Artroscopia de cadera como tratamiento del choque femoroacetabular con seguimiento mínimo de 10 años / Hip arthroscopy for femoroacetabular impingement with 10-year minimum follow-up

Objetivo: Valorar los resultados de la artroscopia de cadera (CAC) como tratamiento del choque femoroacetabular (CFA) con seguimiento mínimo de 10 años, y determinar las variables predictoras de reintervención quirúrgica. Material y métodos: Estudio retrospectivo de una base de datos prospectiva de pacientes intervenidos mediante CAC entre enero de 2010 y diciembre de 2011. Las lesiones del reborde acetabular se evaluaron según la clasificación ALAD. Se realizó valoración clínica y radiológica. La supervivencia de la técnica quirúrgica se calculó con la prueba de Kaplan-Meier y la prueba de regresión de Cox. Resultados: Se incluyeron en el estudio 74 pacientes con un seguimiento medio de 132 meses. La puntuación media en las escalas de valoración mejoró significativamente al final del seguimiento. Diecisiete pacientes (23,9%) fueron reintervenidos. El odds ratio de reintervención en un paciente mayor de 40 años fue de 8,08; en un paciente Tönnis 2-3 de 7,57; y en un paciente con lesión cartilaginosa ALAD 2-3 de 4,25. La supervivencia de la CAC en el CFA a 10 años fue del 77,8%, con un 45,4% en los pacientes con grado de Tönnis mayor de 1 frente al 85,2% en los pacientes con grado de Tönnis de 1 o menor (p<0,001). La variable predictora asociada a la necesidad de reintervención quirúrgica fue la degeneración articular radiológica preoperatoria (p=0,02). Conclusiones: La supervivencia de la CAC en el tratamiento del CFA a 10 años fue del 45,4% en los pacientes con grado de Tönnis mayor de 1 frente al 85,2% en los pacientes con grado de Tönnis 1 o menor. La edad, la lesión cartilaginosa y la degeneración articular incrementarían el riesgo de reintervención quirúrgica.(AU)

Purpose: To determine outcomes after hip arthroscopy (HA) for femoroacetabular impingement (FAI) at a minimun 10-year follow up and identified risk factors for revision surgery. Methods: Retrospective study of a prospective database of patients undergoing HA between January 2010 and December 2011. Rim chondral injuries were evaluated using the acetabular labral articular disruptions system (ALAD). Clinical and radiological data was obtained. Cumulative survival was estimated by Kaplan–Meier and a multivariate Cox proportional hazards model. Results: Seventy-four patients were included in the study. Mean follow-up was 132 months. There was statistically significant improvement from preoperative PROs at latest follow-up. Seventeen patients (23.9%) underwent revision surgery. Odds ratio for revision surgery was 8.08 in a patient above 40 years old, 7.57 in a patient Tönnis greater than 1, and 4.25 in a patient ALAD 2-3. Cumulative survivorship rate at 10 years was 77.8%, with a 45.4% for patients with Tönnis grade greater than 1 in front of 85.2% for patients with Tönnis grade of 1 or less (P<.001). Risk factor for revision surgery was preoperative degree of osteoarthrosis (P=.02). Conclusion: Cumulative survivorship rate at 10 years was 45.4% for patients with Tönnis grade greater than 1 in front of 85.2% for patients with Tönnis grade of 1 or less (P<.001). Age, chondral injuries, and degree of osteoarthrosis would increase the risk for revision surgery.(AU)

[Translated article] Hip arthroscopy for femoroacetabular impingement with 10-year minimum follow-up / Artroscopia de cadera como tratamiento del choque femoroacetabular con seguimiento mínimo de 10 años

Objetivo: Valorar los resultados de la artroscopia de cadera (CAC) como tratamiento del choque femoroacetabular (CFA) con seguimiento mínimo de 10 años, y determinar las variables predictoras de reintervención quirúrgica. Material y métodos: Estudio retrospectivo de una base de datos prospectiva de pacientes intervenidos mediante CAC entre enero de 2010 y diciembre de 2011. Las lesiones del reborde acetabular se evaluaron según la clasificación ALAD. Se realizó valoración clínica y radiológica. La supervivencia de la técnica quirúrgica se calculó con la prueba de Kaplan-Meier y la prueba de regresión de Cox. Resultados: Se incluyeron en el estudio 74 pacientes con un seguimiento medio de 132 meses. La puntuación media en las escalas de valoración mejoró significativamente al final del seguimiento. Diecisiete pacientes (23,9%) fueron reintervenidos. El odds ratio de reintervención en un paciente mayor de 40 años fue de 8,08; en un paciente Tönnis 2-3 de 7,57; y en un paciente con lesión cartilaginosa ALAD 2-3 de 4,25. La supervivencia de la CAC en el CFA a 10 años fue del 77,8%, con un 45,4% en los pacientes con grado de Tönnis mayor de 1 frente al 85,2% en los pacientes con grado de Tönnis de 1 o menor (p<0,001). La variable predictora asociada a la necesidad de reintervención quirúrgica fue la degeneración articular radiológica preoperatoria (p=0,02). Conclusiones: La supervivencia de la CAC en el tratamiento del CFA a 10 años fue del 45,4% en los pacientes con grado de Tönnis mayor de 1 frente al 85,2% en los pacientes con grado de Tönnis 1 o menor. La edad, la lesión cartilaginosa y la degeneración articular incrementarían el riesgo de reintervención quirúrgica.(AU)

Purpose: To determine outcomes after hip arthroscopy (HA) for femoroacetabular impingement (FAI) at a minimun 10-year follow up and identified risk factors for revision surgery. Methods: Retrospective study of a prospective database of patients undergoing HA between January 2010 and December 2011. Rim chondral injuries were evaluated using the acetabular labral articular disruptions system (ALAD). Clinical and radiological data was obtained. Cumulative survival was estimated by Kaplan–Meier and a multivariate Cox proportional hazards model. Results: Seventy-four patients were included in the study. Mean follow-up was 132 months. There was statistically significant improvement from preoperative PROs at latest follow-up. Seventeen patients (23.9%) underwent revision surgery. Odds ratio for revision surgery was 8.08 in a patient above 40 years old, 7.57 in a patient Tönnis greater than 1, and 4.25 in a patient ALAD 2-3. Cumulative survivorship rate at 10 years was 77.8%, with a 45.4% for patients with Tönnis grade greater than 1 in front of 85.2% for patients with Tönnis grade of 1 or less (P<.001). Risk factor for revision surgery was preoperative degree of osteoarthrosis (P=.02). Conclusion: Cumulative survivorship rate at 10 years was 45.4% for patients with Tönnis grade greater than 1 in front of 85.2% for patients with Tönnis grade of 1 or less (P<.001). Age, chondral injuries, and degree of osteoarthrosis would increase the risk for revision surgery.(AU)

Outcomes After Diagnostic Hip Injection.

PURPOSE: To provide a comprehensive review of outcomes associated with local anesthetic (LA) or LA and corticosteroid (CS) diagnostic hip injections, and how well response predicts subsequent operative success. METHODS: A systematic review from database (PubMed, Medline, Scopus, Embase) inception to January 2015 for English-language articles reporting primary patient outcomes data was performed, excluding studies with >50% underlying osteoarthritis. Studies were assessed by 2 reviewers who collected pertinent data. RESULTS: Seven studies were included, reporting on a total 337 patients undergoing diagnostic hip injection. The mean age was 34.4 years, with 5 studies reporting 94 (35.2%) males and 173 (64.8%) females. One study examined the rate of pain relief with LA (92.5%); 2 CS studies reported relief on a scale from 0% to 100% (no to complete relief), ranging from 61% to 82.3%; and 3 studies used 10-point pain scales, with a CS study noting a pain score of 1.0, an LA study with a score of 3.03, and 1 study using either CS or LA scores of 3 to 5.6. Duration of pain relief was 9.8 (CS) and 2.35 days (LA). By pathology, greatest relief was achieved in acetabular chondral injury (93.3%) and least in cam impingement (81.6%), with clinical and imaging findings being unreliable predictors of relief. One study showed nonresponse to be a strong predictor of negative surgical outcome for femoroacetabular impingement. CONCLUSIONS: Diagnostic hip injections provide substantial pain relief for patients with various hip pathologies, with limited data to suggest greatest relief for those with chondral injury. Clinical and imaging findings are unreliable predictors of injection response, and nonresponse to injection is a strong negative predictor of surgical outcome. Future research should focus on elucidating differences by underlying pathology and predicting future operative success. LEVEL OF EVIDENCE: Level IV, systematic review.

Incidence of intraneural needle insertion in ultrasound-guided femoral nerve block: A comparison between the out-of-plane versus the in-plane approaches / Incidencia de inserción intraneural en bloqueo femoral guiado por ecografía: comparación entre los enfoques en plano y fuera de plano

BACKGROUND: The optimal method of ultrasound-guided femoral nerve block (in-plane vs. out-of-plane) has not been established. We tested the hypothesis that the incidence of needle-nerve contact may be higher with out-of-plane than with in-plane needle insertion. METHODS: Forty-four patients with hip fracture (American Society of Anaesthesiologists physical status I-III) were randomized to receive the femoral block with an out-of-plane approach (needle inserted at a 45-60° angle 1 cm caudal to the midpoint of the ultrasound probe just above the femoral nerve) or with an in-plane technique (needle inserted 0.2-0.4 cm from the side of the probe lateral to the femoral nerve). Data collected included depth of needle insertion, response to nerve electric stimulation, and distribution of the injected volume in relation to the nerve (anterior vs. posterior, the latter assuming needle-nerve contact). The sensory block onset was tested at 20 min and block recovery and any neurologic symptoms were evaluated at 24 h. RESULTS: The incidence of needle-nerve contact was significantly higher with the out-of-plane approach (14/22 patients [64%]) than with the in-plane approach (2/22 patients [9%]) (p < 0.001) (OR = 17.5, 95% CI: 4-79). The rate of paraesthesia on crossing the fascia iliaca was similar in the two groups. All blocks uneventfully regressed; and no patient developed neurologic symptoms. CONCLUSIONS: Under the conditions of our study, needle-nerve contact during femoral nerve block occurs frequently with the out-of-plane approach. An in-plane approach results in an equally effective femoral block and less incidence of needle-nerve contact

ANTECEDENTES. No ha quedado establecido un método adecuado para el bloqueo femoral guiado por ecografía (en plano frente a fuera de plano). Probamos la hipótesis de que la incidencia del contacto entre la aguja y un nervio puede ser mayor en la inserción fuera de plano que en el abordaje en plano. MÉTODOS: Cuarenta y cuatro pacientes con fractura de cadera (estadio i-iii según la Sociedad Americana de Anestesiólogos) recibieron de manera aleatorizada un bloqueo femoral con un enfoque fuera de plano (inserción de la aguja en ángulo de 45-60° y 1 cm caudal a la sonda de ecografía sobre el nervio femoral) o con una técnica en plano (inserción de la aguja 0,2-0,4 cm desde el lado de la sonda lateral al nervio femoral). Entre los datos recopilados se incluían la profundidad de inserción de la aguja, la reacción a la estimulación nerviosa y la distribución del volumen inyectado en función del nervio (anterior comparado con posterior, este último con contacto entre la aguja y un nervio). Se analizó el inicio del bloqueo a los 20 min y se evaluaron la recuperación del bloqueo y los síntomas neurológicos después de 24 h. RESULTADOS: La incidencia del contacto entre la aguja y los nervios fue significativamente mayor con el enfoque fuera de plano (14/22 pacientes [64%]) que con el abordaje en plano (2/22 pacientes [9%]) (p < 0,001) (OR = 17,5 [95%]; IC: 4-79). El grado de parestesia en aponeurosis fue similar en ambos grupos. Se revirtieron todos los bloqueos sin incidentes; ningún paciente desarrolló síntomas neurológicos. CONCLUSIONES: En las condiciones de nuestro estudio, el contacto entre la aguja y un nervio durante el bloqueo femoral sucede a menudo con el enfoque fuera de plano. Un abordaje en plano tiene como resultado un bloqueo femoral igualmente efectivo, y una incidencia menor del contacto entre la aguja y un nervio

Polimorfismos del gen VDR en el riesgo de fracturas osteoporótica de cadera en una población adulta española / VDR gene polymorphisms on risk of osteoporotic hip fracture in an adult population spanish

La osteoporosis es una enfermedad esquelética compleja multifactorial con un fuerte componente genético, caracterizada por un deterioro en la microestructura ósea que causa fragilidad ósea y un incremento en el riesgo de fracturas osteoporóticas. El gen VDR podría estar fuertemente involucrado en el riesgo de fractura. El objetivo de este trabajo fue investigar la asociación entre polimorfismos del gen VDR y la susceptibilidad a fractura de cadera (FC). Se reclutaron 147 pacientes andaluces (102 con factores de riesgos de fracturas osteoporóticas y 45 con metabolismo óseo normal). El aislamiento de ADN se realizó a partir de 300 mL de sangre, genotipando 2 SNPs: BsmI y FokI mediante PCRRFLP (PCR-Restriction Fragment Length Polymorphism). Todas las fracturas fueron confirmadas por rayos-X mientras que el riesgo de fracturas a través de la escala FRAX y DMO. Los resultados se evaluaron estadísticamente, considerando significativo valores de p<0,05. La edad media de los pacientes fracturados fue de 68,5 años, cuyas frecuencias alélicas fueron 64.7% G y 68.6% C para BsmI y FokI, respectivamente. La prevalencia de estos SNPs en la población caso fueron: 43,3% GA,43.3% GG y 13,7% AA para BsmI y 49,0% CC, 39,20% CT, 11,8% TT para FokI. Las frecuencias de los alelos y genotipos no mostraron diferencias entre pacientes con riesgo de fracturas y pacientes control. Las frecuencias están acorde con las demostradas en HapMap para población europea caucásica. No se encontró ninguna asociación significativa entre estos SNPs y la susceptibilidad a las FC en la población adulta andaluza(AU)

Osteoporosis is a multifactorial complex skeletal disease with strong genetic component, characterized by a deterioration of bone microstructure that causes bone fragility and an increased risk of osteoporotic fractures. VDR gene could be strongly involved in the risk of fracture. The aim of this study was to investigate the association between VDR gene polymorphisms and susceptibility to hip fracture (HF). 147 Andalusian patients were recruited (102 with risk factors for osteoporotic fractures and 47 with normal bone metabolism). DNA isolation was performed from 300 mL of blood, genotyping 2 SNPs: BsmI and FokI by PCR-RFLP (PCR-Restriction Fragment Length Polymorphism). All fractures were confirmed by X-rays while the risk of fractures through FRAX level and BMD. The results were statistically evaluated, considering significant p-values <0.05. The average age of fractured patients was 68.5 years, whose allele frequencies were 64.7% G and 68.6% C for BsmI and FokI, respectively. Prevalence of these SNPs in the case population were: 43.3% GA, 43.3% GG and 13.7% AA BsmI and 49.0 % CC, 39.2% CT, 11.8% TT for FokI. The frequencies of alleles and genotypes showed no differences between patients with and without risk of hip fracture. The frequencies are agree to HapMap for European-Caucasian population. It was found no significant association between these SNPs and susceptibility to HF in the adult population of Andalusia(AU)

Bone morphogenetic proteins in total hip arthroplasty, osteonecrosis and trauma surgery.

This review provides an overview of the use of bone morphogenetic proteins to enhance bone healing and bone graft incorporation in difficult defects created from failed total hip arthroplasties, osteonecrosis of the femoral head and trauma. Multiple publications have demonstrated that bone morphogenetic proteins are osteoinductive in preclinical trials (i.e., animal models); however, there is controversy and limited understanding of the use of this technology in orthopedic surgical practice. The question remains as to whether they are useful in difficult fractures, nonunions and large defects created from failed total hip arthroplasty or femoral head osteonecrosis. There might be a small risk for infection by the process of introducing foreign materials in a clinical situation, but this has not yet been realized to date. In addition, these materials offer an advantage in large defects where there is not enough transplantable material available from the host. We believe that the use of these materials will become more widespread with newer carriers, minimally invasive applications and diminished commercial costs.

Evaluación de una vía clínica de artritis séptica / Evaluation of a clinical pathway for septic arthritis

Introducción. Una vía clínica es una herramienta que coordina la labor asistencial, disminuyendo la variabilidad entre profesionales, al tiempo que mejora la atención a los pacientes y la gestión. La artritis séptica es candidata a ser abordada mediante una vía clínica porque su evolución es predecible y existe gran diversidad en el manejo. El objetivo del trabajo es evaluar una vía clínica tras 2 años de implantación y describir las características de los pacientes que fueron incluidos. Material y métodos. Documentación de la vía: matriz, hoja de variaciones, hoja informativa, encuesta de satisfacción e indicadores de evaluación. Resultados. Se incluyeron 35 pacientes, siete artritis sépticas seguras y 28 probables. No hubo diferencias entre los 2 grupos, siendo su evolución favorable. Se practicó analítica al ingreso a todos los pacientes, al alta hospitalaria al 51 % y al alta definitiva al 97 %. Los mejores indicadores de evaluación fueron la cobertura de la vía, la realización de artrocentesis/artrotomía y la satisfacción en el trato o información recibidos y los indicadores más alejados del estándar fueron la hospitalización menor de 7 días (77 % frente a > 95 %) y la obtención de líquido articular sin antibióticos (76 % frente a > 90 %). Conclusiones. La vía clínica resulta útil para estandarizar el proceso de diagnóstico y tratamiento de la artritis séptica. Su aplicación con un soporte clínico adecuado permite decidir el alta hospitalaria siguiendo los criterios clínicos de mejoría, sin que por ello empeore el pronóstico. Optimizar el tiempo de hospitalización y conseguir líquido articular antes de iniciar el tratamiento antibiótico son nuestros retos inmediatos

Introduction. Clinical pathways are tools that coordinate clinical work, reducing interclinican variability and improving patient care and management. The use of clinical pathways in septic arthritis is appropriate, as this disease has a predictable course and there is considerable variation in its management. The aim of this study was to evaluate a septic arthritis clinical pathway 2 years after its introduction and to describe the characteristics of the patients included. Material and methods. Clinical pathway documents: pathway matrix sheet, variance form, parent information sheet, satisfaction survey and evaluation indicators sheet. Results. Thirty-five patients were included, seven with a definitive diagnosis of septic arthritis and 28 with probable septic arthritis. No differences were found between the two groups, with good outcomes in both. Laboratory analyses were performed at admission in all patients, at discharge in 51 %, and at the end of treatment in 97 %. The indicators that best met the standard were clinical pathway coverage, performance of arthrocentesis/arthrotomy, and satisfaction with dealings with staff and the information received. The indicators furthest from the standard were admission shorter than 7 days (77 % vs > 95 %) and obtaining articular fluid prior to antibiotic therapy (76 % vs > 90 %). Conclusions. The clinical pathway is useful for standardizing the process of septic arthritis diagnosis and treatment. With adequate clinical support, application of this pathway allows decisions to be made on hospital discharge following the clinical criteria of improvement without worsening prognosis. Our immediate challenges are to reduce inpatient stay and to obtain synovial fluid before starting antibiotic therapy

Nano-mechanics of bone and bioactive bone cement interfaces in a load-bearing model.

Many bioactive bone cements were developed for total hip replacement and found to bond with bone directly. However, the mechanical properties at the bone/bone cement interface under load bearing are not fully understood. In this study, a bioactive bone cement, which consists of strontium-containing hydroxyapatite (Sr-HA) powder and bisphenol-alpha-glycidyl dimethacrylate (Bis-GMA)-based resin, was evaluated in rabbit hip replacement for 6 months, and the mechanical properties of interfaces of cancellous bone/Sr-HA cement and cortical bone/Sr-HA cement were investigated by nanoindentation. The results showed that Young's modulus (17.6+/-4.2 GPa) and hardness (987.6+/-329.2 MPa) at interface between cancellous bone and Sr-HA cement were significantly higher than those at the cancellous bone (12.7+/-1.7 GPa; 632.7+/-108.4 MPa) and Sr-HA cement (5.2+/-0.5 GPa; 265.5+/-39.2 MPa); whereas Young's modulus (6.3+/-2.8 GPa) and hardness (417.4+/-164.5 MPa) at interface between cortical bone and Sr-HA cement were significantly lower than those at cortical bone (12.9+/-2.2 GPa; 887.9+/-162.0 MPa), but significantly higher than Sr-HA cement (3.6+/-0.3 GPa; 239.1+/-30.4 MPa). The results of the mechanical properties of the interfaces were supported by the histological observation and chemical composition. Osseointegration of Sr-HA cement with cancellous bone was observed. An apatite layer with high content of calcium and phosphorus was found between cancellous bone and Sr-HA cement. However, no such apatite layer was observed at the interface between cortical bone and Sr-HA cement. And the contents of calcium and phosphorus of the interface were lower than those of cortical bone. The mechanical properties indicated that these two interfaces were diffused interfaces, and cancellous bone or cortical bone was grown into Sr-HA cement 6 months after the implantation.

[Effects of naloxone, nalorphine and dalargin on the course of shock due to the combination of mechanical trauma and acute blood loss]. / Vliianie naloksona, nalorfina i dalargina na techenie shoka ot sochetaniia mekhanicheskoi travmy i ostroi krovopoteri.

Acute experiments on 75 adult rabbits were made to study action of intravenous injections of naloxone (0.1 mg/kg), nalorphine (0.5 and 2.0 mg/kg) and dalargin (0.1 mg/kg) in early and late periods of irreversible shock caused by combination of non-shockogenic mechanical trauma of the hip and safe blood loss from the femoral artery. In early shock antagonists of opiate receptors did not influence the outcomes while injection of dalargin prolonged survival of the animals noticeably. In late shock injection of the drugs had no significant influence on the course of the pathological process while reinfusion did not help the animals to survive. In the late shock injection of the above drugs after blood reinfusion increased the rabbits' survival.