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Factores pronósticos del fenómeno de crankshaft en los pacientes con escoliosis y cartílago trirradiado abierto. ¿Es el doble abordaje la solución?
Prognostic factors of the crankshaft phenomenon in patients with scoliosis and open triradiate cartilage. Is the double approach the solution?
J. Pizones
Autor para correspondencia
javierpizones@gmail.com

Autor para correspondencia.
, P. Álvarez-González, F. Sánchez-Mariscal, L. Zúñiga, E. Izquierdo
Unidad de Columna, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario de Getafe, Getafe, Madrid, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Dubousset<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> acu&#241;&#243; el t&#233;rmino &#171;fen&#243;meno del cig&#252;e&#241;al&#187; o <span class="elsevierStyleItalic">&#171;crankshaft phenomenon&#187;</span> &#40;CP&#41; para describir la progresi&#243;n de la escoliosis tras haber conseguido una artrodesis posterior s&#243;lida en pacientes inmaduros&#46; Este fen&#243;meno se produce por el continuo crecimiento vertebral anterior en presencia de una fusi&#243;n posterior que act&#250;a como tirante&#44; forzando la columna vertebral a una progresiva lordoescoliosis con rotaci&#243;n en direcci&#243;n de la deformidad original<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Distintos autores han estudiado la progresi&#243;n postoperatoria de las curvas fusionadas&#44; tanto en escoliosis idiop&#225;tica<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;13</span></a>&#44; como cong&#233;nita<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;14&#8211;16</span></a>&#46; Sin embargo&#44; solo unos pocos estudios han analizado los pacientes inmaduros con cart&#237;lago trirradiado &#40;CTR&#41; a&#250;n abierto<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#44;6&#44;8&#44;10&#44;11&#44;14</span></a>&#46; Estos &#250;ltimos han hallado tasas de CP tras artrodesis posterior instrumentada de entre el 15 y 75&#37;&#46; Para evitar el desarrollo de este fen&#243;meno&#44; algunos autores recomiendan realizar una fusi&#243;n apical anterior adicional<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#8211;10&#44;13&#44;15&#44;17&#8211;19</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A pesar de lo publicado&#44; estos estudios no cuentan con un gran n&#250;mero de pacientes&#44; y no son homog&#233;neos en cuanto al abordaje quir&#250;rgico&#44; tipo de instrumental utilizado&#44; definici&#243;n de la progresi&#243;n&#44; estado de madurez de los pacientes o etiolog&#237;a de las curvas&#46; Por eso&#44; sigue existiendo una gran controversia con respecto a la prevalencia del CP&#44; los factores de riesgo&#44; y c&#243;mo evitarlo con &#233;xito durante el tratamiento&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo de este estudio es investigar los factores de riesgo asociados con el desarrollo del CP en los pacientes inmaduros operados de escoliosis con CTR abierto&#44; y evaluar si este fen&#243;meno puede ser evitado mediante una fusi&#243;n apical anterior&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material y m&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se revisaron las historias cl&#237;nicas de 26 pacientes esquel&#233;ticamente inmaduros&#44; operados de escoliosis progresiva por un mismo cirujano&#44; en un solo centro hospitalario&#46; El trabajo ha seguido las normas &#233;ticas establecidas en la declaraci&#243;n de Helsinki&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los criterios de inclusi&#243;n fueron&#58; diagn&#243;stico de escoliosis&#44; CTR abierto con Risser 0 en el momento de la cirug&#237;a y un seguimiento m&#237;nimo de 2 a&#241;os&#46; Seis pacientes fueron excluidos debido a una progresi&#243;n secundaria a&#58; seudoartrosis no dolorosa &#40;3&#41;&#44; selecci&#243;n incorrecta de niveles de fusi&#243;n con fen&#243;meno de <span class="elsevierStyleItalic">adding-on</span> &#40;2&#41;&#44; y desanclaje de gancho caudal &#40;1&#41;&#46; Veinte pacientes fueron finalmente incluidos en el estudio&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Las variables estudiadas fueron&#58; el sexo&#44; la edad cronol&#243;gica en el momento de la cirug&#237;a&#44; el signo de Risser&#44; la localizaci&#243;n de la curva&#44; la etiolog&#237;a de la curva&#44; el abordaje quir&#250;rgico&#44; el tipo de instrumentaci&#243;n y el uso de alambres sublaminares&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Las radiograf&#237;as fueron revisadas de manera preoperatoria&#44; al a&#241;o de la cirug&#237;a&#44; y al final del seguimiento&#46; Los par&#225;metros revisados en la radiograf&#237;a frontal incluyeron&#58; signo de Risser&#59; &#225;ngulo de Cobb&#59; rotaci&#243;n vertebral apical &#40;AVR&#44; del ingl&#233;s <span class="elsevierStyleItalic">apical vertebral rotation</span>&#41; usando el m&#233;todo de Perdriolle&#59; traslaci&#243;n vertebral apical &#40;AVT&#44; sigla del ingl&#233;s <span class="elsevierStyleItalic">apical vertebral translation</span>&#41; medida en las curvas principales tor&#225;cica o toracolumbar como la distancia entre el &#225;pex vertebral y la caja tor&#225;cica en el lado de la convexidad de la curva&#44; o en las curvas lumbares principales como la distancia del &#225;pex a la l&#237;nea sacra vertical&#59; diferencia &#225;ngulo v&#233;rtebra-costilla &#40;DAVC&#41; o &#225;ngulo de Mehta&#59; y la desviaci&#243;n del tronco&#46; En el plano sagital se midieron la cifosis tor&#225;cica T5-T12 y la cifosis en el &#225;pex de la deformidad&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se compararon los par&#225;metros medidos al a&#241;o del postoperatorio y al final del seguimiento&#46; La progresi&#243;n postoperatoria de la curva o fen&#243;meno de <span class="elsevierStyleItalic">crankshaft</span> &#40;CP&#41; se defini&#243; como&#58; un aumento de m&#225;s de 10&#176; en el &#225;ngulo de Cobb<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;8&#44;11&#44;14&#44;15</span></a>&#44; o un aumento de la DAVC mayor de 10&#176;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;5&#44;7&#44;8&#44;10&#44;11&#44;14</span></a>&#44; o un aumento de la AVR mayor de 10&#176;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#44; o una disminuci&#243;n en la AVT tor&#225;cica o aumento en la AVT lumbar<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Para el c&#225;lculo de la AVT se hizo un promedio de las traslaciones que reflejaban progresi&#243;n tanto en las curvas tor&#225;cicas como lumbares en valor absoluto y quedando reflejado como valor negativo en caso de progresi&#243;n&#46; A continuaci&#243;n&#44; se realizaron comparaciones entre los grupos de <span class="elsevierStyleItalic">crankshaft</span> y no <span class="elsevierStyleItalic">crankshaft</span>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">La media de edad fue de 10&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;6 a&#241;os &#40;2-14&#44;9 a&#241;os&#41;&#44; nueve &#40;45&#37;&#41; de los pacientes eran menores de 11 a&#241;os&#46; En la cirug&#237;a&#44; todos los pacientes ten&#237;an Risser 0&#46; Las curvas displ&#225;sicas incluyeron un paciente con s&#237;ndrome de Klippel-Trenaunay&#44; uno con artrogriposis&#44; y uno con s&#237;ndrome de Angelman&#46; Al a&#241;o de la cirug&#237;a&#44; los estadios de Risser se distribu&#237;an de la siguiente manera&#58; en 16 pacientes&#44; Risser 0&#59; en 2 pacientes&#44; Risser 1&#59; y en 2 pacientes&#44; Risser 2&#46; Al final del seguimiento los estadios de Risser se distribu&#237;an de la siguiente manera&#58; en 9 pacientes&#44; Risser 4&#44; y en 11 pacientes&#44; Risser 5&#46; El promedio de seguimiento fue de 6&#44;9 a&#241;os &#40;24-240 meses&#41;&#46; El Cobb frontal medio preoperatorio fue de 62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#176;&#44; y el &#225;ngulo T5-T12 preoperatorio fue de 29&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#176;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico se realiz&#243; utilizando el <span class="elsevierStyleItalic">software</span> SPSS<span class="elsevierStyleSup">&#174;</span> &#40;versi&#243;n 11&#46;5&#44; SAS Institute Inc&#44; Cary&#44; NC&#44; EE&#46; UU&#46;&#41;&#46; La distribuci&#243;n de las variables se expone como media y desviaci&#243;n est&#225;ndar&#46; Las comparaciones entre las variables se realiz&#243; mediante la <span class="elsevierStyleItalic">U</span> de Mann-Whitney&#44; la prueba exacta de Fisher&#44; y estad&#237;sticas de &#967;<span class="elsevierStyleSup">2</span> seg&#250;n correspond&#237;a&#44; con un nivel de significaci&#243;n del 95&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="par0065" class="elsevierStylePara elsevierViewall">Nueve de los 20 pacientes revisados &#40;45&#37;&#41; desarrollaron un CP siendo designados como grupo-CP&#46; Once pacientes no desarrollaron el CP&#44; fueron designados grupo-NCP &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; La <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> muestra los datos principales preoperatorios&#44; al a&#241;o del postoperatorio y al final del seguimiento&#46; Las variables de edad cronol&#243;gica y edad menor de 11 a&#241;os&#44; demostraron diferencias significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41; entre ambos grupos&#46; El sexo y la etiolog&#237;a de la curva no difiri&#243; entre los grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Par&#225;metros radiogr&#225;ficos</span><p id="par0070" class="elsevierStylePara elsevierViewall">Todos los pacientes que desarrollaron el CP tuvieron un incremento final en el &#225;ngulo de Cobb frontal &#40;diferencia entre un a&#241;o del postoperatorio y el seguimiento final&#41;&#44; con un incremento medio de 24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;6&#176;&#46; Este dato mostr&#243; una diferencia estad&#237;stica en comparaci&#243;n con el grupo-NCP &#40;2&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;5&#176;&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;000&#44; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; El grupo-NCP obtuvo un 61&#37; de correcci&#243;n postoperatoria inicial y el grupo-CP del 41&#44;4&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;06&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Ni la cifosis inicial T5-T12 tor&#225;cica &#40;NCP 24&#44;7&#176; vs&#46; CP 35&#44;5&#176;&#41;&#44; ni su correcci&#243;n despu&#233;s de la cirug&#237;a &#40;NCP 0&#44;7&#176; vs&#46; CP -2&#44;7&#176;&#41;&#44; ni la p&#233;rdida al final del seguimiento &#40;NCP 0&#44;5&#176; vs&#46; CP 3&#44;8&#176;&#41; mostraron diferencias estad&#237;sticamente significativas entre los grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">El grupo-NCP present&#243; una diferencia de AVT absoluta final media de &#43;0&#44;4<span class="elsevierStyleHsp" style=""></span>cm&#44; mientras que el grupo-CP present&#243; una diferencia media de &#8722;1&#44;2<span class="elsevierStyleHsp" style=""></span>cm &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#44; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; De los 9 pacientes que desarrollaron el CP&#44; 8 demostraron una progresi&#243;n en la AVT&#44; con un promedio final de &#8722;1&#44;5<span class="elsevierStyleHsp" style=""></span>cm&#46; Ninguno de los pacientes del grupo-NCP mostr&#243; una disminuci&#243;n &#40;progresi&#243;n&#41; de esta distancia al final del seguimiento &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;000&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">El DAVC o &#225;ngulo de Mehta se midi&#243; en los 17 pacientes que presentaron curvas principales tor&#225;cica o toracolumbar&#46; Este &#225;ngulo aument&#243; de manera significativa en el grupo-CP &#40;NCP 2&#44;3&#176; vs&#46; CP 15&#44;2&#176;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#44; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; Todos los pacientes que desarrollaron el CP presentaron un incremento de DAVC superior a 10&#176;&#44; con un promedio de 16&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;9&#176; al final del seguimiento&#46; A&#250;n as&#237;&#44; 6 pacientes del grupo-NCP&#44; tambi&#233;n mostraron un aumento de la oblicuidad costal&#44; aunque ligero&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">De los datos referentes a la AVR y a la cifosis del segmento apical no se obtuvo informaci&#243;n relevante&#46; Ni el estadio de Risser ni el cambio en desequilibrio de tronco mostraron diferencias estad&#237;sticas entre los grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;3&#41;&#44; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Par&#225;metros quir&#250;rgicos</span><p id="par0095" class="elsevierStylePara elsevierViewall">Ninguno de los 6 pacientes con fusi&#243;n apical anterior y artrodesis instrumentada s&#243;lida posterior desarrollaron CP &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Cuatro de los 9 pacientes &#40;44&#37;&#41; en los que se realiz&#243; una artrodesis instrumentada solo posterior desarrollaron un CP durante el seguimiento&#46; Los 3 pacientes en los que se realiz&#243; una fusi&#243;n posterior <span class="elsevierStyleItalic">in situ</span>&#44; desarrollaron CP&#59; al igual que los 2 pacientes en los que se realiz&#243; una fusi&#243;n apical anterior acompa&#241;ado de barra de crecimiento unilateral posterior &#40;sin alargamiento adicional&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; Estos 5 pacientes fueron revisados quir&#250;rgicamente&#44; como tambi&#233;n lo fue un paciente con una artrodesis posterior instrumentada fallida&#46; Las barras de crecimiento se sustituyeron por barras r&#237;gidas bilaterales&#59; en un paciente con fusi&#243;n <span class="elsevierStyleItalic">in situ</span> se llev&#243; a cabo una fusi&#243;n posterior instrumentada&#46; Los otros 3 pacientes se rescataron con una fusi&#243;n anterior&#44; para tratar de detener el aumento de la deformidad&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Comparando los pacientes instrumentados con alambres sublaminares &#40;9&#41; y sin alambres &#40;8&#41;&#44; descubrimos que en el 77&#37; de aquellos en los que se utilizaron alambres no se desarroll&#243; CP&#44; mientras que en el 50&#37; en los que no se utilizaron alambres se desarroll&#243; CP&#46; Los alambres sublaminares fueron utilizados para el tratamiento de curvas mayores &#40;72&#176; de Cobb preoperatorio&#41;&#44; mientras que los ganchos se utilizaron en curvas de menor magnitud &#40;59&#176; de Cobb preoperatorio&#41;&#44; aunque la correcci&#243;n obtenida fue muy parecida &#40;56&#44;8&#37; en alambres vs&#46; 57&#44;4&#37; en ganchos&#41;&#44; la p&#233;rdida postoperatoria final fue de 6&#176; para el grupo de alambres y 16&#176; para el grupo de ganchos&#46; Sin embargo&#44; ninguna de estas cifras ten&#237;an apoyo estad&#237;stico &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discusi&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">Con este estudio hemos tratado de investigar nuevos datos en torno a la prevalencia y los factores de riesgo en el desarrollo de CP en los pacientes con escoliosis e inmadurez &#243;sea &#40;CTR abierto&#41;&#44; y el tratamiento a seguir para prevenirlo&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Existen autores que se&#241;alan que una edad cronol&#243;gica menor de 11 a&#241;os<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;11&#44;12</span></a>&#44; una edad &#243;sea menor de 10 a&#241;os<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;14</span></a> o un estadio de Risser 0-1<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9</span></a>&#44; se asocian con mayor prevalencia de CP&#46; Sanders et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> enfatizan la importancia del CTR y de la velocidad del pico de crecimiento como predictores fundamentales en el desarrollo del CP<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;11&#44;20</span></a>&#46; Desde entonces&#44; tan solo unos pocos estudios han comenzado a incluir pacientes esquel&#233;ticamente inmaduros &#40;con CTR abierto&#41; para estudiar el CP&#44; mostrando tasas de entre el 15 y el 75&#37;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#44;10&#44;14</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En el presente estudio&#44; todos los pacientes ten&#237;an un CTR abierto&#44; un estadio de Risser 0&#44; y eran de media menores de 11 a&#241;os de edad&#44; por lo que ten&#237;an alto riesgo de desarrollar el CP<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;5&#44;8&#44;11&#44;14&#44;15</span></a>&#46; Hemos detectado un CP postoperatorio en el 45&#37; de los pacientes&#46; El CP se produjo en los pacientes m&#225;s inmaduros &#40;con una edad media de 8&#44;2 a&#241;os&#41;&#46; Los pacientes menores de 11 a&#241;os mostraron un riesgo de un 78&#37; de desarrollar la CP en comparaci&#243;n con el 18&#37; de los mayores de 11 a&#241;os&#46; El estado de Risser en el momento de la cirug&#237;a no parece asociarse con este fen&#243;meno&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Todos los pacientes que desarrollaron un CP sufrieron un aumento del Cobb frontal &#40;entre el postoperatorio y el seguimiento final&#41; mayor de 10&#176; &#40;establecido como definici&#243;n&#41; con 24&#176; de incremento medio&#46; Todos estos pacientes mostraron un aumento del &#225;ngulo de Mehta &#40;DAVC&#41; con un promedio de 16&#176;&#44; aunque algunos pacientes sin CP tambi&#233;n sufrieron un ligero aumento del &#225;ngulo costal&#46; Adem&#225;s&#44; todos menos uno de los pacientes que desarrollaron CP mostraron una variaci&#243;n en la AVT con un promedio de progresi&#243;n de 1&#44;5<span class="elsevierStyleHsp" style=""></span>cm&#44; lo que no ocurri&#243; a ninguno de los pacientes sin CP&#46; Como se demuestra en el presente trabajo&#44; el CP se presenta&#44; no solo como una progresi&#243;n significativa en el &#225;ngulo de Cobb frontal&#44; sino tambi&#233;n con otros signos de progresi&#243;n tridimensional de la deformidad&#44; como el estrechamiento del hemit&#243;rax en la convexidad de la curva&#44; el incremento de la oblicuidad costal o la cifosis rotacional apical &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Factores de riesgo</span><p id="par0125" class="elsevierStylePara elsevierViewall">Contrariamente a lo que se ha publicado<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9</span></a>&#44; las curvas preoperatorias de mayor magnitud no mostraron en nuestro estudio un mayor riesgo de CP &#40;67&#176; NCP vs&#46; 56&#176; CP&#41;&#46; Sin embargo&#44; las curvas de mayor magnitud han sido tratadas de forma m&#225;s agresiva &#40;muchas de ellas con dobles abordajes&#41;&#44; y como veremos m&#225;s adelante&#44; la fusi&#243;n apical anterior en presencia de una instrumentaci&#243;n posterior s&#243;lida&#44; ha protegido a nuestros pacientes del CP&#46; El &#225;ngulo postoperatorio de Cobb &#40;26&#176; NCP vs&#46; 32&#176; CP&#41; no parece que se asocie con progresi&#243;n de la curva final&#46; Sin embargo&#44; una mejor correcci&#243;n en el postoperatorio inmediato &#40;61&#37; NCP vs&#46; 41&#37; CP&#41; parece tener una tendencia hacia la protecci&#243;n contra el desarrollo del CP&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Se ha sugerido que la hipocifosis tor&#225;cica preoperatoria puede conducir a un mayor riesgo de desarrollar CP<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;24</span></a>&#44; mientras que una cifosis bien moldeada postoperatoria podr&#237;a proteger<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;17&#44;23&#44;25</span></a>&#46; Esta cifosis postoperatoria puede ser restaurada de mejor manera usando alambres que cualquier otro tipo de instrumentaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a>&#44; proporcionando as&#237; una protecci&#243;n frente al CP<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; En nuestro estudio ni la cifosis inicial &#40;24&#176; NCP vs&#46; 35&#176; CP&#41;&#44; ni su correcci&#243;n quir&#250;rgica &#40;25&#176; NCP vs&#46; 32&#176; CP&#41;&#44; ni la p&#233;rdida al final del seguimiento &#40;0&#44;7&#176; NCP vs&#46; &#8722;2&#44;7&#176; CP&#41; parece haberse asociado con el desarrollo del CP&#46; Aunque solo el 23&#37; de los pacientes fusionados con alambres sublaminares desarrollaron CP en comparaci&#243;n con un 50&#37; de aquellos en los que se usaron ganchos tor&#225;cicos&#44; no pudimos demostrar estad&#237;sticamente los beneficios del alambre en la prevenci&#243;n de la progresi&#243;n&#46; Aunque empieza a haber referencias sobre el tema&#44; a&#250;n no hay estudios que demuestren que utilizar tornillos tor&#225;cicos para la correcci&#243;n de las curvas&#44; muestren beneficios adicionales frente al desarrollo de CP &#40;35&#37; en la serie publicada&#41;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Tratamiento</span><p id="par0135" class="elsevierStylePara elsevierViewall">El CP se ha evitado en todos nuestros pacientes en los que se ha realizado desde un primer momento una fusi&#243;n apical anterior con fusi&#243;n s&#243;lida posterior instrumentada&#46; Cuando solo se a&#241;adi&#243; una barra unilateral de crecimiento posterior despu&#233;s de la fusi&#243;n anterior&#44; los pacientes tuvieron que ser finalmente rescatados por haber desarrollado CP&#46; Se ha publicado que la fusi&#243;n apical anterior puede contribuir a un aumento de la cifosis postoperatoria<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;29</span></a>&#44; y puede tambi&#233;n interrumpir el crecimiento vertebral anterior ayudando a prevenir el CP<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#8211;10&#44;13&#44;15&#44;17&#8211;19&#44;28</span></a>&#46; Sin embargo&#44; en nuestra opini&#243;n&#44; se precisa de una fusi&#243;n s&#243;lida posterior adicional para prevenir este fen&#243;meno&#46; La falta de una artrodesis posterior r&#237;gida podr&#237;a ser la raz&#243;n por la cual otros autores no consiguieron frenar su desarrollo a pesar de una fusi&#243;n anterior previa<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;13</span></a>&#46; Otra manera en la que otros autores han abordado esta situaci&#243;n ha sido a&#241;adiendo instrumentaci&#243;n anterior a la fusi&#243;n anterior dorsal&#44; en cirug&#237;a de curvas tipo Lenke 1&#44; sin embargo a&#250;n existen controversias en lo referente a la protecci&#243;n de este sistema frente al desarrollo de CP<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La fusi&#243;n posterior <span class="elsevierStyleItalic">in situ</span> ha mostrado los &#237;ndices m&#225;s altos de CP<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Sin embargo&#44; hay que tener en cuenta que esta t&#233;cnica se realiz&#243; en los pacientes m&#225;s j&#243;venes con enorme potencial de crecimiento anterior&#46; En estos pacientes&#44; a&#250;n siendo revisados quir&#250;rgicamente&#44; puede ser que no se controle la progresi&#243;n en la evoluci&#243;n &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; Es probable que la deformidad tor&#225;cica asociada en estos pacientes influya de esta manera en la progresi&#243;n de la deformidad espinal&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">La bibliograf&#237;a muestra tasas entre el 5 y el 97&#37; en el desarrollo de CP tras<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;6&#44;8&#44;10&#44;11&#44;28</span></a> artrodesis posterior instrumentada&#46; Nuestro estudio revel&#243; una tasa del 44&#37;&#44; pero solo un paciente tuvo que ser reintervenido&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Existen algunas limitaciones de nuestro estudio&#46; Se trata de un estudio retrospectivo&#44; con etiolog&#237;as heterog&#233;neas y distintas modalidades quir&#250;rgicas&#44; con un tama&#241;o muestral peque&#241;o&#46; Sin embargo&#44; los criterios de inclusi&#243;n han sido muy estrictos limitados a pacientes muy inmaduros con alto riesgo de desarrollar CP&#44; y el prolongado seguimiento &#40;7 a&#241;os de media&#41; nos ha permitido evaluar los resultados a muy largo plazo&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; la cifosis tor&#225;cica preoperatoria y postoperatoria&#44; y la magnitud de la curva coronal no parecen asociarse al desarrollo del CP&#46; El factor de riesgo crucial es la inmadurez&#58; los pacientes menores de 11 a&#241;os que presentan un CTR abierto pueden tener un riesgo significativamente mayor de desarrollar el CP y si esto ocurre&#44; necesitar&#225;n revisi&#243;n quir&#250;rgica en la mayor&#237;a de los casos&#46; Somos conscientes de las dificultades que entra&#241;a un abordaje adicional anterior&#44; y que algunos autores han cuestionado su necesidad<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;8&#44;31</span></a>&#46; Sin embargo&#44; nuestros datos sugieren que estos pacientes inmaduros pueden beneficiarse de un doble abordaje con fusi&#243;n apical anterior y fusi&#243;n s&#243;lida instrumentada posterior concomitante&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Nivel de evidencia</span><p id="par0160" class="elsevierStylePara elsevierViewall">Nivel de evidencia <span class="elsevierStyleSmallCaps">iv</span>&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Responsabilidades &#233;ticas</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Protecci&#243;n de personas y animales</span><p id="par0165" class="elsevierStylePara elsevierViewall">Los autores declaran que los procedimientos seguidos se conformaron a las normas &#233;ticas del comit&#233; de experimentaci&#243;n humana responsable y de acuerdo con la Asociaci&#243;n M&#233;dica Mundial y la Declaraci&#243;n de Helsinki&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Confidencialidad de los datos</span><p id="par0170" class="elsevierStylePara elsevierViewall">Los autores declaran que han seguido los protocolos de su centro de trabajo sobre la publicaci&#243;n de datos de pacientes y que todos los pacientes incluidos en el estudio han recibido informaci&#243;n suficiente y han dado su consentimiento informado por escrito para participar en dicho estudio&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Derecho a la privacidad y consentimiento informado</span><p id="par0175" class="elsevierStylePara elsevierViewall">Los autores han obtenido el consentimiento informado de los pacientes y&#47;o sujetos referidos en el art&#237;culo&#46; Este documento obra en poder del autor de correspondencia&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicto de intereses</span><p id="par0180" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Estudiar los pacientes inmaduros con cart&#237;lago trirradiado abierto&#44; operados de escoliosis&#44; en busca de factores de riesgo y de prevenci&#243;n para desarrollar un fen&#243;meno de <span class="elsevierStyleItalic">crankshaft</span> &#40;CP&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de una cohorte de 26 pacientes esquel&#233;ticamente inmaduros&#46; Seis se excluyeron por progresi&#243;n de distinta etiolog&#237;a&#46; Se defini&#243; <span class="elsevierStyleItalic">crankshaft</span> como un aumento del Cobb mayor de 10&#176;&#44; o un incremento en la diferencia del &#225;ngulo de Mehta &#40;diferencia &#225;ngulo v&#233;rtebra-costilla&#44; DAVC&#41; mayor de 10&#176;&#44; o cualquier disminuci&#243;n de la distancia &#225;pex-costilla tor&#225;cica o aumento de la traslaci&#243;n vertebral apical lumbar &#40;AVT&#44; sigla del ingl&#233;s <span class="elsevierStyleItalic">apical vertebral translation</span>&#41;&#46; Se compararon los pacientes con y sin desarrollo de CP para analizar los factores de riesgo preoperatorios&#44; quir&#250;rgicos y postoperatorios&#46; Se estudi&#243; la influencia de las distinta t&#233;cnicas quir&#250;rgicas&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El seguimiento medio fue de 83&#44;9 meses&#46; Nueve pacientes &#40;45&#37;&#41; desarrollaron el CP&#46; Solo los par&#225;metros de inmadurez &#243;sea se asociaron al desarrollo de CP&#46; Ning&#250;n par&#225;metro radiogr&#225;fico preoperatorio o postoperatorio parece influir en su desarrollo&#46; La cantidad de correcci&#243;n podr&#237;a ser un factor de protecci&#243;n &#40;41&#44;4 vs&#46; 61&#44;4&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;06&#41;&#46; El doble abordaje fue capaz de evitar el desarrollo de CP &#40;0&#37;&#41; en comparaci&#243;n con la instrumentaci&#243;n &#250;nica posterior &#40;44&#37;&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Discusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">No se ha conseguido demostrar que los siguientes factores preoperatorios predispongan a la aparici&#243;n de <span class="elsevierStyleItalic">crankshaft</span>&#58; sexo o etiolog&#237;a&#44; cifosis T5-T12&#44; hipocifosis apical&#44; Cobb coronal&#44; rotaci&#243;n vertebral o DAVC&#46; Tampoco parecen influir el Cobb postoperatorio residual&#44; la cifosis conseguida&#44; o la instrumentaci&#243;n con alambres frente a ganchos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusi&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En los pacientes con cart&#237;lago trirradiado abierto menores de 11 a&#241;os parece aconsejable corregir la escoliosis mediante doble abordaje para evitar el fen&#243;meno del cig&#252;e&#241;al o CP &#40;progresi&#243;n de la deformidad tras una artrodesis posterior por crecimiento anterior vertebral&#41;&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Objective</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">To study young patients after scoliosis surgery in order to determine risk and prevention factors for developing a crankshaft phenomenon &#40;CP&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Material and methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of a cohort of 26 skeletally immature patients&#46; Six were excluded due to progression of various conditions&#46; Crankshaft was defined as an increase in the Cobb angle &#62;10&#176;&#44; or an increase in the Mehta angle &#40;DAVC&#41; &#62;10&#176;&#44; or any decrease in the apex-rib thoracic distance&#44; or increase in the apical vertebral translation &#40;AVT&#41;&#46; Patients with and without CP development were compared in order to analyse preoperative&#44; surgical and postoperative risk factors&#44; as well as the influence of different surgical techniques&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The mean follow-up was 83&#46;9 months&#46; Nine patients &#40;45&#37;&#41; developed the crankshaft phenomenon&#46; Only immaturity parameters were associated with development of CP&#46; No preoperative or postoperative radiographic parameters appeared to influence its development&#46; The amount of correction may be a protective factor &#40;41&#46;4 vs&#46; 61&#46;4&#37;&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;06&#41;&#46; The double approach was able to prevent the development of CP &#40;0&#37;&#41; compared with single posterior instrumentation &#40;44&#37;&#41;&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;02&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">None of these preoperative factors seemed to predispose to CP&#58; gender or aetiology&#44; T5-T12 kyphosis or apical hypokyphosis&#44; coronal Cobb&#44; vertebral rotation&#44; or DAVC&#46; The residual postoperative Cobb&#44; achieved kyphosis&#44; or wired instrumentation versus hooks&#44; also seemed to have no influence&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusion</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">In patients with open triradiate cartilage under 11 years of age&#44; it seems advisable to correct by double approach to avoid the appearance of the crankshaft phenomenon&#46;</p>"
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          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Caso n&#250;mero 1&#46; Paciente con escoliosis idiop&#225;tica&#46; A los 2 a&#241;os de edad &#40;A&#41; se realiza fusi&#243;n posterior <span class="elsevierStyleItalic">in situ</span>&#46; Las im&#225;genes postoperatorias muestran una correcci&#243;n moderada &#40;B&#41;&#46; A los 10 a&#241;os de edad&#44; desarrolla un fen&#243;meno de <span class="elsevierStyleItalic">crankshaft</span> con un incremento del Cobb frontal de 14&#176;&#44; y el desarrollo de una cifosis rotacional muy marcada de 110&#176; &#40;C&#41;&#46; Se realiz&#243; un abordaje anterior para frenar el colapso rotacional sagital con discectom&#237;a&#44; artrodesis e injerto pediculado de costilla &#40;D&#41;&#46; Trece a&#241;os despu&#233;s&#44; a la edad de 25 a&#241;os &#40;E&#41;&#44; el paciente se mantiene equilibrado y el injerto le ha protegido frente al incremento del colapso&#46;</p>"
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          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Caso n&#250;mero 2&#46; Paciente con hemiv&#233;rtebra en T6&#46; A los 2 a&#241;os de edad se realiza una fusi&#243;n posterior <span class="elsevierStyleItalic">in situ</span> T2-T8 &#40;A&#41;&#46; A la edad de 14 a&#241;os&#44; la curva tor&#225;cica hab&#237;a progresado de 30 a 46&#176;&#44; la distancia &#225;pex-costilla hab&#237;a disminuido 3<span class="elsevierStyleHsp" style=""></span>cm&#44; y el &#225;ngulo costal de Mehta hab&#237;a aumentado 12&#176; &#40;B&#41;&#46; Comenzado su pico de alta velocidad de crecimiento se realiz&#243; un doble abordaje&#46; Discectom&#237;a y fusi&#243;n anterior con instrumentaci&#243;n posterior adicional &#40;C&#41;&#46; Siete a&#241;os despu&#233;s hab&#237;a vuelto a progresar su &#225;ngulo frontal de Cobb&#44; hab&#237;a disminuido su distancia &#225;pex-costilla y aumentado su oblicuidad costal de Mehta &#40;D&#41;&#46; El doble abordaje de revisi&#243;n no consigui&#243; detener la progresi&#243;n de la deformidad&#46;</p>"
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ED&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FPI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NCP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">T&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FPI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">H&#237;brido&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">L&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ENM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FPI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">H&#237;brido&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">NCP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">T&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">EI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FPI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">NCP&nbsp;\t\t\t\t\t\t\n
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                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab351337.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Datos demogr&#225;ficos</p>"
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      3 => array:7 [
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">AVR&#58; rotaci&#243;n apical vertebral&#59; AVT&#58; traslaci&#243;n v&#233;rtebra apical&#59; Cif&#58; cifosis&#59; DAVC&#58; diferencia del &#225;ngulo v&#233;rtebra-costilla&#59; Fin&#58; final del seguimiento&#59; Pre&#58; preoperatoro&#59; Post&#58; un a&#241;o de postoperatorio&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
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                  \t\t\t\t" style="border-bottom: 2px solid black">AVT Fin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">DAVC Fin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">AVR Pre&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">AVR Post&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">AVR Fin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">Cobb final &#40;&#176;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">56&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cifosis T5-T12 preoperatoria &#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">24&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cifosis T5-T12 postoperatoria &#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cifosis T5-T12 final &#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AVT postoperatoria &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AVT final &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diferencia AVT final &#40;cm&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#8722;1&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DAVC postoperatoria &#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">DAVC final &#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diferencia DAVC final &#40;&#176;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">DC preoperatorio &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">DC postoperatorio &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DC final &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;1&nbsp;\t\t\t\t\t\t\n
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                  "referenciaCompleta" => "Dubousset J&#46; Recidive d&#8217;une scoliose lombaire et d&#8217;un bassin oblique apres fusion precoce&#58; le phenomene due villebrequin&#44; Group etud de la Scoliose&#44; Paris 1973&#46;"
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Información del artículo
ISSN: 18884415
Idioma original: Español
DOI:10.1016/j.recot.2013.03.002
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