Epidemiologia de les fractures perinatals a l'Hospital Germans Trias i Pujol. Relació entre el tipus de fractura de clavícula i la paràlisi braquial obstètrica.

Les fractures de clavícula perinatals són una complicació impredictible i inevitable dels nounats i un percentatge presentarà paràlisi braquial (PBO) que freqüentment s'autoresolt. S'estudien els factors de risc de la fractura i és el primer treball que estudia la relació entre el tipus de fractura clavicular i la presència de PBO al naixement i la permanència d'aquesta complicació. L'afectació del terç proximal de clavícula i la distòcia d'espatlles són factors de risc per al desenvolupament de la PBO inicial, però no el desplaçament de la fractura. La permanència de la complicació no s'ha relacionat amb cap factor de risc.

Blockade of both alpha1A- and alpha1B-adrenergic receptor subtype signaling is required to inhibit neointimal formation in the mouse femoral artery.

Attenuation of early restenosis after percutaneous coronary intervention (PCI) is important for the successful treatment of coronary artery disease. Some clinical studies have shown that hypertension is a risk factor for early restenosis after PCI. These findings suggest that alpha(1)-adrenergic receptors (alpha(1)-ARs) may facilitate restenosis after PCI because of alpha(1)-AR's remarkable contribution to the onset of hypertension. In this study, we examined the neointimal formation after vascular injury in the femoral artery of alpha(1A)-knockout (alpha(1A)-KO), alpha(1B)-KO, alpha(1D)-KO, alpha(1A)-/alpha(1B)-AR double-KO (alpha(1AB)-KO), and wild-type mice to investigate the functional role of each alpha(1)-AR subtype in neointimal formation, which is known to promote restenosis. Neointimal formation 4 wk after wire injury was significantly (P < 0.05) smaller in alpha(1AB)-KO mice than in any other group of mice, while blood pressures were not altered in any of the groups of mice after wire injury compared with those before it. These results suggest that lack of both alpha(1A)- and alpha(1B)-ARs could be necessary to inhibit neointimal formation in the mouse femoral artery.

Medial femoral condyle fracture as a complication of antegrade intramedullary nailing.

A 49-year-old man suffered a closed oblique fracture of the middle third of his left femur. Closed reduction and internal fixation by intramedullary (IM) nailing were performed. Per-operative fluoroscopic imaging and initial postoperative X-rays were judged normal and the patient followed the usual rehabilitation protocol. At 3-month follow-up the patient still demonstrated poor knee function and pain. A plain X-ray and a CT scan of the left knee revealed a displaced fracture of the medial femoral condyle. Analysis of the postoperative imaging suggests that the fracture occurred during the insertion of the IM nail. The nail possibly hit the Steinmann traction pin in the distal femur causing the medial condyle fracture. The patient was reoperated; open reduction and internal plate and screw fixation were performed with satisfactory clinical progress postoperatively. The description and illustration of this case is intended to make trauma surgeons aware of this rare but serious complication of IM femoral nailing.

Calcification des grandes artères et risque de fracture ostéoporotique [Aortic calcification and the risk of osteoporotic fractures].

Osteoporosis and atherosclerosis seem to be epidemiologically correlated. Several medical conditions are risk factors for both osteoporosis and atheromatosis (i.e. age, diabetes, end stage renal disease, sedentarity, smoking), but a common pathogenic link may be present beyond this. The burden of cardiovascular events and of osteoporotic fracture is considerable for the health care system in term of costs and resources. However, both diseases are rarely managed together. This article is a review of the recent studies in this new field.

Is amoxicillin/clavulanic acid sufficient for preemptive antibiotic therapy in type III grade open fractures ?

The risk of infection after type III° open fractures is high (10-50%).Preemptive antibiotic therapy may prevent posttraumatic infection andimprove the outcome. Recommendations about the type and durationof antibiotic vary among the institutions and it remains unclear whethergram-negative bacilli or anaerobs need to be covered. In Europe, themost commonly recommended antibiotic is amoxicillin/clavulanic acid.We retrospectively analyzed microbiology, characteristics and outcomeof patients with open type III° fractures treated at our institution.Methods: Between 01/2005 and 12/2009 we retrospectively includedall type III grade open fractures of the leg at our institution classifiedafter Gustilo into type IIIA, IIIB and IIIC. Demographic characteristics,clinical presentation, microbiology, surgical and antibiotic treatmentand patient outcome were recorded using a standardized case-reportform.Results: 30 cases of patients with type III° open fractures wereincluded (25 males, mean age was 40.5 years, range 17-67 years).27 fractures (90%) were located on the lower leg and 3 (10%) on theupper leg. Microbiology at initial surgery was available for 19 cases(63%), of which 10 grew at least one organism (including 8 amoxicillin/clavulanic acid-resistant gram-negative bacilli [GNB], 7 amoxicillin/clavulanic acid-resistant Bacillus cereus), 11 were culture-negative.Preemptive antibiotics were given in all cases (100%) for an averageduration of 8.5 days (range 1-53 days), the most common antibioticwas amoxicillin/clavulanic acid in 60% (n = 18). 11 cases just receivedpreemptive antibiotic treatment, in 19 of 30 cases the antibiotic therapywas changed and prolonged. Microbiology at revision surgery wasavailable for 25 cases and 22 grew at least one pathogen (including32 amoxicillin/clavulanic acid-resistant gram-negative bacilli and 10amoxicillin/clavulanic acid-resistant Bacillus cereus), 3 were culturenegative.Conclusions: At initial surgery, most common isolated organismswere coagulase-negative staphylococci (43%), Bacillus cereus (23%),and gram-negative bacilli (27%), and others (7%) of which 48% wereresistant to amoxicillin/clavulanic acid. At revision surgery, isolatedorganisms were gram-negative bacilli (64%), Bacillus cereus (20%),and others (16%) of which 88% were resistant to amoxicillin/clavulanicacid. The spectrum of amoxicillin/clavulanic does not cover the mostcommon isolated organisms.FM32

Osteoporosis e índice de masa corporal en el trasplantado renal.

INTRODUCTION: frequently after kidney transplantation there is an increase in weight with a resulting high percent of obesity in these recipients. This combined with a rapid loss of bone mass, a higher prevalence of osteoporosis and fractures is evident than in normal populations. OBJECTIVES: to explore the relationship between body mass index (BMI) and prevalence of osteoporosis in a population of renal transplant recipients. METHODS: prospective longitudinal study design. The study was conducted on 306 kidney transplant recipients. The relationship between weigh and body mass index with femoral and lumbar osteopenia and osteoporosis prevalence at the moment of transplant and at 12 months post was explored. RESULTS: there was a high prevalence of overweight (35.6%) and obese (14.1%) recipients after renal transplant and 1 year after (42.2% and 24.2% respectively). Significant differences were found(p = 0.049) between the weight at the time of transplant and the presence of osteopenia or osteoporosis at the lumbar level one year after, the highest weights were in recipients with osteoporosis. The mean BMI was higher (p = 0.028) in osteoporotic patients (26.59 kg/m2) than in patients with osteopenia (24.23 kg/m2). CONCLUSION: results seem to be consistent with recent studies in the general population showing excessive weight as a possible factor detrimental to the bone health.

Dorsal fractures of the triquetrum: MRI findings with an emphasis on dorsal carpal ligament injuries.

OBJECTIVE: The objective of our study was to report the MRI findings in dorsal fractures of the triquetrum, with an emphasis on dorsal carpal ligament injuries. MATERIALS AND METHODS: A total of 21 patients (16 men, five women; mean age, 41.9 years) with acute or subacute (≤ 6 weeks) dorsal triquetral fractures on radiography and MRI were included in this two-center retrospective study. MRI of the wrist was performed on 3-T units with transverse T1-weighted, coronal or transverse (or both) fat-suppressed T2weighted, transverse gadolinium-enhanced fat-suppressed T1-weighted turbo spin-echo, and 3D gadolinium-enhanced fat-suppressed T1-weighted gradient-recalled echo sequences. Three musculoskeletal radiologists evaluated the ulnar styloid process index (USPI) on radiographs and the following MRI features: fracture pattern (types 1-6), bone fragment size and displacement, bone marrow edema distribution, and dorsal carpal ligament tears. RESULTS: Eight type 1, one type 2, six type 3, five type 4, and one type 5 fractures were identified. These fractures were associated with 14 (66.7%), 17 (81.0%), and 16 (76.2%) tears of the dorsal radiocarpal, ulnotriquetral, and intercarpal ligaments, respectively. There was no correlation between bone marrow edema distribution and dorsal carpal ligament injuries (all p > 0.05). The mean (± SD) bone fragment volume and displacement were 205 ± 157 mm(3) and 1.0 ± 1.1 mm, respectively. The mean USPI was 0.21 ± 0.10. CONCLUSION: Dorsal fractures of the triquetrum are frequently associated with dorsal carpal ligament injuries. Bone marrow edema distribution is not correlated with these ligament tears.

Comparing Bone Microarchitecture by Trabecular Bone Score (TBS) in Caucasian American Women with and Without Osteoporotic Fractures.

Several cross-sectional studies have shown the ability of the TBS to discriminate between those with and without fractures in European populations. The aim of this study was to assess the ability of TBS to discriminate between those with and without fractures in a large female Caucasian population in the USA. This was a case-control study of 2,165 Caucasian American women aged 40 and older. Patients with illness or taking medications known to affect bone metabolism were excluded. Those in the fracture group (n = 289) had at least one low-energy fracture. BMD was measured at L1-L4, TBS calculated directly from the same DXA image. Descriptive statistics and inferential tests for difference were used. Univariate and multivariate logistic regression models were created to investigate possible association between independent variables and the status of fracture. Odds ratios per standard deviation decrease (OR) and areas under the ROC curve were calculated for discriminating parameters. Weak correlations were observed between TBS and BMD and between TBS and BMI (r = 0.33 and -0.17, respectively, p < 0.01). Mean age, weight, BMD and TBS were significantly different between control and fracture groups (all p ≤ 0.05), whereas no difference was noted for BMI or height. After adjusting for age, weight, BMD, smoking, and maternal and family history of fracture, TBS (but not BMD) remained a significant predictor of fracture: OR 1.28[1.13-1.46] even after adjustment. In a US female population, TBS again was able to discriminate between those with and those without fractures, even after adjusting for other clinical risk factors.

Ostéoporose : les fractures non traumatiques de la personne âgées

La survenue d'une fracture non traumatique chez la personne âgée a un impact humain, médical et économique important. L'amélioration des connaissances et des moyens à disposition pour sa prise en charge doivent nous inciter à mettre en place une stratégie multidisciplinaire personnalisée et précoce (comprenant un médecin spécialisé dans les maladies osseuses qu'il soit rhumatologue, endocrinologue, interniste/généraliste, gériatre, et al.).

Comparison of three bone ultrasounds for the discrimination of subjects with and without osteoporotic fractures among 7562 elderly women.

Bone ultrasound measures (QUSs) can assess fracture risk in the elderly. We compared three QUSs and their association with nonvertebral fracture history in 7562 Swiss women 70-80 years of age. The association between nonvertebral fracture was higher for heel than phalangeal QUS. INTRODUCTION: Because of the high morbidity and mortality associated with osteoporotic fractures, it is essential to detect subjects at risk for such fractures with screening methods. Because quantitative bone ultrasound (QUS) discriminated subjects with osteoporotic fractures from controls in several cross-sectional studies and predicted fractures in prospective studies, QUS could be more practical than DXA for screening. MATERIAL AND METHODS: This cross-sectional and retrospective multicenter (10 centers) study was performed to compare three QUSs (two heel ultrasounds: Achilles+ [GE-Lunar] and Sahara [Hologic]; the phalanges: ultrasound DBM sonic 1200 [IGEA]) for determining by logistic regression nonvertebral fracture odds ratio (OR) in a sample of 7562 Swiss women, 75.3 +/- 3.1 years of age. The two heel QUSs measured the broadband ultrasound attenuation (BUA) and the speed of sound (SOS). In addition, Achilles+ calculated the stiffness index (SI) and the Sahara calculated the quantitative ultrasound index (QUI) from BUA and SOS. The DBM sonic 1200 measured the amplitude-dependent SOS (AD-SOS). RESULTS: Eighty-six women had a history of a traumatic hip fracture after the age of 50, 1594 had a history of forearm fracture, and 2016 had other nonvertebral fractures. No fracture history was reported by 3866 women. Discrimination for hip fracture was higher than for the other nonvertebral fractures. The two heel QUSs had a significantly higher discrimination power than the QUSs of the phalanges, with standardized ORs, adjusted for age and body mass index, ranging from 2.1 to 2.7 (95% CI = 1.6, 3.5) compared with 1.4 (95% CI = 1.1, 1.7) for the AD-SOS of DBM sonic 1200. CONCLUSION: This study showed a high association between heel QUS and hip fracture history in elderly Swiss women. This could justify integration of QUS among screening strategies for identifying elderly women at risk for osteoporotic fractures.

Acute total hip arthroplasty for acetabular fractures in the elderly: 11 patients followed for 2 years.

We describe the use of cable fixation and acute total hip replacement for acetabular fracture in the elderly. 12 patients with acetabular fractures, having a mean age of 79 (65-93) years, were treated with cable fixation and acute total hip arthroplasty. 8 were T-shaped fractures and 4 associated fractures of the posterior column and posterior wall. 1 patient died 5 months after surgery and the remaining 11 were followed for 2 years. All patients had a good clinical outcome. Radiographic assessment showed healing of the fracture and a satisfactory alignment of the cup without loosening. This surgical technique provides good primary fixation, stabilizes complex acetabular fractures in elderly patients with osteoporotic bone and permits early postoperative mobilization.

Fractures dorsales du triquetrum : avulsion ou conflit ulno-carpien? Aspects IRM 3T et lésions associées.

Objectifs: Déterminer les caractéristiques en IRM 3T et discuter l'étiologie des fractures dorsales du triquetrum. Evaluer les lésions associées, notamment des ligamentsextrinsèques dorsaux.Matériels et méthodes: Etude rétrospective (septembre 2007 - décembre 2010) incluant 18 patients avec radiographies conventionnelles et IRM du poignet à 3T présentant une fracturedorsale du triquetrum. Protocole IRM comprenant une séquence T1-VIBE coronale haute résolution (0,3mm) isotropique avec suppression de graisse et aprèsinjection intraveineuse de Gadolinium. Lecture consensuelle par 2 radiologues évaluant les caractéristiques suivantes : taille et déplacement du fragment osseux,localisation de l'oedème médullaire, lésion des ligaments extrinsèques dorsaux (radio-triquetral, scapho-triquetral et ulno-triquetral), autres lésions associées.Inclusion d'un groupe contrôle de 20 patients, afin d'évaluer localisation et visibilité des enthèses ligamentaires extrinsèques dorsales .Résultats: Identification de 14 lésions ligamentaires scapho-triquetrales, 12 ulno-triquetrales et 8 radio-triquetrales, corrélées à la localisation de l'oedème osseux. Absenced'oedème de la styloïde ulnaire évocatrice de conflit. Volume moyen des fragments de 210 mm3, avec déplacement le plus fréquemment distal. Dans le groupecontrôle, visibilité des ligaments scapho-triquetral, radio-triquetral et ulno-triquetral dans respectivement 100% (20/20), 90% (18/20) et 70% (14/20) des cas.Conclusion: L'IRM 3T permet d'évaluer précisément les fractures dorsales du triquetrum et leurs lésions associées , y compris la distribution des oedèmes osseux. Cesfractures auraient donc une étiologie mixte.

A new technique to measure micromotion distribution around a cementless femoral stem.

The interfacial micromotion is closely associated to the long-term success of cementless hip prostheses. Various techniques have been proposed to measure them, but only a few number of points over the stem surface can be measured simultaneously. In this paper, we propose a new technique based on micro-Computer Tomography (μCT) to measure locally the relative interfacial micromotions between the metallic stem and the surrounding femoral bone. Tantalum beads were stuck at the stem surface and spread at the endosteal surface. Relative micromotions between the stem and the endosteal bone surfaces were measured at different loading amplitudes. The estimated error was 10μm and the maximal micromotion was 60μm, in the loading direction, at 1400N. This pilot study provided a local measurement of the micromotions in the 3 direction and at 8 locations on the stem surface simultaneously. This technique could be easily extended to higher loads and a much larger number of points, covering the entire stem surface and providing a quasi-continuous distribution of the 3D interfacial micromotions around the stem. The new measurement method would be very useful to compare the induced micromotions of different stem designs and to optimize the primary stability of cementless total hip arthroplasty.