André Rodrigues Pinho

Purpose: Pelvic ring fractures involving the iliopubic rami can cause functional impairment. Percutaneous retrograde fixation is a less invasive procedure when compared to traditional open approaches, however precise anatomical knowledge is crucial for safe screw placement. This study aims to describe the morphology of the iliopubic rami, define a safety corridor for percutaneous screw fixation, specially focusing on the relationships between the iliopubic rami and neurovascular structures. Methods: A retrospective cross-sectional study was conducted on 29 patients using high-resolution computed tomography scans. Measurements included rami shape, narrowest diameter, and distances between the iliopubic rami and neurovascular structures. Statistical comparisons were performed using the Wilcoxon, Mann-Whitney, and Kruskal-Wallis tests. Results: Triangular and trapezoidal rami shapes were most common being the median narrowest diameter larger in males (8.67 mm) than females (6.83 mm) ( p = 0.011). The obturator neurovascular bundle was approximately 3 mm from the iliopubic rami, while the external iliac vein and artery were about 5 mm and 11 mm away, respectively. Women also had a greater external iliac vein proximity to the iliopubic rami on the left, compared to men ( p = 0.032). Conclusion: Therefore, preoperative imaging is essential to reduce neurovascular risks and given anatomical variations, screw selection should be sex-specific, with 6.5 mm screws for males and 4.5 mm for females. The polygonal rami shapes allow the use of straight plates. The obturator neurovascular bundle is highly vulnerable during screw placement as so it is the external iliac vein compared to the homonym artery, especially in women.

Resumen: La fractura del cuello del quinto metacarpiano es una lesión frecuente cuyo tratamiento sigue siendo objeto de debate. Suele presentarse en adultos jóvenes en edad laboral y representa una carga importante tanto para los servicios sanitarios como para el paciente. El objetivo de este estudio era comparar los resultados del tratamiento quirúrgico y conservador de esta fractura.Se realizó un estudio retrospectivo de 60 pacientes con fractura del cuello del quinto metacarpiano. La muestra se dividió en dos grupos, pacientes tratados quirúrgicamente y no quirúrgicamente. La angulación media en los distintos grupos se comparó mediante la prueba t y la varianza conseguida mediante manipulación o cirugía se comparó mediante la prueba t emparejada. Se aplicó el cuestionario QuickDash.La angulación media inicial del ápex dorsal fue de 53° en el grupo quirúrgico y de 45° en el grupo conservador. La angulación media al alta fue de 28° en el grupo quirúrgico y de 38° en el grupo conservador. Los resultados del cuestionario QuickDASH fueron similares entre los grupos, y los pacientes tratados quirúrgicamente refirieron más dolor y menos satisfacción estética.Este estudio corrobora la creciente evidencia a favor de ampliar el tratamiento conservador a la mayoría de estas fracturas.

Differences in lumbar morphology and nerve root positioning between supine and prone decubitus are poorly analyzed. This study aimed to perform a magnetic resonance imaging (MRI) study to describe lumbar morphology, nerve root, and related structures positioning in the prone position, while comparing with conventional supine MRI, in patients with lumbar symptoms. The second aim was to define safe working zones for lumbar surgical procedures. This study was a prospective, single-center, observational study. Fifty patients with persistent low back and/or radicular pain that was unresponsive to conservative treatment were consecutively selected. Supine and prone 3 Tesla MRIs were performed. Two independent researchers performed an imaging analysis of predefined variables. Lumbar lordosis significantly changed from 49.3° in the supine position to 52.1° in the prone position (P = 0.005), without a statistically significant difference in lower lumbar lordosis. No consistent changes were found regarding foraminal height, root-to-pedicle or root-to-superior articular process distances. The exiting nerve root was found between 42% and 49% of the foraminal height (as measured from the upper border of the lower pedicle). The left retroperitoneal lateral corridor showed no significant size variation from the supine to the prone position (P = 0.196 and P = 0.600, for L3-L4 and L4-L5 levels, respectively). This study suggests prone positioning may increase global lumbar lordosis, without changing the position of other major anatomical structures. The exiting nerve root positioning can be estimated in relation to foraminal height. These finding may help optimizing planning and minimizing iatrogenic lesions.

Case: A 19-year-old man with Multiple Hereditary Exostoses presented with cervical pain without neurological symptoms and/or signs. Magnetic resonance revealed a large C2 osteochondroma, occupying a part of the medullary canal. He was submitted to an en bloc resection with hemilaminectomy without fusion. At the 1-year follow-up, he presented resolution of pain and no neurological symptoms or signs, without cervical instability or radiological signs of disease recurrence. Conclusion: Cervical osteochondroma is usually asymptomatic. Neurological compression and differentiation to chondrosarcoma are the main concerns. Surgical excision allows the local cure of the disease and is usually performed without fusion.

Case: We present a case of azole and partial caspofungin-resistant Candida albicans spondylodiscitis, after bariatric surgery with bowel perforation. Treatment included debridement and several months of anidulafungin, complemented with antibacterial therapy because of relapse for bacterial superinfection. After treatment, the infection did not recur clinically or radiologically during one and half years follow-up. Conclusion: Although C. albicans spondylodiscitis is rare, fungi should be suspected as a causative agent. Adequate history, imaging and laboratory testing, and medical and surgical treatment should be performed to successfully eradicate the infection and resolve potential neurological deficits.