Classification of intervertebral disc degeneration by magnetic resonance

The authors suggest an analysis of the degeneration of intervertebral disks on human cadavers using magnetic resonance imaging. Nine lumbar spines were collected from fresh human cadavers and resonance images were captured. The images were analyzed and classified according to the degeneration grades, with the authors proposing a subdivision of type IV into IV-a and IV-b. Forty-four intervertebral disks were analyzed and authors found the following distribution: 4,5% type I; 40,9% type II; 32% type III and 18% type IV-a. However, the investigators disagreed with the conclusions in 4,5% of the disks. The authors found that the progressive signal lost in the T2-weighted images may be correlated to disk degeneration. Changes found in the magnetic resonance images must be standardized and classified for providing a better understanding.Os autores propõem uma análise da degeneração dos discos intervertebrais de cadáveres através de exame de ressonância magnética. Foram coletadas nove peças de coluna lombar de cadáveres frescos as quais foram submetidas a exame de ressonância magnética. As imagens foram analisadas e classificadas de acordo com o grau de degeneração sendo proposta uma subdivisão no tipo IV em IV-a e IV -b. A análise de 44 discos intervertebrais encontrou uma distribuição de 4,5% do tipo I, 40,9% do tipo II, 32% do tipo III e 18% do tipo IV-a. Houve 4,5% em que não houve concenso entre os examinadores. Os autores concluíram que a perda do sinal do disco nas imagens ponderadas em T2 pode ser correlacionada com a progressiva degeneração do disco. A correlação das alterações encontradas nas imagens produzidas pela ressonância magnética devem ser padronizadas e classificadas para sua melhor compreensão.Universidade Federal de São Paulo (UNIFESP) Departamento de Ortopedia e TraumatologiaUniversidade Federal de São Paulo (UNIFESP) Departamento de Diagnóstico por ImagemUNIFESP, Depto. de Ortopedia e TraumatologiaUNIFESP, Depto. de Diagnóstico por ImagemSciEL

Profilaxia primária e secundária de fraturas osteoporóticas: avaliação de uma coorte prospectiva

ResumoObjetivoMedir a prevalência da profilaxia medicamentosa primária de fraturas por osteoporose em pacientes internados em um hospital terciário de ensino, em uma cidade de médio porte, admitidos com fraturas osteoporóticas. Além disso, identificar a incidência de prescrição de profilaxia medicamentosa secundária após o evento da primeira fratura. Paralelamente, medimos a prevalência de fatores de risco para fratura por osteoporose descritos na literatura.MétodoEstudo longitudinal de uma coorte prospectiva de pacientes admitidos em hospital terciário de ensino de outubro de 2015 a janeiro 2016. Foram incluídos pacientes com fraturas de baixa energia ou por fragilidade, independentemente do gênero ou etnia, acima de 50 anos. Todos os pacientes que não apresentavam essas características foram excluídos. O seguimento foi de quatro meses. Foram aplicados questionários seriados na admissão, no retorno com quatro a oito semanas e com 16 semanas.ResultadoSomente um paciente referiu ter recebido tratamento com drogas específicas para a doença antes da internação hospitalar, o que revela uma prevalência de quimioprofilaxia primária de apenas 2,27%. Nenhum paciente recebeu prescrição para tratamento da osteoporose após a fratura. A prevalência dos fatores de risco de fratura se assemelha àquela encontrada na literatura.ConclusãoA frequência de quimioprofilaxia primária e secundária da osteoporose em pacientes admitidos com fraturas por fragilidade é baixa em nosso meio, assim como a indicação precoce de tratamento medicamentoso após a primeira fratura. A prevalência dos fatores de risco de fratura por fragilidade é semelhante àquela citada na literatura.AbstractObjectiveTo measure the prevalence of primary drug prevention of osteoporosis fracture in patients admitted to a tertiary teaching hospital, in a medium‐sized city, admitted with osteoporotic fractures. Moreover, to identify the incidence of prescribing secondary prophylaxis after the first fracture event. At the same time, the prevalence of risk factors for such fractures as described in the literature was measured.MethodsThis longitudinal prospective study was based on a cohort of patients admitted in a tertiary teaching hospital from October 2015 to January 2016. Patients with low energy or fragility fractures, regardless of gender or race, over the age of 50 years, were included in the study. All patients who did not have these characteristics were excluded. The follow‐up lasted four months. Serial questionnaires were applied at admission and in the follow‐up consultations at four to eight weeks and at 16 weeks.ResultsOnly one patient reported receiving treatment with specific drugs for the disease before the hospital admission, resulting in a prevalence of primary chemoprophylaxis of only 2.27%. No patient was prescribed medication for the treatment of osteoporosis after the fracture. The prevalence of risk factors was similar to those found in the literature review.ConclusionIn the present study, the frequency of primary and secondary osteoporosis chemoprophylaxis in patients who were admitted with fragility fractures was low, revealing the need to develop specific strategies to address this issue. The prevalence of fragility fracture risk factors are similar to those reported in the literature

Three-Dimensional Digital Surgical Planning and Rapid Prototyped Surgical Guides in Bernese Periacetabular Osteotomy

Bernese periacetabular osteotomy (PAO) developed by Ganz is currently the treatment of choice for skeletally mature symptomatic patients with developmental dysplasia of the hip (DDH) without osteoarthritis. However, the steep learning curve and considerable number of severe complications lead surgeons to seek for alternatives to promote greater reproducibility and safety of this procedure. This is a report of a DDH case surgically treated with the aid of a digital three-dimensional (3D) planning and rapidly prototyped sterile ABS plastic osteotomy guide, developed in Brazil. We present details regarding the planning, guide production, and surgical technique and report the early results of this treatment approach in a single patient. Digital 3D planning and rapidly prototyped surgical guides are applicable and helpful in PAO surgery as shown in this case. We noted no safety issues, good accuracy, and low production costs with this approach

Espondilite tuberculosa em paciente com doença de Crohn em uso de terapia imunossupressora: relato de caso

Introduction: Infection with Mycobacterium tuberculosis (Mt) is one of the ten main causes of mortality in the world. Only 0.5% of tuberculosis (TB) cases are in the spine, leading to neurological disorders, mechanical instability and deformities. The use of immunosuppressive drugs to treat inflammatory diseases such as Crohn's disease (CD) can make the patient susceptible to this opportunistic infection. Objective: Report the case of a patient with tuberculous spondylitis undergoing treatment for CD with immunosuppressive therapy. We describe its clinical-surgical treatment and evolution comparing it with the current literature. Case Report: A 51-year-old woman, diagnosed with CD in continuous use of azathioprine, was admitted to our hospital for worsening middle back pain, difficulty in walking and weight loss without neurological repercussions. Magnetic Resonance (MRI) and Computerized Tomography (CT) of the dorsal column showed patterns suggestive of tuberculous spondylitis. Because of the disease´s evolution without pain relief and associated with vertebral instability with imminent risk of fracture and neurological damage, surgery was indicated for vertebral stabilization, decompression of neural elements and removal of material for histopathological study. The result confirmed the presence of Mt in the sample. The patient was hospitalized for 28 days with antibiotic treatment, showing good evolution, with progressive improvement in pain and walking. During his entire hospital stay, his CD condition was kept under control. Conclusion: It is important to consider tuberculous spondylitis as a differential diagnosis in patients with back pain and alarm signs, especially in the presence of immunosuppressive treatment, even with negative PPD.Introdução: A infecção pelo Mycobacterium tuberculosis (Mt) é uma das dez principais causas de mortalidade no mundo. Apenas 0,5% dos casos de tuberculose (TB) se localizam na coluna, podendo ocorrer disfunções neurológicas, instabilidade mecânica e deformidades. O uso de drogas imunossupressoras para tratamento das doenças inflamatórias, como a doença de Crohn (DC), pode tornar o paciente suscetível a esta infecção oportunista. Objetivo: Relatar o caso de uma paciente com espondilite tuberculosa na vigência do tratamento de DC com terapia imunossupressora. Descrevemos seu tratamento clínico-cirúrgico, sua evolução e comparamos com a literatura vigente. Relato de Caso: Mulher, 51 anos, com diagnóstico de DC em uso contínuo de azatioprina iniciou quadro de dorsalgia, dificuldade de deambulação e perda ponderal sem repercussões neurológicas. Ressonância magnética (RM) e Tomografia Computadorizada (TC) de coluna dorsal apresentaram padrões sugestivos de espondilite tuberculosa. Em decorrência da evolução sem alívio da dor e com instabilidade vertebral iminente sob risco de fratura e lesão neurológica, foi indicada cirurgia para estabilização vertebral, descompressão de elementos neurais e coleta de material para estudo histopatológico. O resultado comprovou a presença de Mt na amostra. Paciente manteve internação por 28 dias com tratamento antibiótico, apresentando boa evolução, com melhora progressiva do quadro álgico e da deambulação. Durante toda a internação seu quadro de DC se manteve controlado. Conclusão: É importante considerar a espondilite tuberculosa como diagnóstico diferencial em pacientes com dorsalgia e sinais de alarme, especialmente, em vigência de tratamento imunossupressor, mesmo com PPD negativo

Economic analysis of surgical treatment of hip fracture in older adults

OBJECTIVE To analyze the incremental cost-utility ratio for the surgical treatment of hip fracture in older patients.METHODS This was a retrospective cohort study of a systematic sample of patients who underwent surgery for hip fracture at a central hospital of a macro-region in the state of Minas Gerais, Southeastern Brazil between January 1, 2009 and December 31, 2011. A decision tree creation was analyzed considering the direct medical costs. The study followed the healthcare provider&#8217;s perspective and had a one-year time horizon. Effectiveness was measured by the time elapsed between trauma and surgery after dividing the patients into early and late surgery groups. The utility was obtained in a cross-sectional and indirect manner using the EuroQOL 5 Dimensions generic questionnaire transformed into cardinal numbers using the national regulations established by the Center for the Development and Regional Planning of the State of Minas Gerais. The sample included 110 patients, 27 of whom were allocated in the early surgery group and 83 in the late surgery group. The groups were stratified by age, gender, type of fracture, type of surgery, and anesthetic risk.RESULTS The direct medical cost presented a statistically significant increase among patients in the late surgery group (p < 0.005), mainly because of ward costs (p < 0.001). In-hospital mortality was higher in the late surgery group (7.4% versus 16.9%). The decision tree demonstrated the dominance of the early surgery strategy over the late surgery strategy: R$9,854.34 (USD4,387.17) versus R$26,754.56 (USD11,911.03) per quality-adjusted life year. The sensitivity test with extreme values proved the robustness of the results.CONCLUSIONS After controlling for confounding variables, the strategy of early surgery for hip fracture in the older adults was proven to be dominant, because it presented a lower cost and better results than late surgery

Artroplastias de quadril no Sistema Único de Saúde: análise dos dados brasileiros de 2008 a 2015

Objective: To evaluate the incidence, spatial distribution and the factors that influence the numbers of hip arthroplasties in the Unified Health System in Brazil(SUS), especially total hip arthroplasties (THA). Methods: An level III analytical ecological study of the time series and the spatial distribution of the cases of hip arthroplasties performed in SUS between 2008 and 2015, using of data obtained from the DATASUS platform. Results: 166,365 hip arthroplasties were performed, of which 94,737 (56,9%) were primary THA. The total cost of the former was of BRL636,332,731.90 for SUS and there was an increase in the number of surgeries performed, especially from 2012. The annual average of primary THA was 11,842.1 surgeries/year (sd= 868.3 surgeries/year), at an average cost of BRL45,473,445.65/year (sd= BRL8,269,970.10/year).In 2012 the uncemented and hybrid arthroplasties became the most common. The distribution in the Brazilian states is heterogeneous and the factors positively associated were the % of citizens aging above 50 (p=0,000175) and the % of cities with high or very high HDI in each State (p=0,037). Conclusion: The incidence of primary THA in the SUS increased between 2008 and 2015. Its spatial distribution was greater on States with bigger proportions of people aging above 50 years and more cities with HDI rated as high or very high. The incidence of cemented primary THA was overcome by the uncemented and hybrid in 2012.Objetivo: Analisar a incidência, distribuição espacial e os fatores que influenciam a realização de artroplastias de quadril no SUS, especialmente artroplastias totais (ATQs). Material e Método: Estudo ecológico analítico nível III, analisou uma série temporal e a distribuição espacial dos casos de artroplastias de quadril realizadas no SUS entre 2008 e 2015, através de dados obtidos da plataforma DATASUS. Resultados: Foram realizadas 166.365 artroplastias de quadril, sendo 94.737 (56,9%) ATQs primárias. O custo total foi R$636.332.731,90. Houve aumento no número de cirurgias realizadas, em especial após 2012. A média anual de ATQ primárias foi 11.842,1 cirurgias/ano (dp=868,3 cirurgias/ano), a um custo médio de R$45.473.445,65/ano (dp=R$8.269.970,1/ano). Em 2012 as não-cimentadas e híbridas se tornaram as mais comuns. A distribuição das frequencias nos estados brasileiros é heterogênea e os fatores associados foram proporção de indivíduos com mais de 50 anos de idade (p=0,000175) e proporção de municípios com IDH alto ou muito alto (p=0,037). Conclusão: A incidência de ATQs no SUS aumentou no período de 2008 a 2015. Sua distribuição foi maior nos Estados com maior proporção de indivíduos &gt;50 anos e com maior proporção de municípios com IDH alto ou muito alto. A incidência de ATQs primárias cimentadas foi superada pelas não cimentadas e híbridas em 2012

Mixed-type femoroacetabular impingement associated with subspine impingement: recognizing the trifocal femoropelvic impingement

To describe the arthroscopic surgical technique for subspine impingement (SSI) of the anterior inferior iliac spine (AIIS) associated with mixed type femoroacetabular impingement (FAI), through two standard arthroscopic portals (anterolateral and distal mid-anterior) in two patients with trifocal impingement. The authors report the cases of two young male patients, aged 32 and 36 years old, with trifocal femoropelvic impingement (TFPI). The technique consists of segmental capsulectomy, arthroscopic dissection of the AIIS, partial release of the direct head of the rectus femoris, resection of the AIIS projection with a burr and with fluoroscopic aid, correction of the pincer deformity, repair of the labrum with bioabsorbable anchors, and femoral osteoplasty. Details of the diagnostic workup and of the surgical technique are provided and discussed. In these cases, full range of motion was regained after surgery, as well as complete relief of pain, which was sustained in the last follow-up, one year post-operatively. Radiographs show adequate correction of the deformities in all three impingement sites. Simultaneous correction of the three sites (cam, pincer, and subspinal) provided full relief of symptoms and allowed return to work and sports. The authors propose that when approaching the symptomatic SSI, the possibility of concomitant FAI should always be considered and, in those cases, the approach must be comprehensive.