Resultados en reducción abierta de cadera por via interna: necrosis avascular y concordancia interobservador

Introducción: la luxación típica de la cadera es una patología con alta incidencia, de ahí la necesidad de métodos efectivos para lograr una reducción de esta. Han surgido varios métodos de reducción, uno de estos métodos es la reducción abierta por vía interna. Metodología Estudió descriptivo retrospectivo, incluyo los casos operados de reducción abierta por vía interna en el Instituto de Ortopedia Infantil Roosevelt y Clínica Jorge Piñeros Corpas por uno de los tutores, desde enero de 2006 hasta junio de 2011, valorando estas caderas según los criterios de Salter de necrosis avascular (NAV), con un seguimiento mínimo de 18 meses. Se evaluó la concordancia interobservador para la clasificación de Salter en tres ortopedistas infantiles. Resultados Se evaluaron 20 caderas en 16 pacientes a los que se realizo reducción abierta de luxación típica de cadera por vía interna. El 40 % de las caderas presentaron NAV, el 75% de estas caderas presentan NAV tipo I según la clasificación de Kalamchi. El índice Kappa para la clasificación de Salter en tres ortopedistas infantiles fue 0.6. Discusión El abordaje por vía interna para la reducción de luxación de cadera típica en niños menores de 18 meses es una alternativa más para el manejo de estos pacientes, que puede producir NAV en la cadera, pero esta NAV es tipo I de Kalamchi en la mayoría de casos. La reproducibilidad de la radiografía para la evaluación de NAV, realizada por personas expertas es buena, medida con índice kappa de 0.6.

Factors associated to avascular necrosis of the femoral head and non-union in patients younger than 65 years old with displaced femoral neck fractures treated with reduction and internal fixation.

Pocos estudios han evaluado el tratamiento de las fracturas desplazadas de cuello femoral en pacientes menores de 65 años de edad, y no han sido claramente definidos los factores de riesgo para necrosis avascular o no-unión dentro de este rango de edad. Para determinar los factores asociados a la necrosis avascular de la cabeza femoral (AVN) y no-unión en pacientes menores de 65 años de edad con fracturas desplazadas del cuello femoral tratados con reducción y fijación interna, se realizó un estudio retrospectivo de 29 fracturas desplazadas del cuello femoral en 29 pacientes consecutivos tratados en una sola institución. La influencia de la edad, la energía del trauma, tipo de reducción, y el tiempo entre la fractura y el tratamiento en desarrollo de la AVN y no-unión fueron evaluados. Los pacientes que desarrollaron NAV fueron significativamente mayores y sufrieron un trauma de más baja energía que en los casos sin AVN. Ninguna variable fue asociada con la no-unión. La regresión logística determinó que sólo la edad se asoció de forma independiente a NAV. La edad es un buen predictor para el desarrollo de NAV, con un C-estadístico de 0.861, y un mejor corte-determinado en 53,5 años. Conclusión: Los pacientes de entre 53,5 y 65 años presentan un riesgo más alto de NAV. La artroplastia primaria se debe considerar en este subgrupo.

Fracturas de astrágalo

Estudio retrospectivo de 63 fracturas de astrágalo recogidas durante un periodo de 13 años. De las 31 fracturas del cuello astragalino se obtuvo un seguimiento de 2 años en 23 de ellas, pudiéndose valorar la aparición en la radiología del signo de Hawkins entre la 6ª y 8ª semana después del traumatismo y el desarrollo o no de necrosis avascular. Se concluye con el estudio que la observación del signo de Hawkins garantiza la correcta perfusión del astrágalo (sensibilidad del 100%). Sin embargo, la no detección de dicho signo no es predictiva del desarrollo de necrosis.

Tratamiento del deslizamiento epifisiario capital femoral con fijación in situ versus luxación quirúrgica

Introducción: El Deslizamiento Epifisiario Capital Femoral es la enfermedad de la cadera más común en adolescentes entre los 9 y 16 años. Es de causa idiopática, más frecuente en hombres, se clasifica en 4 estadios según criterios clínicos y radiológicos. Se buscó evaluar la evolución de los deslizamientos moderados y severos tratados con una de las dos técnicas propuestas. Metodología Se realizó un estudio descriptivo con pacientes que fueron llevados a fijación in situ o luxación controlada entre 2008 y 2011. Resultados: Se incluyeron 26 pacientes, los cuales el 65.4% se les realizó luxación quirúrgica controlada y el 34.6% fijación in situ. El 70,6% de pacientes tenían DECF inestable y 70,5% tenían desplazamiento severo. La evaluación de la escala WOMAC para dolor, rigidez y capacidad funcional encontró mejores beneficios para el grupo de fijación in situ, estadísticamente significativos (p<0,05), no solo en términos de dolor, rigidez y capacidad funcional sino menor frecuencia de complicaciones. Las complicaciones más frecuentes en el grupo de luxación quirúrgica controlada fueron un caso de infección, 7 casos (41,2%) de necrosis avascular de cabeza femoral, 5 casos (29,4%) de condrolisis y 2 casos (11,8%) de pseudoartrosis; En el grupo de fijación in situ, solo 1 (11,1%) presentó Infección del Sitio Operatorio y 1 (11,1%) Condrolisis. Resultados significativos solo para necrosis avascular. Discusión: Los pacientes con deslizamientos moderados y severos manejados con fijación in situ tuvieron una mejor resultado con menor proporción de complicaciones.

Hip pain in renal transplant recipients: symptomatic gluteus minimus and gluteus medius tendon abnormality as an alternative MRI diagnosis to avascular necrosis

OBJECTIVE: The purpose of this study was to review the diagnosis on MRI and radiography of 24 renal transplant recipients with hip pain suspicious for avascular necrosis and to investigate whether there is an association between kidney transplant patients with end-stage renal disease and symptomatic gluteus minimus and medius tendon abnormality. CONCLUSION: Symptomatic gluteus minimus and medius tendon lesions and abnormalities can occur in renal allograft recipients. The MRI findings of this entity allow an alternative diagnosis in this patient population.

[Avascular necrosis of the hamate--case report]

Avascular necrosis of the hamate is a very rare condition. After repetitive stress a young male developed left wrist pain which was found to be an avascular necrosis of the hamate. After progression of the necrosis with cyst formation on follow-up magnetic resonance imaging (MRI) and persisting pain, the patient underwent successful revascularisation with a vascular bone graft of the distal radius.

Free microvascular iliac crest flap for extensive talar necrosis--case report with a 16-year long-term follow up.

Atraumatic osteonecrosis of the talus can be extremely painful and lead to significant functional impairment. Although clinical, radiographic, and demographic characteristics of atraumatic osteonecrosis of the talus have been well documented, the diagnosis is frequently missed or delayed; the most common causes are use of corticosteroids and the presence of immune disorders. Operative treatment of large osteochondral lesions of the talus is difficult because the blood supply is poor in the talar dome. Microvascular reconstruction of the talar dome with iliac crest autografts is a complex but functionally excellent therapeutic option. We present a 48-year-old man, who developed an extensive atraumatic avascular necrosis of the talar dome without collapse. Except for insulin dependent diabetes mellitus no further comorbidities were known. A microvascular iliac crest bone flap was inserted into the talus. A follow-up 16 years postoperatively showed a clinically as well as radiographically stable reconstruction of the talar dome and an excellent mobility of the ankle joint. The AOFAS hindfoot scale had improved from initially 33 points to 100 on the last follow-up. Free microvascular bony reconstruction of the talar dome should not only be considered in younger patients but also for middle aged active patients, since our follow-up shows an excellent long term result. Early reconstruction can prevent collapse of the talar bone.

Modelling the formation of necrotic regions in avascular tumours

The mechanisms underlying the formation of necrotic regions within avascular tumours are not well understood. In this paper, we examine the relative roles of nutrient deprivation and of cell death, from both the proliferating phase of the cell cycle via apoptosis and from the quiescent phase via necrosis, in changing the structure within multicellular tumour spheroids and particularly the accumulation of dead cell material in the centre. A mathematical model is presented and studied that accounts for nutrient diffusion, changes in cell cycling rates, the two different routes to cell death as well as active motion of cells and passive motion of the dead cell material. In studying the accumulation of dead cell matter we do not distinguish between the route by which each was formed. The resulting mathematical model is examined for a number of scenarios. Results show that in many cases the size of the necrotic core is closely correlated with low levels in nutrient concentration. However, in certain cases, particularly where the rate of necrosis is large, the resulting necrotic core can lead to regions of non-negligible nutrient concentration-dependent upon the mode of cell death.

Necrose avascular da cabeça femoral em pacientes HIV positivos: resultados iniciais do tratamento cirúrgico por substituição articular cerâmica-cerâmica

OBJETIVOS: Avaliar os resultados funcionais iniciais e o índice de complicações precoces das artroplastias totais do quadril cerâmica-cerâmica em pacientes que convivem com o HIV e apresentam osteonecrose da cabeça femoral. MÉTODO: Doze pacientes HIV+ com diagnóstico de osteonecrose da cabeça do fêmur incongruente foram avaliados através de critérios clínicos, laboratoriais, pela escala funcional WOMAC antes e após o tratamento com substituição articular. RESULTADOS: Observamos que 83,3% dos indivíduos faziam uso de inibidores de protease, 75% apresentavam dislipidemia e 66,6% síndrome lipodistrófica, a melhora na evolução no escore WOMAC foi estatisticamente significativa para seis e 12 meses de pós-operatório em comparação com o escore pré-operatório e não observamos complicações secundárias a esse procedimento. CONCLUSÃO: A artroplastia total do quadril com implante de cerâmica-cerâmica para o tratamento da necrose avascular do quadril nessa parcela da população é opção cirúrgica adequada, apresenta melhora funcional inicial significativa e baixo índice de complicação precoce.

Minimum ten year results of total hip arthroplasty with the acetabular reinforcement ring in avascular osteonecrosis

Total hip arthroplasty (THA) still carries a higher failure rate in patients with avascular necrosis of the femoral head (AVN) than in a similar patient population with THA for other reasons. This is particularly true for the acetabular component. One of the major factors accounting for this is the compromised acetabular bone quality with structural defects subsequent to collapsing of the femoral head in high-grade AVN. In this study we implanted an acetabular reinforcement ring with hook (ARRH), which had been used successfully for other indications with acetabular bone stock deficiency, in 32 consecutive THA's in 29 patients with AVN. Five patients died during the observation period of causes unrelated to the surgery, one patient was lost to follow-up and one patient could not be followed up due to chronic illness, leaving 25 hips (23 patients) with a minimum follow-up of ten years (mean: 11.8; range: 10-15). The mean Merle d'Aubigne score increased significantly from 7.7 preoperatively to 16.6 postoperatively (p < 0.001). One revision was performed for aseptic stem loosening. Of the unrevised hips, one acetabular component was classified as definitively loose. The cumulative 12-year survivorship for THA with ARRH in AVN was 95.2% (confidence interval: 86.1-100%) for both components, 100% for the cup and 95.2% for the stem (86.1-100%).

Macrophage Cell Activation With Acute Apical Abscess Contents Determined By Interleukin-1 Beta And Tumor Necrosis Factor Alpha Production.

This clinical study has investigated the antigenic activity of bacterial contents from exudates of acute apical abscesses (AAAs) and their paired root canal contents regarding the stimulation capacity by levels of interleukin (IL)-1 beta and tumor necrosis factor alpha (TNF-α) throughout the root canal treatment against macrophage cells. Paired samples of infected root canals and exudates of AAAs were collected from 10 subjects. Endodontic contents were sampled before (root canal sample [RCS] 1) and after chemomechanical preparation (RCS2) and after 30 days of intracanal medication with calcium hydroxide + chlorhexidine gel (Ca[OH]2 + CHX gel) (RCS3). Polymerase chain reaction (16S rDNA) was used for detection of the target bacteria, whereas limulus amebocyte lysate was used to measure endotoxin levels. Raw 264.7 macrophages were stimulated with AAA exudates from endodontic contents sampled in different moments of root canal treatment. Enzyme-linked immunosorbent assays were used to measure the levels of TNF-α and IL-1 beta. Parvimonas micra, Porphyromonas endodontalis, Dialister pneumosintes, and Prevotella nigrescens were the most frequently detected species. Higher levels of endotoxins were found in samples from periapical exudates at RCS1 (P < .005). In fact, samples collected from periapical exudates showed a higher stimulation capacity at RCS1 (P < .05). A positive correlation was found between endotoxins from exudates with IL-1 beta (r = 0.97) and TNF-α (r = 0.88) production (P < .01). The significant reduction of endotoxins and bacterial species achieved by chemomechanical procedures (RCS2) resulted in a lower capacity of root canal contents to stimulate the cells compared with that at RCS1 (P < .05). The use of Ca(OH)2 + CHX gel as an intracanal medication (RCS3) improved the removal of endotoxins and bacteria from infected root canals (P < .05) whose contents induced a lower stimulation capacity against macrophages cells at RCS1, RCS2, and RCS3 (P < .05). AAA exudates showed higher levels of endotoxins and showed a greater capacity of macrophage stimulation than the paired root canal samples. Moreover, the use of intracanal medication improved the removal of bacteria and endotoxins from infected root canals, which may have resulted in the reduction of the inflammatory potential of the root canal content.

Inhibition Of Tumor Necrosis Factor-alpha And Cyclooxigenase-2 By Isatin: A Molecular Mechanism Of Protection Against Tnbs-induced Colitis In Rats.

Isatin, an indole alkaloid has been shown to have anti-microbial, anti-tumor and anti-inflammatory effects. Due to its findings, we evaluated whether this alkaloid would have any effect on TNBS-induced colitis. Animals (male Unib:WH rats, aged 8 weeks old) were induced colitis through a rectal administration of 2,4,6-trinitrobenzene sulphonic acid using a catheter inserted 8 cm into the rectum of the animals. The rats were divided into two major groups: non-colitic and colitic. The colitic group was sub-divided into 6 groups (10 animals per group): colitic non-treated, Isatin 3; 6; 12.5; 18.75 and 25 mg/kg. Our main results showed that the oral treatment with Isatin 6 and 25 mg/kg were capable of avoiding the increase in TNF-α, COX-2 and PGE₂ levels when compared to the colitic non-treated group. Interestingly, the same doses (6 and 25 mg/kg) were also capable of preventing the decrease in IL-10 levels comparing with the colitic non-treated group. The levels of MPO, (an indirect indicator of neutrophil presence), were also maintained lower than those of the colitic non-treated group. Isatin also prevented the decrease of SOD activity and increase of GSH-Px and GSH-Rd activity as well as the depletion of GSH levels. In conclusion, both pre-treatments (6 and 25 mg/kg) were capable of protecting the gut mucosa against the injury caused by TNBS, through the combination of antioxidant and anti-inflammatory properties, which, together, showed a protective activity of the indole alkaloid Isatin.

Development and mechanical testing of a short intramedullary nail for fixation of femoral rotational osteotomy in cerebral palsy patients

Background: Rotational osteotomy is frequently indicated to correct excessive femoral anteversion in cerebral palsy patients. Angled blade plate is the standard fixation device used when performed in the proximal femur, but extensile exposure is required for plate accommodation. The authors developed a short locked intramedullary nail to be applied percutaneously in the fixation of femoral rotational osteotomies in children with cerebral palsy and evaluated its mechanical properties. Methods: The study was divided into three stages. In the first part, a prototype was designed and made based on radiographic measurements of the femoral medullary canal of ten-year-old patients. In the second, synthetic femoral models based on rapid-prototyping of 3D reconstructed images of patients with cerebral palsy were obtained and were employed to adjust the nail prototype to the morphological changes observed in this disease. In the third, rotational osteotomies were simulated using synthetic femoral models stabilized by the nail and by the AO-ASIF fixed-angle blade plate. Mechanical testing was done comparing both devices in bending-compression and torsion. Results: The authors observed proper adaptation of the nail to normal and morphologically altered femoral models, and during the simulated osteotomies. Stiffness in bending-compression was significantly higher in the group fixed by the plate (388.97 +/- 57.25 N/mm) than in that fixed by the nail (268.26 +/- 38.51 N/mm) as torsional relative stiffness was significantly higher in the group fixed by the plate (1.07 +/- 0.36 Nm/degrees) than by the nail (0.35 +/- 0.13 Nm/degrees). Conclusions: Although the device presented adequate design and dimension to fit into the pediatric femur, mechanical tests indicated that the nail was less stable than the blade plate in bending-compression and torsion. This may be a beneficial property, and it can be attributed to the more flexible fixation found in intramedullary devices.