Lógica clínica en cirugía ortopédica de la parálisis cerebral

The evolution of muscular contractures and skeletal deformities in cerebral palsy, and criteria for prevention or therapeutical decisions are analized. Developmental brain damage produces a disbalance between bone and muscular growth. Orthopaedic palliative treatments try to avoid malposition of the extremities and to compensate mechanical disbalance during the entire skeletal growth. Therapeutical options are based is on the distinction between dynamic situations and rigid ones; and also on the presence or absence of articular fixed deformities

Metal levels in corrosion of spinal implants

Corrosion affects spinal instrumentations and may cause local and systemic complications. Diagnosis of corrosion is difficult, and nowadays it is performed almost exclusively by the examination of retrieved instrumentations. We conducted this study to determine whether it is possible to detect corrosion by measuring metal levels on patients with posterior instrumented spinal fusion. Eleven asymptomatic patients, with radiological signs of corrosion of their stainless steel spinal instrumentations, were studied by performing determinations of nickel and chromium in serum and urine. Those levels were compared with the levels of 22 patients with the same kind of instrumentation but without evidence of corrosion and to a control group of 22 volunteers without any metallic implants. Statistical analysis of our results revealed that the patients with spinal implants without radiological signs of corrosion have increased levels of chromium in serum and urine (P < 0.001) compared to volunteers without implants. Corrosion significantly raised metal levels, including nickel and chromium in serum and urine when compared to patients with no radiological signs of corrosion and to volunteers without metallic implants (P < 0.001). Metal levels measured in serum have high sensibility and specificity (area under the ROC curve of 0.981). By combining the levels of nickel and chromium in serum we were able to identify all the cases of corrosion in our series of patients. The results of our study confirm that metal levels in serum and urine are useful in the diagnosis of corrosion of spinal implants and may be helpful in defining the role of corrosion in recently described clinical entities such as late operative site pain or late infection of spinal implant

Infecciones no tuberculosas del raquis

La espondilodiscitis infecciosa no tuberculosa es una entidad rara que afecta con mayor frecuencia a niños y adultos de sexo masculino. La zona con mayor incidencia es la región lumbar. Habitualmente el germen causal se propaga por vía hemática desde un foco infeccioso extrarraquídeo. El cuadro clínico comienza con una fase aguda de raquialgia segmentaria y contractura muscular paravertebral en un contexto febril. En casos especiales de niños muy pequeños o ante la presencia de dolor irradiado la forma de presentación puede ser más confusa. Hay invariablemente una rigidez vertebral en la exploración física y un aumento de la velocidad de sedimentación globular. Una fórmula leucocitaria séptica en la analítica es más inconstante. Entre el comienzo de los síntomas y la aparición de alteraciones radiológicas (disminución de altura del disco, erosión y destrucción vertebral, neoformación ósea reactiva) hay un período de latencia variable entre 2 y 8 semanas. La escintigrafía con Tc 99 y Ga 67 y la TAC tienen un gran interés de cara al diagnóstico definitivo. Para llegar al diagnóstico bacteriológico empleamos la punción-aspiración del disco. El germen aislado con mayor frecuencia es el estafilococo aureus. El diagnóstico diferencial más complejo resulta en ocasiones con espondilodiscitis tuberculosas. La evolución es favorable si el tratamiento es precoz y adecuado (antibioterapia e inmovilización). Si no es así, pueden presentarse recurrencias y cronificación de la infección, así como complicaciones de tipo ortopédico (cifosis) y/o neurológico

Eosinophilic Granuloma of the Spine With and Without Vertebra Plana: Long-term Follow-up of Six Cases (Cast Reports)

Vertebral eosinophilic granuloma is a rare condition frequently associated with vertebra plana. In this paper we present six patients with eosinophilic granuloma of the spine; three were without vertebra plana, which represents a diagnostic problem. The mean follow-up was 9 years, (range 2 to 23) and the mean age was 10.8 years at diagnosis. All complained of pain with no neurological deficit. The lesions were located on the vertebral bodies of C4, T9, T10, L1, L2, and L5, respectively. Histologic confirmation of diagnosis was obtained in all patients, two by puncture and four by open biopsy. The patients with vertebra plana (T10, L1, and L5, respectively) were treated conservatively. Long-term follow-up demonstrated total healing of the vertebral body in two and partial rebuilding 8 years after diagnosis in one. Patients without vertebra plana (C4, T9, and L2, respectively) underwent curettage and bone grafting. In the patient with T9 location, a T8-10 anterior arthrodesis with autogenous rib graft was performed. The outcome was satisfactory in all

Lumbosacral arthrodesis using pedicular screws and ringed rods

Sixty-one patients who had lumbar instability and chronic low back pain or deformity from nontraumatic lumbar pathologies were studied. In all of them a posterior lumbosacral fusion with CUN (Clinic of the University of Navarre) pedicle rod fixation was used. The mean follow-up period was 36 months (range 26-46 months). The consolidation rate was evaluated according to plain and functional radiographs, and a clinical evaluation was made using an analogue pain scale. The rate of fusion was 93.5%. Neurological complications occurred in 3.3%. The incidence of screw failure was 2.3% of all the screws. No other implant failure occurred. The patients rated their clinical results as 'excellent' in 33.8% of the cases, 'good' in 42.2%, 'fair' in 16.9% and 'poor' in 6.7%. CUN instrumentation is a versatile internal fixation system that has been shown to provide satisfactory stability. Furthermore, the clinical results are comparable to those reported in studies in which the most common hardwares were used

Sinostosis congénitas del tarso: concepto, clasificación, diagnóstico y planteamiento terapéutico

incidencia de las sinostosis congénitas del tarso se estima en torno al 1% de la población, siendo una de las causas más comunes de pie plano rígido doloroso en la población pediátrica. La barra calcáneoescafoidea (50%) y el puente astragalocalcá¬neo (40%) son las formas de presentación más frecuentes. La restricción de la movilidad, el dolor mecánico en el lugar de la fusión y la deformidad del calzado referida en la anamnesis deben hacernos sospechar esta entidad. En la exploración física destaca la rigidez del retropié con limitación dolorosa característica de la pronosupinación que ha motivado clásicamente la errónea denominación de pie plano peroneo espástico. El diagnóstico radiológico se hace normalmente con radiografías simples (proyecciones laterales y oblicuas entre 35 y 45º), en las que observamos el osteofito anterior de la cabeza del astrágalo o la imagen de condensación en "media luna" del astrágalo superpuesto con el calcáneo, siendo necesario en ocasiones recurrir al TAC. Entre las posibilidades terapéuticas, el tratamiento quirúr¬gico es el único resolutivo del problema de base. La resección-artroplastia de interposición debe intentarse en pacientes jóvenes en los que se quiera preservar la biomecánica normal del pie, evitándose los problemas a largo plazo de la artrodesis. La triple artrodesis o la artrodesis subastragalina, se reservan para pacientes mayores con signos degenerativos, en casos de fusio¬nes tarsianas múltiples y tras fracaso de la resección¬-artroplasti

Scoliosis induced by medullary damage: an experimental study in rabbits

To date, there have been no reports of experiments designed to induce scoliosis by direct damage of different areas of the spinal cord. In a series of rabbits with medullary damage, the authors attempted selectively to interrupt the pathways that mediate proprioceptive input. Unilateral lesion of the dorsal column and posterior horn of the spinal cord was performed using three different techniques: coagulation with laser, stereotaxic microcoagulation, and longitudinal electrocoagulation. Of 32 operated rabbits, 17 developed scoliosis, exhibiting clear pathologic damage of the spinal cord. Electrophysiologic study, including EMG and analysis of the tonic -- vibratory reflex, was performed on 10 rabbits with medullary damage (scoliotic and non-scoliotic) and 12 matched controls. The data suggest disturbance of the sensory afferences that control the postural tone and consequent muscular imbalance, expressed as reduced activity in the muscles of the convex side. This work supports the view that loss of proprioceptive neural impulses caused by medullary damage can induce scoliosi

Valoración radiológica del pie zambo congénito idiopático y su correlación clínica en la operación de Codivilla

Thirty-seven patients (52 idiopathic clubfeet) were treated with Codivilla's technique between 1971 and 1985. Radiological measurements and clinical evaluation before and after surgery were performed; a correlation was carried out between these evaluations and personal satisfaction. The results were rated as follows: poor in 4 feet (7.7%), fair in 18 feet (34.6%), good in 24 feet (46.2%) and excellent in 6 feet (11.5%) with a total percentage of satisfactory results amounting to 57.7%. Our conclusion is that when the indications are properly established, Codivilla's technique is a good procedure to correct clubfoot