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Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_16 | Pages 42 - 42
1 Dec 2015
Branco P Paulo L Dias C Santos R Babulal J Moita M Marques T Martinho G Gonçalves L Mendes F
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This clinical case refers to a male patient, 45 years old, with a past medical history of Hepatitis C, admitted at the Emergency Department on July 2014, after a fall from 7 meters high at his workplace – dump – which resulted in an open fracture of the distal end of the right forearm bones – Gustillo & Anderson IIIA.

With this work, the authors aim to describe the evolution of the patient's clinical status, from the initial fracture to the septic arthritis of the right wrist, as also the surgical interventions and other treatments he has undergone.

There were used all patient's records from Hospital's archives, including Emergency Department registry, Clinical Diaries, Operative Reports, and results of diagnostic exams. It was also revised all patient's clinical process, with support of photographs obtained during the successive revaluations.

The clinical case we present on this work began on July 2014, when the patient suffered an open fracture – Gustillo & Anderson IIIA – on the distal end of the right forearm bones.

The lesion was subjected to washing, closed reduction and internal fixation with Kirschner wires, and also a cycle of antibiotic.

At the fourth day after surgery, because of an unfavorable evolution of the wound, the patient was submitted to a bulky abscess drainage and a joint osteotaxis.

About 1 month and a half after the traumatic event, it was performed a revision of the osteotaxis, following a failed attempt of osteosynthesis.

By unfavorable evolution of the clinical status, with the development of septic arthritis in the right wrist, it was decided to undertake a Masquelet technique.

Analyzing the evolution of the patient's clinical status, the authors conclude that, besides the appropriate therapeutic options taken at each stage, the development of septic arthritis at the right wrist was inevitable.

This framework, in association to the fact that this is a 45 years old patient, with the dominant hand affected, raises issues of questionable therapeutic order.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_16 | Pages 74 - 74
1 Dec 2015
Branco P Paulo L Dias C Santos R Babulal J Moita M Marques T Martinho G Tomaz L Mendes F
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The clinical case refers to a male patient, 34 years old, admitted at the Emergency Department after a fall of 2 meters. Of that trauma, resulted an exposed Monteggia fracture type III – Gustillo & Anderson IIA – on his left arm.

With this work, the authors intend to describe the evolution of the patient's clinical condition, as well as the surgical procedures he was submitted to.

The authors used the patient's records from Hospital's archives, namely from the Emergency Department, Operating Room, Infirmary and Consultation, and also the diagnostic exams performed throughout the patient's clinical evolution.

The clinical case began in December 2011, when the patient suffered a fall of 2 meters in his workplace. From the evaluation in the Emergency Department, it was concluded that the patient presented, at the left forearm, an exposed Monteggia type III fracture – Gustillo & Anderson IIA – combined with a comminuted fracture of the radial head. At the admission day, the wound site was thoroughly rinsed, the fracture was reduced and immobilized with an above-the-elbow cast, and antibiotics were initiated. Six days after admission, the patient was submitted to open reduction with internal fixation with plate and screws of the fracture of the ulna and radial head arthroplasty. The postoperative period was uneventful. Two months after the surgical procedure, inflammatory signals appeared with purulent secretion in the ulnar suture. Accordingly, the patient was submitted to fistulectomy, rinsing of the surgical site and a cycle of antibiotics with Vancomycin, directed to the S. aureus isolated from the purulent secretion. The clinical evolution was unfavorable, leading to the appearance of a metaphyseal pseudarthrosis or the ulna and dislocation of the radial head prosthesis. The previously implanted material was therefore removed, 4 months after the traumatic event; at the same time an external fixation device was applied and the first part of a Masquelet Technique was conducted. The second part of the aforementioned procedure was carried out in December 2012. The patient was discharged from the consultation after a 2 years follow-up, with a range of motion of the left elbow acceptable for his daily living activities.

In spite of the multiple surgical rinsing procedures and directed antibiotics, the development of a metaphyseal pseudarthrosis of the ulna was inevitable. This clinical case illustrates how the Masquelet Technique presents itself as a good solution for the cases of non-union of fractures in the context of infection.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_16 | Pages 39 - 39
1 Dec 2015
Branco P Paulo L Santos R Babulal J Moita M Marques T Martinho G Infante F Gonçalves L Mendes F
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This work refers to a male patient, 25 years of age, admitted in the Emergency Department following a bicycle accident, of which resulted an open fracture of the right forearm bones – Gustillo & Anderson I.

With this work, the authors have as objective the description of the patient's clinical condition – starting with the fracture, over to the osteomyelitis – as well as the surgical procedures and remaining treatments he was submitted to.

The authors used the patient's records from Hospital's archives, namely records from the Emergency Department, Operating Room, Infirmary and Consultation, and also the diagnostic exams performed throughout the patient's clinical evolution.

This clinical case began in May 2013, when the patient suffered an open fracture of the right forearm bones – Gustillo & Anderson I – due to a bicycle accident. At the time, the exposure site was thoroughly rinsed, a cast immobilization was made, and antibiotics were prescribed. In the fifth day following the trauma, the patient was submitted to an open reduction with internal fixation with plate and screws of both forearm bones. In the following period, the distal segment of the suture suffered necrosis, exposing the radial plate and the tendons of the first dorsal compartment. The Plastic Surgery team was then contacted, proposing the execution of a graft over the exposed area, which was made in August 2013. In the postoperative period, about half the graft lost its viability and it was noted that a radial pseudoarthrosis had developed – in the context of osteomyelitis – with a defect of about 9 centimeters. This condition prompted the extraction of the osteosynthesis material, about 4 months after its application, and at the same time the first stage of a Masquelet Technique was performed. The second stage of the aforementioned procedure was carried out two months later. Currently, the patient is clinically stable, with right hand mobility acceptable for his daily living activities.

Analyzing the patient's clinical evolution, we concluded that, even though the adequate therapeutic decisions have been made in each stage, the development of osteomyelitis was inevitable. This realization, in association with the patient's young age, raises debatable questions of therapeutic order.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_II | Pages 143 - 143
1 May 2011
Cordero-Ampuero J De Dios-Pérez M Bustillo-Badajoz J González-Fernández E García-Araujo C De Los Santos-Real R
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Introduction: Deep infection continues to be the first most important early complication in knee arthroplasty. It is usual to apply standard prophylaxis to all patients, but it is not usual to use special measures in those of them who present a higher risk. Moreover, sometimes these patients are even not identified.

Purpose: To analyse statistically significant risk factors for deep infection in patients with a knee arthroplasty.

Patients and Methods:

Design: Case-control study.

Observational and retrospective comparison of incidence or prevalence of all risk factors described in the literature. These factors have been classified according to the period of risk in: epidemiologic; pre, intra and postoperative; and distant infections.

Case series: 32 consecutive patients with a deeply infected knee arthroplasty operated in the same Department of a University General Hospital.

Control series: 100 randomly selected patients, operated in the same hospital and period of time, with no deep infection in their knee arthroplasty along follow-up.

Pearson was used for comparison of qualitative variables and ANOVA for quantitative ones.

Results: The following risk factors were significantly more frequent (p< 0.05) in the patients with an infected knee arthroplasty:

Preoperative conditions: previous surgery in the same knee (25% vs 9%), chronic therapy with glucocorticoids (19% vs 4%), immunosuppressive treatments (16% vs 3%), and non-rheumatoid inflammatory arthritis (13% vs 0%). Patients in this case-control did not present a significant difference in the prevalence of rheumatoid arthritis, diabetes, obesity (BMI> 30), chronic liver diseases, or alcohol addiction.

Intraoperative facts: a prolonged surgical time (149 min vs 108 min) and intraoperative fractures. Differences were not found in the amount of bleeding or need for transfusion.

Postoperative events: secretion of the wound longer than 10 days (48% vs 0%), wound haematoma (36% vs 6%), new surgery in the knee (30% vs 0%), and deep venous thrombosis in lower limbs (10% vs 1%).

Distant infections (risk for haematogenous seeding): deep cutaneous (27% vs 3%), generalized sepsis (7% vs 0%), upper and lower urinary tract (27% vs 5%), pneumonias and bronchopneumonias (27% vs 5%), and diverse abdominal focus (17% vs 1%). On the contrary, significant differences were not found in the prevalence of severe oral or dental infections.

Epidemiologic characteristics: significant differences were not found in gender or in the prevalence of any aetiology.

Conclusion: To identify significative risk factors for deep infection in knee arthroplasty is important:

to control and minimize these risk factors when present

when this is not possible not possible, to implement additional prophylactic measures.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_II | Pages 144 - 144
1 May 2011
Cordero-Ampuero J De Dios-Pérez M Martín-García R Martínez-Vélez D Noreña-González I De Los Santos-Real R
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Introduction: Deep infection continues to be the second most important early complication in hip arthroplasty. It is usual to apply standard prophylaxis to all patients, but it is not usual to use special measures in those of them who present a higher risk. Moreover, sometimes these patients are even not identified.

Purpose: To analyse statistically significant risk factors for deep infection in patients with a hip arthroplasty

Patients and Methods:

Design: Case-control study.

Observational and retrospective comparison of incidence or prevalence of all risk factors described in the literature. These factors have been classified according to the period of risk in: epidemiologic; pre, intra and postoperative; and distant infections.

Case series: 47 consecutive patients with a deeply infected hip arthroplasty operated in the same Department of a University General Hospital.

Control series: 200 randomly selected patients, operated in the same hospital and period of time, with no deep infection in their hip arthroplasty along follow-up.

Pearson was used for comparison of qualitative variables and ANOVA for quantitative ones.

Results: The following risk factors were significantly more frequent (p< 0.05) in the patients with an infected hip arthroplasty:

Epidemiologic characteristics: female gender, post-traumatic osteoarthritis (17% vs 3%). On the contrary, primary osteoarthritis is a “protective” factor.

Preoperative conditions: previous surgery in the same hip (60% vs 6%), obesity (BMI> 30) (9% vs 1%), chronic therapy with glucocorticoids (13% vs 0%), immunosuppressive treatments, chronic liver diseases (20% vs 2%), alcohol addiction (13% vs 0%) and intravenous drug abuse. Patients in this case-control did not present a significant difference in the prevalence of diabetes (a recognised risk factor for spine and knee surgery) or rheumatoid arthritis.

Intraoperative facts: a prolonged surgical time is the only significant risk factor (133 min vs 98 min), but differences were not found in the amount of bleeding, need for transfusion or intraoperative fractures.

Postoperative events: secretion of the wound longer than 10 days (46% vs 8%), palpable deep haematoma (27% vs 1%), dislocation of the prosthesis (40% vs 6%), and need for new surgery in the hip (21% vs 1%).

Distant infections (risk for haematogenous seeding): deep cutaneous (30% vs 8%), upper and lower urinary tract (36% vs 2%), pneumonias and bronchopneumonias (23% vs 5%), and diverse abdominal focus (14% vs 3%). On the contrary, significant differences were not found in the prevalence of severe oral or dental infections.

Conclusion: To identify significative risk factors for deep infection in hip arthroplasty is important:

to control and minimize these risk factors when present

when this is not possible not possible, to implement additional prophylactic measures.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_I | Pages 232 - 232
1 Mar 2010
Pincus T Santos R Vogel S
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Aim of investigation: Fear of movement (avoidance) has been implicated as an obstacle to recovery in back pain. We have argued that the concept of fear-avoidance needs clarifying, to identify sub-groups of avoiders. This study explored the patterns of activation during exposure to previously reported feared movement in patients with chronic back pain. The aim was to explore activation in areas associated with catasrophizing.

Method: 13 chronic back pain patients, who scored above a cut-point on the Tampa Scale of Kinesiophobia selected photographic images representing 5 movements they feared most and five movements they hadno concerns with carrying out. Stimuli were therefore individually selected. Two other sets of stimuli included generally threatening images, and neutral images. These four stimulus types were presented in blocks in a fMRI scanner in random order. Ratings of pain were taken after the presentation of each block.

Results: Analysis of contrasts-of-interest showed that the highly feared movements caused selective activation in areas related to preparation for action, and attentional modulation. The canonical ‘pain matrix’, and areas associated with catasrophizing was not activated.

Conclusion: The activation seen may indicate the involvement of heightened attentional processing and/or response processes (bracing and protecting) when viewing pictures of feared movements. The absence of activity in affective pain areas in the contrast analysis will be discussed in reference to theoretical developments and methodological limitations.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 486 - 486
1 Aug 2008
Pincus T Santos R Breen A Burton K Underwood M
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Objective: To improve the quality of prospective cohorts studying the transition from early stages of back pain to persistent problems, in order to allow researchers to improve the predictive quality, and pool data from multi-centre studies.

Summary of background: The progress from early stages of back pain to persistent problems is poorly understood, and only a fraction of the variance at outcome can be accounted for by current prospective cohorts. Standardization of a core set of factors would allow pooling and facilitate comparison between studies.

Method: Teams from 12 nations with expertise in clinical practice, prospective cohorts, epidemiology, social sciences, and health services were appointed.

The steering committee produced checklists of predictors and outcomes based on systematic reviews and a Delphi focus group. The international teams of experts coded each item for inclusion or exclusion, and recommended new items. This process was iterated twice to resolve disagreement between teams, and to receive scores for new items. The steering committee carried out a consensus synthesis and produced the final lists for predictors and outcome. Finally, the measurements for each factor were selected based on:

original systematic review

recommendations from existing systematic review

Recommendations from consensus statements and narrative reviews

consultation with independent experts.

Results: The checklist for predictors include information about demographics, clinical status, psychosocial status, work, and the first consultation for back pain. The recommendation for outcomes include pain, disability, return to work and sick leave, satisfaction, psychological factors, health care utilization and treatment over the follow up period.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_I | Pages 168 - 168
1 Mar 2006
Santos R Cordero-Ampuero J Pisonero E
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Objective: to measure cartilage and bone acetabular erosion in patients treated with a bipolar hip hemiarthroplasty because of a femoral neck fracture.

Material and methods:

- 34 patients, 31 female. average age 72.9 +/− 7.1 years (56–90)

- Level of activity previous to fracture: 82.4% level III, 14.6% level II

- Displaced (Garden III and IV) fracture of femoral neck excluding pathologic fractures

- Hip hemiartrhoplasty with a JRI Furlong bipolar head (22.25 mm inner head), 30 patients with a Furlong HAP-coated uncemented stem and 4 patients with an auto-blocking-type Surgival cemented stem

- Follow-up: minimum 2 years, average 2.9 years (2–5)

- Clinical evaluation: Merle-DAubigne-Postel six-point scale for pain and for function

- Radiological evaluation: measure of joint line width at superior-lateral quadrant (weight bearing area), perpendicular distance from prosthesis head to Kohler line

- Statistical analysis: Kolmogorov-Smirnov, ANOVA, Bonferroni, Pearson, and Spearman tests

Results – Pain: average score 4.5 +/− 1.3 after 1 year, 4.7 +/− 1.3 after 2 years, 4.6 +/− 1.4 after 3 years

- Function: average score 4.7 +/− 1.1 after 1 year, 4.7 +/− 1.4 after 2 years, 4.8 +/− 1.3 after 3 years

- Radiological joint line: disappeared in 13 patients (38.2%) after 1 year, in 14 (41.2%) after 2 years, in 54.5% of patients after 3 years. Average joint line width in the other patients: 0.9 mm (0.6–1.3) immediately after surgery, 0.6 mm (0.4–0.8) after 1 year, 0.5 mm (0.3–0.7) after 2 years, 0.5 mm (0.2–0.7) after 3 years (p< 0.05)

- Distance from head to Kohler line: 5.7 +/− 3.8 mm (4.6–6.8) immediately after surgery, 4.6 +/− 3.7 mm (3.6–5.6) after 1 year, 4.3 +/− 2.9 mm (3.3–5.3) after 2 years, 4.0 +/− 3.3 mm (2.5–5.5) after 3 years (p< 0.05). There were 2 cases of acetabular protrusion.

Conclusions 1. Bipolar heads in hemiarthroplasty do not avoid acetabular erosion. 2. The radiological progressive erosion does not correlate with clinical worsening of the patients.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_II | Pages 207 - 207
1 Apr 2005
Pincus T Vogel S Santos R Breen A Foster N Underwood M
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Purpose and background: Practitioners’ beliefs about their professional role, their patients and the nature of back pain can impact on clinical decisions. These attitudes are likely to affect their choice to implement guidelines, whether they engage with their patients’ psychological problems, and their decisions about referral. We aimed to develop, test and explore the underlying dimensions of a new questionnaire, ‘The Attitudes to Back Pain Scale’ (ABS), in a specific group of clinicians, practitioners who specialise in musculoskeletal therapy: chiropractors, osteopaths and physiotherapists (COPs).

Methods and Results: We used a mixed methods study design. Using transcripts of interviews with 42 practitioners, we constructed 54 attitudinal statements, grouped theoretically into six sub-headings. We tested the validity of our categorization on 14 practitioners, who carried out a sorting task, including a rating of difficulty in cat-egorising each item. We sent the draft questionnaires to a large random sample of practitioners (300 COPs). 546 questionnaires were returned (61%). Exploratory and confirmatory factor analyses were performed on split samples of the dataset. Separate exploratory analyses were done for attitudes concerned with personal interaction (34 items) and attitudes about treatment orientation (18 items), producing six domains ‘Limitations on sessions’, ‘Psychological’, ‘System and Void’, ‘Clinical Limitations’, ‘Reactivation’, and ‘Biomedical’. Confirmatory analyses indicated that the model tested presented a good fit. Validity interviews revealed high agreement of categorisation and low levels of difficulty in categorising the items.

Conclusions: A new questionnaire for measuring clinicians’ attitudes towards back pain has been developed. Further work is required to assess the impact of these factors on practitioners’ behaviour and patient outcomes.