reductible por métodos cerrados. Los pacientes fueron valorados según criterios de Flynn (estético y funcional). También fueron evaluados los parámetros radiográficos, complicaciones, rango de movilidad y valoración subjetiva del paciente. El seguimiento medio fue de 11,52 años. Resultados. Un ángulo de Baumann medio de 17,6° reflejó una satisfactoria reducción postoperatoria de la fractura. Al final del seguimiento, según criterios de Flynn se obtuvieron resultados satisfactorios en el 85,8% de los pacientes. El déficit medio de flexión fue de 5,1° (rango: 0-20°), y de extensión de 0,71° (rango: 0-10°). El 90% de los pacientes presentaron un rango de movilidad del codo con valores dentro de la normalidad. Las complicaciones más frecuentes fueron la infección superficial y la protrusión de las agujas. Al final del seguimiento todos los pacientes menos 2 refirieron estar bastante o muy contentos con el resultado. Ningún paciente refirió dificultades para la realización de sus actividades de la vida diaria, ni para la práctica deportiva. Conclusiones. En casos de reducción insatisfactoria o fallo para mantener una reducción estable por métodos cerrados, la reducción abierta demuestra resultados comparables al quirúrgico cerrado (AU)

Objective. The aim of this study was to evaluate the long term results of the surgical treatment by means of open reduction and internal fixation of displaced supracondylar humerus fractures in a paediatric population. Patients and methods. Descriptive retrospective study conducted between 1996-2003, which included 21 patients who underwent open reduction and internal fixation for the treatment of displaced, supracondylar humerus fractures according to the Gartland classification, which were irreducible by closed methods. The patients were clinically evaluated according to the Flynn criteria (functional and cosmetic). Data collection also included postoperative radiological evaluation, range of movement, the presence of post-operative complications, and a questionnaire on satisfaction with treatment received. The mean age of the patients was 5.8 years. Mean follow-up was 11.52 years. Results. The average post-operative Baumann angle was 17.6°. Final loss of flexion averaged 5.1° (range: 0-20°), and loss of extension 0.71° (range: 0-10°), with 90% of patients demonstrating an elbow range of movement within normal limits. According to the Flynn criteria, functional and cosmetic results were satisfactory in 85.5%. Superficial wound infection and metal work migration were the most common post-operative complications. At the final follow-up all patients, except two, were very happy with the result, and no patient complained of difficulties in carrying out normal living activities or their favourite sports. Conclusions. In cases of unsatisfactory reduction or failure to maintain a stable closed reduction, open reduction and internal fixation demonstrates equivalent results to closed procedures (AU)

Spondylodiscitis in infancy: a potentially fatal condition that can lead to major spinal complications.

An eight-week-old boy developed severe thoracic spondylodiscitis following pneumonia and septicaemia. A delay in diagnosis resulted in complete destruction of the T4 and T5 vertebral bodies and adjacent discs, with a paraspinal abscess extending into the mediastinum and epidural space. Antibiotic treatment controlled the infection and the abscess was aspirated. At the age of six months, he underwent posterior spinal fusion in situ to stabilise the spine and prevent progressive kyphosis. At the age of 13 months, repeat imaging showed lack of anterior vertebral body re-growth and he underwent anterior spinal fusion from T3 to T6 and augmentation of the posterior fusion. At the age of five years, he had no symptoms and radiographs showed bony fusion across the affected levels. Spondylodiscitis should be included in the differential diagnosis of infants who present with severe illness and atypical symptoms. Delayed diagnosis can result in major spinal complications with a potentially fatal outcome.

Síndrome de cauda equina secundaria a hernia discal lumbar gigante / Cauda equina syndrome secondary to giant lumbar disc herniation

Objetivo: Relacionar los hallazgos clínicos de presentación de síndrome de cauda equina secundario a hernia discal lumbar con el resultado final en cinco pacientes. Pacientes y metodología: Presentamos una serie de 5 pacientes con SCE secundario a hernia discal lumbar gigante confirmado por RMN, sometidos a discectomía más descomprensión temprana del canal medular. Resultados: La descompresión quirúrgica se realizó de forma urgente, todas las pacientes presentaban trastornos viscerales al ingreso. A pesar del tratamiento precoz, solo tres pacientes experimentaron una recuperación completa de la disfunción visceral y de los déficits motor y sensitivo previos. Conclusiones: la descompresión precoz, en ningún caso va en detrimento del pronóstico, y puede ser de ayuda para prevenir que una lesión incompleta progrese hacia una parálisis completa de esfínteres (AU)

Objetive: To determine the relation between clinical symptoms at presentation and the outcomes in a group of patients with CES secondary lumbar disc herniation. Patients and method: We present 5 patients with CES secondary to a giant lumbar disc herniation confirmed by MRI, submitted to discectomy and early decompression of the spinal canal. Results: Urgent surgical decompression was performed, all the patients were presenting visceral dysfunction on admission. Despite early treatment, only three patients have experienced a complete recovery of the visceral dysfunction and motor and sensory previous symptoms. Conclusions: The influence in a delay in the surgical treatment may well be overestimated due to the classic recommendations of the first published studies. However, early decompression is not detrimental, and may help to prevent an incomplete lesion progressing to complete sphincter paralysis (AU)

[Open reduction and internal fixation of supracondylar fractures of the humerus in children. Analysis of results at ten-year of follow-up]. / Revisión de los resultados a los 10 años del tratamiento quirúrgico de las fracturas supracondíleas de húmero en el niño, tratadas mediante reducción abierta y fijación interna.

OBJECTIVE: The aim of this study was to evaluate the long term results of the surgical treatment by means of open reduction and internal fixation of displaced supracondylar humerus fractures in a paediatric population. PATIENTS AND METHODS: Descriptive retrospective study conducted between 1996-2003, which included 21 patients who underwent open reduction and internal fixation for the treatment of displaced, supracondylar humerus fractures according to the Gartland classification, which were irreducible by closed methods. The patients were clinically evaluated according to the Flynn criteria (functional and cosmetic). Data collection also included postoperative radiological evaluation, range of movement, the presence of post-operative complications, and a questionnaire on satisfaction with treatment received. The mean age of the patients was 5.8 years. Mean follow-up was 11.52 years. RESULTS: The average post-operative Baumann angle was 17.6°. Final loss of flexion averaged 5.1° (range: 0-20°), and loss of extension 0.71° (range: 0-10°), with 90% of patients demonstrating an elbow range of movement within normal limits. According to the Flynn criteria, functional and cosmetic results were satisfactory in 85.5%. Superficial wound infection and metal work migration were the most common post-operative complications. At the final follow-up all patients, except two, were very happy with the result, and no patient complained of difficulties in carrying out normal living activities or their favourite sports. CONCLUSIONS: In cases of unsatisfactory reduction or failure to maintain a stable closed reduction, open reduction and internal fixation demonstrates equivalent results to closed procedures.

[Current concepts on Scheuermann kyphosis: clinical presentation, diagnosis and controversies around treatment]. / Conceptos actuales sobre la enfermedad de Scheuermann: presentación clínica, diagnóstico y controversias sobre su tratamiento.

Scheuermann kyphosis is a structural deformity of the thoracic or thoracolumbar spine that develops prior to puberty and deteriorates during adolescence. There is limited information on its natural history but many patients are expected to have a benign course. Severe kyphosis can progress into adult life and cause significant deformity and debilitating back pain. Conservative treatment includes bracing and physical therapy, but although widely prescribed they have not been scientifically validated. Surgical treatment may be considered in the presence of a progressive kyphosis producing severe pain resistant to conservative measures, neurological compromise, or unacceptable deformity. This is associated with significant risks of major complications that should be discussed with the patients and their families. Modern techniques allow better correction of the deformity through posterior-only surgery with lower complication rates. Simultaneous shortening of the posterior vertebral column across the apical levels, along with spinal cord monitoring, reduces the risk of neurological deficits.

Pseudoartrosis tras osteotomía distal percutánea de los radios menores / Pseudoarthrosis after distal percutaneous osteotomy of lower distal radii

Objetivo. La introducción de la cirugía percutánea ha permitido la corrección quirúrgica del pie a través de pequeñas incisiones, minimizando así la exposición quirúrgica, la agresión de los tejidos blandos y rentabilizando el tiempo quirúrgico. Pero a pesar de sus buenos resultados, no está exenta de posibles complicaciones. Material y método. Presentamos dos pacientes intervenidos por metatarsalgia mediante abordaje percutáneo, que tuvieron que ser reintervenidos por presentar dolor y ausencia de consolidación de las osteotomías distales de los metatarsianos a los seis meses de la cirugía inicial. Ambos casos fueron tratados mediante reducción abierta y síntesis mediante placa atornillada, tras realizar curetaje del foco de pseudoartrosis y aporte de injerto óseo. Resultados. La cirugía puso en evidencia la presencia de una gran cantidad de tejido fibroso adyacente a los distintos focos de pseudoartrosis, que podría estar relacionada con las altas temperaturas generadas por el fresado óseo y que repercuten en su totalidad sobre los tejidos blandos adyacentes. El punto exacto de la realización de las osteotomías distales de los metatarsianos o los efectos del incremento de la temperatura durante el fresado óseo podrían estar relacionados con la aparición de la pseudoartrosis de las osteotomías. Conclusiones. La cirugía mínimamente invasiva del antepie ha venido a solucionar algunos de los problemas encontrados mediante "técnicas abiertas". Sin embargo, su generalización puede plantear la aparición de otras complicaciones que hasta la fecha eran más difíciles de encontrar y para las que se necesita saber de su posible aparición para poder poner todos los medios para evitarlas, e informar al paciente de su existencia (AU)

Objective. The introduction of the minimally invasive surgery allows the surgical correction of the foot through small incisions, minimizing the surgical exposure, the aggression to the soft tissues, and improving surgical efficiency. But in spite of its good results, it is not exempt from possible complications. Material and methods. We report two patients treated for metatarsalgia with minimally invasive surgery, who six months after the initial surgery had to be re-operated due to pain and absence of consolidation of the distal metatarsal osteotomies. Both cases were treated by means of curettage of the area of pseudoarthrosis, open reduction, internal fixation and bone grafting. The surgery showed the presence of a great quantity of fibrous tissue adjacent to the different areas of pseudoarthrosis, which could be related to the high temperatures generated by the procedure and which had a total effect on the adjacent soft tissues. Results. The exact point of the distal metatarsal osteotomies or the effects of the increase of the temperature during the procedure might be related to the appearance of the pseudoarthrosis. Conclusion. Minimally invasive surgery of the forefoot has led to solving some of the problems found with open procedures. Nevertheless its generalization can give rise to other complications that up until now were more difficult to find. Therefore knowledge of their appearance will enable those to be aware of them and for those that it is necessary to be aware of, put all the means to avoid them, and inform the patient of their (AU)

Tratamiento quirúrgico de las luxaciones acromioclaviculares tipo iii de Rockwood mediante técnica de Phemister modificada. Evaluación de resultados a los cinco años / Modified Phemister procedure for the treatment of type iii Rockwood acromioclavicular joint dislocation. Results after five-years follow-up

Objetivo. Evaluar el resultado del tratamiento quirúrgico de la luxación AC tipo iii de Rockwood. Pacientes y metodología. Estudio descriptivo retrospectivo en 26 pacientes varones, con una edad media de 34 años, intervenidos con técnica modificada de Phemister, entre los años 2000 y 2006, por presentar luxación aguda AC tipo iii de Rockwood. Los pacientes fueron valorados según escala de Constant, parámetros radiográficos, presencia de cambios degenerativos, complicaciones e índice de valoración subjetiva del paciente. El seguimiento medio fue de 5 años. Resultados. La escala de Constant fue excelente o buena en el 88,5% de los casos con una reducción de la luxación en todos ellos, perdiéndose la reducción parcialmente menos del 50% durante el seguimiento. Un 61,5% de las imágenes presentaron cambios degenerativos asintomáticos. Las complicaciones más frecuentes fueron las infecciones superficiales y la protrusión de las agujas. El grado de satisfacción fue muy alto y ningún paciente cambió su actividad profesional o deportiva. Conclusión. La técnica de Phemister modificada proporciona un buen resultado en el tratamiento quirúrgico de las luxaciones AC tipo iii y la pérdida parcial de la reducción radiológica a medio-largo plazo no implica peor valoración funcional (AU)

Objective. Rockwood type iii acromioclavicular (AC) joint dislocation is a common shoulder injury. Its treatment is subject to continuing controversy. The aim of this study was to evaluate the outcomes of the surgical treatment for Rockwood type iii AC joint dislocation. Patients and methods. Descriptive retrospective study between 2000–2006, including 67 patients who underwent modified Phemister procedure for the treatment of a type iii AC joint dislocation. Patients clinically evaluated according to the Constant score. Data collection also included radiological findings, the presence of degenerative radiological changes, post-operative complications and a questionnaire on satisfaction with treatment received. Mean age of patients 34.1 years. Mean follow-up 4.7 years. Results. Twenty-one patients were finally included. Functional result good/excellent in 88.5% according to the modified Constant score. Post-operative radiological reduction achieved in all patients, <50% of all cases being partially lost during the follow-up. Asymptomatic radiological degenerative changes appeared in 61.5% of the patients. Superficial wound infection and metal work migration were the most common post-operative complications. Patients expressed high satisfaction with the treatment received. After surgery no patient had to change their jobs or favourite sports activities. Conclusions. Modified Phemister procedure provides a good result in the surgical treatment of Rockwood type iii AC joint dislocation. Functional results and patient satisfaction with the treatment performed are very high. The partial loss of the radiological reduction during the follow-up does not necessarily mean a worse functional result, and in any case the radiological assessment was worse than that resulting from the initial injury. The ability to carry out normal daily living activities and the functional assessment obtained the most satisfactory results (AU)

Dolor lumbar crónico de origen facetario. Resultado del tratamiento mediante rizolisis percutánea. Selección de pacientes y técnica quirúrgica / Chronic lumbar facet joint pain. Treatment results using percutaneous rhizolysis. Patient selection and surgical technique

Objetivo: Evaluar la eficacia del tratamiento del dolor lumbar crónico de origen facetario mediante denervación percutánea facetaria por radiofrecuencia (rizolisis) para reducir el dolor y mejorar la discapacidad asociada en un grupo de pacientes meticulosamente seleccionados mediante combinación de la clínica, la exploración, las pruebas por imagen y el bloqueo anestésico facetario, y compararlo con la literatura médica previa. Material y métodos Estudio prospectivo de 70 pacientes con dolor lumbar crónico facetario de más de 3 meses de evolución, que no mejoraron con tratamiento conservador. Pacientes valorados clínicamente siguiendo indicaciones del Grupo para el Estudio de las Enfermedades del Raquis (GEER). Edad media: 49,52 años. Duración media del dolor: 6,86 años. Seguimiento mínimo: un año. Resultados Tras la rizolisis, el dolor lumbar medido mediante escala analógica visual (EAV) disminuye significativamente (p<0,05). Igualmente, mejoran de forma significativa los valores para el cuestionario Oswestry de discapacidad (ODI), reflejando una notable mejoría en su calidad de vida (p<0,05) al disminuir su incapacidad por el dolor lumbar. El 91,42% de los pacientes experimenta alivio significativo del dolor tras rizolisis, que llega a ser superior o igual a 6 meses en el 61,4% de los pacientes. Al año, el 84,5% de los pacientes afirma que volvería a recibir el mismo tratamiento. Conclusiones La rizolisis es una valiosa herramienta para el tratamiento sintomático del dolor lumbar crónico facetario. Una meticulosa selección de los pacientes mediante la combinación de la clínica, la exploración, las pruebas por imagen y el bloqueo anestésico facetario obtiene resultados duraderos en el tiempo ayudando a disminuir en estos pacientes su incapacidad por el dolor lumbar(AU)

Purpose: To evaluate the efficacy of percutaneous radiofrequency zygapophysial joint neurotomy (rhizotomy) to decrease pain and improve associated disability, in a group of patients suffering from low back pain from facet joint origin meticulously selected on the basis of a combination of by clinical findings, physical examination, imaging tests and anaesthetic diagnostic blocks. Materials and methods Prospective study with 70 patients treated with rhizotomy for low back pain from facet joint origin of longer than three months who did not improved after conservative treatment. Patients evaluated following the guidelines of the Spanish Society for the Study of the Spinal Diseases (GEER). Mean age was 49.52 years. Mean duration of pain: 6.86 years. Minimum follow-up: one year. Results Following percutaneous rhizotomy, mean low back pain as measured on the Visual Analogue Scale (VAS), decreased significantly (p<0.05). Likewise, there was a significant improvement in the values given for the Owestry Disability Index (ODI) reflecting a notable improvement in terms of quality of life (p<0.05). Following rhizotomy 91.4% of patients reported significant pain relief, wich was higher than or equal to six month in 61.4% of patients. At one year, 84.5% of patients stated that they would undergo the same treatment again, showing high satisfaction with the treatment received. Conclusions Percutaneous rhizotomy can be considered a valuable treatment for the symptomatic relief of chronic low back pain from facet joint origin. Meticulous patient selection by combining clinical and physical findings, imaging tests and anaesthetic diagnostic blocks, provides significant and lasting pain relieve, contributing to a reduction in the associated disability in patients suffering from chronic low back pain(AU)

Short anterior instrumented fusion and posterior convex non-instrumented fusion of hemivertebra for congenital scoliosis in very young children.

A variety of treatments has been described in the literature for the treatment of HV. We report the results of early surgical anterior instrumented fusion with partial preservation of the HV and posterior non-instrumented fusion in the treatment of progressive congenital scoliosis in children below the age of six. Between 1996 and 2006, 31 consecutive patients with 33 lateral HV and progressive scoliosis underwent short segment fusions. Mean age at surgery was 2 years and 10 months. Mean follow-up period was 6.1 years. The major scoliotic curve improved from 41 degrees preoperatively to 17 degrees on follow-up. Preoperative segmental Cobb angle averaging 39 degrees was corrected to 15 degrees after surgery, being 15 degrees at the last follow-up (62% of improvement). Compensatory cranial and caudal curves corrected by 47 and 45%, respectively. The angle of segmental kyphosis averaged 16 degrees before surgery, 11 degrees after surgery, and 11 degrees at follow-up. There were two wound infections requiring surgical debridment, one intraoperative fracture of the vertebral body and one case lost correction due to implant failure. All went on to stable bony union. There were no neurological complications. Early diagnosis and early and aggressive surgical treatment are mandatory for a successful treatment of congenital scoliosis and prevention of the development of secondary compensatory deformities. Anterior instrumentation is a safe and effective technique capable of transmitting a high amount of convex compression allowing short segment fusion, which is of great importance in the growing spine.

Artroplastia total de muñeca en pacientes con artritis reumatoide. Evaluación de resultados iniciales / Total wrist arthroplasty in patients with rheumatoid arthritis. Evaluation of preliminary results

Introducción. La articulación de la muñeca es una de las articulaciones más frecuentemente afectadas en la artritis reumatoide (AR). Desde principios de los años setenta la artroplastia de muñeca se propone como alternativa a la artrodesis de muñeca para, además del alivio del dolor, incrementar la movilidad y mejorar así la función articular.Objetivo. Evaluar los resultados objetivos conseguidos tras la cirugía, y los resultados subjetivos de la percepción del paciente tras la artroplastia de muñeca realizada a pacientes afectos de AR en nuestro centro.Material y método. Estudio retrospectivo del resultado delas 7 artroplastias de muñeca en pacientes afectos de AR,realizadas en nuestro centro desde 1993:1. Criterios objetivos: movilidad, estabilidad y evaluación radiológica según el método descrito por Cobb y Beckenbaugh sobre radiografías en anteroposterior y proyección lateral de muñeca.2. Criterios subjetivos: el dolor y la habilidad medidos mediante escalas de EAV y DASH respectivamente, satisfacción del paciente y comparación de prestaciones con la artrodesis contralateral.Resultados. Tras la cirugía el dolor y la habilidad (medidos mediante escalas de EAV y DASH) mejoraron de forma notable.La movilidad se vio incrementada de forma generalmejorando muy significativamente. Radiográficamente noaparecen signos de fallo precoz. Casi todos los pacientesmostraron su satisfacción con el procedimiento quirúrgico.La preferencia de artroplastia a artrodesis es la norma.Conclusiones. Aunque estos resultados ayudan a confirmarlas bondades de la artroplastia de muñeca en pacientes afectos de AR, aún está por conseguir el éxito de las artroplastias de cadera o rodilla. Una buena selección de pacientes, una buena técnica quirúrgica y la constante evolución en la calidad de los implantes, sin duda ayudarán a mejorar los resultados de la artroplastia de muñeca

Introduction. The wrist is one of the most commonly involved joints in Rheumatoid Arthritis (RA). Since the early 1970s, wrist arthroplasty has been introduced as an alternative to arthrodesis of the wrist, allowing maintenance of wrist motion, while at the same time relieving pain and increasing function.Purpose. This study reports the short term clinical followup of total wrist arthroplasty in the rheumatoid, used to evaluate the effectiveness of this procedure based on objective and subjective results.Materials and methods. Retrospective study of the 7 wristarthroplasties in patients with rheumatoid arthritis implanted in our department since 1993:1. Objective results: range of motion, stability and radiological evaluation according to the Cobb and Beckenbaugh scale.2. Subjective results: pain and ability assessed by the EAV scale and the DASH questionnaire respectively, patient satisfaction and comparison between arthroplasty and arthrodesis.Results. After the surgical procedure, both pain and ability, as assessed by means of the EAV pain scale and the DASH questionnaire, improved markedly. Overall ROM improved significantly. No signs of early radiographic failure were seen. Patient satisfaction with the procedure was high. All patients who had undergone fusion of the wrist on the opposite side would have preferred arthroplasty.Conclusions. Although these good results help confirm theusefulness of wrist arthroplasty in RA, total wrist arthroplasty still yields less satisfactory clinical outcomes than hip

Dolor lumbar crónico de origen facetario. Eficacia del tratamiento mediante rizolisis percutánea / Chronic low back pain from facet joint origin. Efficacy of treatment with percutaneous rizhotomy

El dolor lumbar es el motivo más frecuente de consulta médica por patología del aparato locomotor de la población. Se estima que el 70-80% de la población sufrirá algún episodio de dolor lumbar durante su vida. Las articulaciones interapofisarias son el origen del dolor en un gran porcentaje de los casos. La denervación percutánea facetaria lumbar por radiofrecuencia o rizolisis es una técnica mínimamente invasiva para el tratamiento sintomático del dolor lumbar crónico de origen facetario. Su principio se basa en dañar de forma controlada las fibras transmisoras del dolor mediante el calor aplicado por medio de un electrodo en el ramo posterior, causando una lesión que provoca el cese de la transmisión del dolor. Una meticulosa selección de los pacientes y una correcta indicación, considerando que la mayoría de las veces se aplicara a pacientes en el que suelen existir diversas implicaciones (i.e. socioeconómicas, afectivas, laborales,...) obtienen resultados duraderos en el tiempo ayudando a disminuir el impacto sobre la actividad cotidiana de estos pacientes

Low back pain is the most frecuent reason for musculoskeletal medical consultation. It is estimated that betwen 70% to 80% of the population will suffer at least one episode of low back pain during his life. The zygoapophyseal joints represent the origin of the pain in most part of the cases. Percutaneous radiofrecuency lumbar facet joint denervation also called rizhotomy, is a minimally invasive procedure for the symptomatic treatment of low back pain from facet joint origin. The heat transmitted by an electrode placed percutaneously colse to the dorsal rami, produces an injury to the nervous fibres that conduces the pain that stops the transmision of the painful information originated on its inervation area. A careful patient selection and an adequate indication for rizhotomy, considering that in most part of the cases patients suffering for low back pain presents as well some other considerations (i.e. finantial motivation, affective, work problems,...) obtains long lasting good results and helps to diminish the impact of the low back pain over the patients life