Postoperative limb alignment in total knee replacement. Conventional versus navigated versus robotic techniques.

BACKGROUND: Our objective was to compare the coronal mechanical axis after total knee replacement (TKR) obtained in three groups of patients subjected to conventional, navigated, and robotic surgery. METHODS: Retrospective analysis. RESULTS: 124 knees were included (36 conventional, 41 navigated, 47 robotic). No statistically significant differences were found between the postOp tibiofemoral angle of the conventional, navigated and robotic groups (p = 0.396). A repeated-measure analysis of preOp-to-postOp also found no significant differences (p = 0.387). There were no differences in the proportion of outliers (3-degree) found (p = 0.211). Nevertheless, a higher proportion of patients in the robotic group improved their mechanical alignment, as compared with conventional surgery (p = 0.023), although no differences were found when comparing with navigation (p = 0.121). CONCLUSIONS: No statistically significant differences were found with respect to the postOp alignment achieved. However, statistically significant differences were detected between robotic and conventional surgery when considering the percentage of patients with improved limb alignment.

Use of the Heracles straight blade in the treatment of intertrochanteric hip fractures: a prospective study with a 1-year follow-up.

INTRODUCTION: The treatment of intertrochanteric fractures in the elderly remains challenging for orthopedic surgeons, due to aging, comorbidities, and poor bone quality. The Heracles straight blade has proven a lower rate of cut-out and femoral head displacement in biomechanical studies; however, there are currently no published clinical studies using this nail. PURPOSE: To analyze the clinical and radiological results of the Heracles nail with the straight cephalic Heracles blade as a device to treat osteoporotic intertrochanteric fractures of the proximal femur. METHODS: A total of 136 patients with trochanteric hip fractures were operated on by the same surgeon, using the Heracles nail with a straight cephalic blade. However, only 86 patients completed the 1-year follow-up both clinically and radiologically. According to the Association of Osteosynthesis classification, 38 patients (44.1%) had 31-A1, 36 patients (41.6%) had 31-A2, and 12 patients (14.1%) had 31-A3. Functional outcomes were assessed according to the Katz and Barthel scores, finding that 58% of patients recovered their original functional level, According to Barthel score, a mean loss of 11.8 points was found. RESULTS: The mean hospital stay was 8.22 days (mean preoperative stay of 2.71 days). The mean tip-apex distance was 15.2 mm. During the follow-up, 6 complications (6.96%) were detected: 4 cut-out, 1 cut-in, and 1 nail breakage. According to the Katz score, 58% of the patients recovered their previous functional status and 20.58% needed an additional walking aid. The mean loss in the Barthel score was 11.8 points. CONCLUSION: The Heracles nail using a cephalic straight blade has proven to be a valid treatment of trochanteric fractures, due to the functional recovery of the patients and low level of complications.

Factors of presenting an acute confusional syndrome after a hip fracture.

INTRODUCTION: Acute confusional syndrome (ACS) is a geriatric syndrome that manifests itself with changes in cognition, attention, underactive or hyperactive motor response, and fluctuation in the level of consciousness after trauma, hospitalisation or surgery. The objective is to know the risk factors and prevention of acute confusional syndrome in the elderly with hip fractures (HF) . METHODS: Prospective observational cohort study. The inclusion criteria was to be age ≥ 65 and HF operated under selective spinal anesthetic (bupivacaine ≤ 7 mg + fentanyl 10-15 .mu.g) without benzodiazepine, ketamine or propofol. The potential risk factors of ACS were recorded: demographic variables, fracture type, Charlson index, ASA risk, performance of a peripheral nerve block (PNB), and scale scores: Barthel, Fried, Pfeifer, RCMS, MNA and VAS. ACS was diagnosed by the CAM questionnaire. The risk factors were estimated by binary logistic regression. RESULTS: Of the 133 patients included, 60 (45.11%) developed preoperative ACS, and 25 developed (18.8%) postoperative ACS. Having identified cognitive impairment with ≥ 3 points on the RCMS (OR 11.04 [ 95% ic: 1.3 - 89.1], p <0.001) or Pfeiffer (OR 6.94 [95% ic: 1.07 - 44.69], p <0.0 41) was a risk factor of ACS. Among patients with cognitive impairment or dementia, the increase of surgical delay (OR 1.95 [ 95% CI: 1.2 -2.91], p <0.001) was associated with the increased likelihood of presenting perioperative ACS, while performing a perioperative PNB decreased the likelihood of presenting perioperative ACS (without PNB: 43.8%, with PNB: 4.7%, OR 0.3 [0.2 to 0.43], p <0.001). CONCLUSION: Identifying patients with HF and cognitive impairment using RCMS or the Pfeiffer test and performing HF surgery within 36 h administering perioperative PNB could reduce the incidence of ACS.

Osteosynthesis in Vancouver type B1 periprosthetic fractures.

INTRODUCTION: The incidence of hip periprosthetic fractures (PPF) has been increasing in recent years. In Vancouver type B1 there are several osteosynthesis options. The aim of this paper is to assess both the treatment and results of Vancouver type B1 PPF in patients operated at our centre. MATERIAL AND METHOD: An observational retrospective study of patients operated at Hospital Universitario Miguel Servet for type B1 PPF via osteosynthesis with plate between January 2014 and March 2017. Such details were documented and analysed as type of implant used for fixation, patient demographics, complications, time to union and function score using the Harris Hip Score. The minimum follow up was 2 years. RESULTS: Overall, 37 patients (21 women)  were available for review with a mean age of 80.7 years (range 54-99). 8 of these patients died, with an average age of 85.6 (83-95). Out of these 8 dead patients, 4 died in the first year, with an average age of 87 (83-95). 19 fractures had cemented stems whereas 18 were uncemented. According to prosthesis type, 8 had a cemented partial arthroplasty, 11 a cemented total hip arthroplasty (THA), 18 a non-cemented THA; with an average period until PPF of 2.5 years (0.2-5.6), 7 years (0.09-18.1) and 8.1 years (2.6-12.7) respectively. Devises used for stabilisation of the fracture included 27 Cable-Ready® plates (Zimmer-Biomet), 5 Dall-Miles® plates (Stryker) and 5 femur NCB® plates (Zimmer-Biomet). Complications included 5 acute superficial infections of surgical wound, 1 chronic infection, 5 pressure ulcers (4 sacral, 1 heel), 7 patients required intra-operational blood transfusion. The mean time to union was 10.35 weeks (range 6-13). The mean Harris Hip Score postoperatively was 65 (44-95). DISCUSSION: Treatment via open reduction and internal fixation with locked lateral plate covering most of the femur in elderly patients or those with poor bone quality, or a plate with proximal cerclages and distal screws in patients with better bone quality are appropriate treatment methods. To achieve good results using these techniques, we consider minimisation of soft tissue dissection highly important likewise using a meticulous osteosynthesis technique with special attention to biology and biomechanics.

[Quantitative assessment of the loss of functionality associated with the appearance of complications in osteosynthesis of proximal humerus fractures.] / Valoración cuantitativa de la pérdida de funcionalidad asociada a la aparición de complicaciones en osteosíntesis de fracturas de húmero proximal.

Objetive: To evaluate the relationship between incidence of complications and clinico-functional outcomes, after fractures of the proximal humerus treated with locking plates. Material and Methods: Our study reviewed 47 patients who underwent internal fixation with plate for a period of 5 years. We present the clinico-functional outcomes with Constant-Murley and Quick-Dash scores, and cinematic analysis. Statistical analysis of the relationship complication-functional results and new surgery-functional results. Results: At the end of the follow-up period, a total of 47 patients were recollected and the mean age was 74,85 years. 11 patients (23,4%) had complications, of whom 6 patients (12,7%) needed a new surgery. The complication rate is associated with loss of 65,41º of flexion, 14,49º of extension, 36,71º of abduction, 8,84º of aduction, 5,47º of external rotation and 30,82º of internal rotation. Furthermore, we found statistically significant differences between the incidence of complications and Constant-Murley and Quick Dash scores. Conclusion: There is a high percentage of patients who developes complications after ORIF with and its functionality is significantly reduced. Our study accurately quantifies this loss and, in this way, it predicts the functional situation, according to the possible complicactions that may arise.

Objetivo: Evaluar la relación entre la incidencia de complicaciones y los resultados clínico-funcionales, tras el tratamiento de las fracturas de húmero proximal mediante osteosíntesis con placa bloqueada. Material y método: Nuestro estudio revisa 47 pacientes intervenidos mediante osteosíntesis con placa en un periodo de 5 años. Presentamos los resultados clínico-funcionales con las escalas de Constant-Murley y Quick Dash, y con un análisis cinemático. Análisis estadístico de las relaciones complicación-resultados funcionales y reintervención-resultados funcionales. Resultados: Al final del seguimiento, fueron recogidos un total de 47 pacientes, con una edad media de 74,85 años. 11 pacientes (23,4%) tuvieron complicaciones, de los cuales 6 pacientes (12,7%) precisaron ser reintervenidos. La aparición de complicaciones se asoció a una pérdida de 65,41º de flexión, 14,49º de extensión, 36,71º de abducción, 8,84º de aducción, 5,47º de rotación externa y 30,82º de rotación interna. Además, se encontró relación estadísticamente significativa entre el desarrollo de complicaciones y las escalas Constant-Murley y Quick Dash. Conclusiones: Existe un porcentaje elevado de pacientes que desarrollan complicaciones tras RAFI con placa, los cuales ven disminuida su funcionalidad de forma notable. Nuestro estudio cuantifica de forma exacta ésta pérdida y, de esta manera, predice la situación funcional, según las eventuales complicaciones que puedan aparecer.