Evaluación de la evidencia del tratamiento de las lesiones del ligamento cruzado anterior de la rodilla

Introducción: El aumento de la accidentalidad deportiva y viaria ha dado origen a un incremento de las lesiones de rodilla y en particular del ligamento cruzado anterior. La presencia de inestabilidades residuales, los cambios degenerativos de la articulación y las lesiones secundarias, han sido invocadas como razones para justificar una actitud intervencionista. No obstante, la incompleta consecución de los objetivos propuestos ha llevado a que la opción conservadora se siga manteniendo vigente. Objetivos: Analizar la evidencia científica existente en el cuerpo bibliográfico que aborda el tratamiento de las lesiones del LCA de la rodilla. Establecer si se cumplen las motivaciones que inducen la elección del tratamiento, en sus posibilidades quirúrgica o conservadora. Concluir una guía de recomendaciones a la hora de enfocar el tratamiento de estas lesiones. Material y Métodos: Se analiza la evidencia científica existente en la literatura encontrada sobre este tema. Se plantea la realización de un metaanálisis con los resultados aportados por otros autores en estudios seleccionados. Éstos deberán responder a unos criterios de estudios comparativos entre tratamiento quirúrgico y conservador con exigencias de ser estudios prospectivos y aleatorizados, con un seguimiento mínimo de siete años y que tuvieran en cuenta análisis de resultados en los que se incluyeran criterios objetivos, así como consideración de la evaluación subjetiva en cuanto a la satisfacción del enfermo. Resultados: No se ha encontrado ningún estudio que se ajustara exactamente a la propuesta realizada. Si que se han hallado dos trabajos secuenciales, de una evolución más corta de la exigida y en el que la comparación se hacía entre tres tratamientos de las lesiones del ligamento cruzado anterior, si bien ninguno de ellos era una opción totalmente conservadora y además empleaban unas técnicas de reconstrucción que en la actualidad tienen muy pocos seguidores dentro de los que defienden la opción quirúrgica, como es la sutura primaria del ligamento cruzado anterior deteriorado. Conclusiones: La opción que deja menos inestabilidad residual es la realización de sutura directa del LCA acompañada de plastia de apoyo periférica. No obstante, no se encuentra un resultado final con rodillas totalmente estables. También son independientes del tratamiento recibido la reincorporación a actividades deportivas previas, así como la aparición de lesiones estructurales secundarias en la rodilla. Debido a la falta de cumplimentación de las exigencias de evaluación y a la falta de adecuación de las técnicas analizadas, no se puede concluir una guía de recomendación.Introduction. The increase in the sport activities and the traffic accidentability has raised an increase of the injuries of the knee and more precisely of the anterior cruciate ligament. The residual instability, the degenerative changes in the joint and the secondary lesions have been invocated as reasons to justify a surgical approach. But, the incomplete consecution of the aims of this treatment has provoked that the conservative option is still in use. Aims: To analyze the scientific evidence in the bibliography for the treatment of the lesions of the knee ACL, to establish if the aims of the treatment are observed in the conservative and surgical options and to conclude with a recommended guide to face these injuries. Material and methods: It is analized the scientific evidence in the reviewed literature in this topic. It is projected a metanalysis with the integrated bibliography for the selected papers. This should assure the criteria of being comparative between the conservative and surgical treatment and should be prospective and randomized, with a minimum follow-up of seven years and taking into account an analysis of the results with objective criteria, as well as an evaluation of the subjective satisfaction of the patient. Results: No papers have been found that properly fit for the exigencies of the design. Two sequential papers have been selected with a shorter follow-up and with a comparison between three different treatments, none of them being a complete conservative treatment. The proposed surgical technique, the suture of the disrupted ACL, is not any more among the preferred by the surgeons. Conclusions: The option with less residual instability is the direct suture with a peripheral plastia. But, they do not provide an absolute stable knee. The reincorporations to the sport activities, as well as the secondary structural lesions are independent to the treatment. Because of the lack of complementation of the exigencies of the evaluation and the lack of adequacy of the proposed surgical techniques, it is not possible to recommend a practical guide

Displasia glenoidea bilateral dolorosa asociada a inestabilidad

La hipoplasia glenoidea es una alteración relativamente infrecuente, de la que han sido descritos menos de 100 casos. Se comunica un caso de una enferma de 17 años de edad con clínica de dolor e inestabilidad en ambos hombros y hallazgo de displasia bilateral de cavidad glenoidea. Se realizó tratamiento conservador mediante pauta de refuerzo muscular con bandas elásticas de resistencia creciente con un resultado excelente calificado según puntuación de tabla de Rowe y cols. Desapareciendo la sensación de inestabilidad y habiendo cedido la clínica álgica.The glenoid hypoplasia is an uncommon condition. Less than 100 cases have been reported. We present the case of a 17 year old girl complaining of pain and instability in both shoulders and radiological findings of bilateral dysplasia of the glenoid. A non-operative treatment has been followed with an exercise program to strengthen the shoulder. This has been achieved with a progressive resistance rubber bands program. The final result has been excellent according to the appraisal table by Rowe et al., disappearing the instability sensation as well as the pain

Fractura bipolar de clavícula

Se presenta un caso de fractura que afecta a ambos extremos de la clavícula. Fractura tipo II de Neer del fragmento distal y fractura del extremo esternal de la clavícula. Se realizó tratamiento quirúrgico mediante reducción abierta y osteosíntesis con agujas de Kirschner en ambas. El resultado a largo plazo ha sido satisfactorio cosmética y funcionalmente.A case of bipolar fracture affecting both ends of the clavicle is reported. The lesion consisted of a Neer type II fracture at the distal segment and a fracture close to the proximal joint with the sternum. Surgical treatment was carried out by open reduction and Kirschner wire fixation stabilizing both sides. At follow up, clinical and cosmetic results are satisfactories

Resultados del tratamiento quirúrgico del dolor lumbar con instrumentación diapasón

Se presenta un estudio sobre 23 pacientes con patología lumbosacra tratados quirúrgicamente mediante artrodesis e instrumentación vertebral transpedicular tipo diapasón. El promedio de seguimiento ha sido de 25 meses (18-38). El dolor lumbar estaba relacionado en 10 casos con estenosis de canal, en 6 con espondilolistesis y en 7 con hernia discal y artrosis secundaria. Todos fueron instrumentados por vía posterior mediante fijación transpedicular y artrodesados posterolateralmente con injerto autólogo. Se consiguió una artrodesis sólida en un 96%. No se han presentado complicaciones preoperatorias. Ocho pacientes presentaron complicaciones en el postoperatorio inmediato. Observamos un desplazamiento de barra y un desanclaje del tornillo fuera del pedículo. Siguiendo los criterios de valoración de Henderson se ha conseguido un 96% de excelentes y buenos resultados.A series of 23 patient with lumbosacral pathology, surgically treated by posterior arthrodesis and vertebral diapason transpedicular fixation was retrospectively review. The average follow-up period was 25 months (18-38). The diagnosis was spinal stenosis in 10 cases, spondylolisthesis in 6, and disc herniation with secondary osteoartrhitis in 7 cases. Apart from transpedicular fixation all cases underwent posterolateral fusion with autogenous bone graft. A solid arthrodesis was achieved in a 96% of patients. There were no per-operative complication. Eight cases showed complications in the immediate postoperative period. We observed displacement of a bar and detachement of a screw out off the pedicle. According to Henderson's assessment criteria we obtained 96% of excellent and good results

Protein markers of Bursaphelenchus xylophilus Steiner & Buhrer, 1934 (Nickle, 1970) populations using quantitative proteomics and character compatibility

The Pine Wood Nematode (PWN) Bursaphelenchus xylophilus is a severe forest pathogen in countries where it has been introduced and is considered a worldwide quarantine organism. In this study, protein markers for differentiating populations of this nematode were identified by studying differences among four selected Iberian and one American population. These populations were compared by quantitative proteomics (iTRAQ). From a total of 2860 proteins identified using the public database from the B. xylophilus genome project, 216 were unambiguous and significantly differentially regulated in the studied populations. Comparisons of their pairwise ratio were statistically treated and supported in order to convert them into discrete character states, suggesting that 141 proteins were not informative as population specific markers. Application of the Character Compatibility methodology on the remaining 75 proteins (belonging to families with different biological functions) excludes 27 which are incompatible among them. Considering only the compatible proteins, the method selects a subset of 30 specific unique protein markers which allowed the compared classification of the Iberian isolates. This approach makes it easier search for diagnostic tools and phylogenetic inference within species and populations of a pathogen exhibiting a high level of genetic diversity.This work has been funded by the CSIC (PI:201130E033), and the EU project REPHRAME FP7‐KBBE‐2010‐4.Peer Reviewe

Conventional drainage versus four hour clamping drainage after total knee arthroplasty in severe osteoarthritis: a prospective, randomised trial

Total knee replacement in severe osteoarthritis usually requires extensive soft tissue releases often associated with considerable bleeding. In a prospective, randomised trial we compared postoperative conventional suction drainage versus four hour clamping drainage in 60 patients undergoing total knee arthroplasty for severe osteoarthritis. We compared blood loss, number of transfusions, postoperative complications and knee function and found significantly less postoperative blood loss through the drains (p < 0.001), and fewer blood transfusions (p = 0.09) were needed in the clamped group. We conclude that clamping drainage after total knee arthroplasty in severe osteoarthritis reduces blood loss through the drains and the need for blood transfusions