Situación actual de la robótica en cirugía protésica de rodilla, ¿una tecnología que ha venido para quedarse? / Current situation of robotics in knee prosthetic surgery, a technology that has come to stay?

La cirugía robótica es una técnica quirúrgica que va en aumento. El objetivo de la artroplastia total de rodilla asistida por robot (ATRar) es el de proveer al cirujano de una herramienta para ejecutar de forma precisa los cortes óseos de acuerdo con una planificación quirúrgica previa para restablecer la cinemática de una rodilla primitiva y el balance de partes blandas, pudiendo aplicar de forma precisa el tipo de alineación que escojamos. Además, la ATRar es una herramienta muy útil para la formación.Dentro de las limitaciones, encontramos la curva de aprendizaje, la necesidad de equipos específicos, los costes elevados de adquisición de los dispositivos, en algunos sistemas el aumento de radiación y que cada robot está ligado a un tipo específico de implante.Los estudios actuales muestran que con la ATRar disminuyen las variaciones de alineación del eje mecánico, mejora el dolor posoperatorio y se facilita un alta más precoz. Por otro lado, no muestran diferencias a nivel de rango de movimiento, alineación, balance de gaps, complicaciones, tiempo quirúrgico o resultados funcionales.(AU)

Robotic surgery is a surgical technique that is on the rise. The goal of robotic-assisted total knee arthroplasty (RA-TKA) is to provide the surgeon with a tool to accurately execute bone cuts according to previous surgical planning to restore knee kinematics and balance of soft tissue, being able to precisely apply the type of alignment that we choose. In addition, RA-TKA is a very useful tool for training.Within the limitations, there is the learning curve, the need for specific equipment, the high cost of the devices, the increase in radiation in some systems and that each robot is linked to a specific type of implant.Current studies show, with RA-TKA, variations in the alignment of the mechanical axis are reduced, postoperative pain is improved and earlier discharge is facilitated. On the other hand, there are no differences in terms of range of motion, alignment, gap balance, complications, surgical time or functional results.(AU)

[Translated article] Current situation of robotics in knee prosthetic surgery: A technology that has come to stay? / Situación actual de la robótica en cirugía protésica de rodilla, ¿una tecnología que ha venido para quedarse?

La cirugía robótica es una técnica quirúrgica que va en aumento. El objetivo de la artroplastia total de rodilla asistida por robot (ATRar) es el de proveer al cirujano de una herramienta para ejecutar de forma precisa los cortes óseos de acuerdo con una planificación quirúrgica previa para restablecer la cinemática de una rodilla primitiva y el balance de partes blandas, pudiendo aplicar de forma precisa el tipo de alineación que escojamos. Además, la ATRar es una herramienta muy útil para la formación.Dentro de las limitaciones, encontramos la curva de aprendizaje, la necesidad de equipos específicos, los costes elevados de adquisición de los dispositivos, en algunos sistemas el aumento de radiación y que cada robot está ligado a un tipo específico de implante.Los estudios actuales muestran que con la ATRar disminuyen las variaciones de alineación del eje mecánico, mejora el dolor posoperatorio y se facilita un alta más precoz. Por otro lado, no muestran diferencias a nivel de rango de movimiento, alineación, balance de gaps, complicaciones, tiempo quirúrgico o resultados funcionales.(AU)

Robotic surgery is a surgical technique that is on the rise. The goal of robotic-assisted total knee arthroplasty (RA-TKA) is to provide the surgeon with a tool to accurately execute bone cuts according to previous surgical planning to restore knee kinematics and balance of soft tissue, being able to precisely apply the type of alignment that we choose. In addition, RA-TKA is a very useful tool for training.Within the limitations, there is the learning curve, the need for specific equipment, the high cost of the devices, the increase in radiation in some systems and that each robot is linked to a specific type of implant.Current studies show, with RA-TKA, variations in the alignment of the mechanical axis are reduced, postoperative pain is improved and earlier discharge is facilitated. On the other hand, there are no differences in terms of range of motion, alignment, gap balance, complications, surgical time or functional results.(AU)

[Translated article] Current situation of robotics in knee prosthetic surgery: A technology that has come to stay?

Robotic surgery is a surgical technique that is on the rise. The goal of robotic-assisted total knee arthroplasty (RA-TKA) is to provide the surgeon with a tool to accurately execute bone cuts according to previous surgical planning to restore knee kinematics and balance of soft tissue, being able to precisely apply the type of alignment that we choose. In addition, RA-TKA is a very useful tool for training. Within the limitations, there is the learning curve, the need for specific equipment, the high cost of the devices, the increase in radiation in some systems and that each robot is linked to a specific type of implant. Current studies show, with RA-TKA, variations in the alignment of the mechanical axis are reduced, postoperative pain is improved and earlier discharge is facilitated. On the other hand, there are no differences in terms of range of motion, alignment, gap balance, complications, surgical time or functional results.

Current situation of robotics in knee prosthetic surgery, a technology that has come to stay? / Situación actual de la robótica en cirugía protésica de rodilla, ¿una tecnología que ha venido para quedarse?

Robotic surgery is a surgical technique that is on the rise. The goal of robotic-assisted total knee arthroplasty (RA-TKA) is to provide the surgeon with a tool to accurately execute bone cuts according to previous surgical planning to restore knee kinematics and balance of soft tissue, being able to precisely apply the type of alignment that we choose. In addition, RA-TKA is a very useful tool for training. Within the limitations, there is the learning curve, the need for specific equipment, the high cost of the devices, the increase in radiation in some systems and that each robot is linked to a specific type of implant. Current studies show, with RA-TKA, variations in the alignment of the mechanical axis are reduced, postoperative pain is improved and earlier discharge is facilitated. On the other hand, there are no differences in terms of range of motion, alignment, gap balance, complications, surgical time or functional results.

Mortality Rates of Patients with Proximal Femoral Fracture in a Worldwide Pandemic: Preliminary Results of the Spanish HIP-COVID Observational Study.

BACKGROUND: The outbreak of coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), in December 2019 in Wuhan, People's Republic of China, has developed into an unprecedented pandemic with enormous pressure on health-care providers around the world. A higher mortality rate has been described in older infected individuals. Patients with hip fracture are a particularly vulnerable population during this pandemic because older age is associated with a higher mortality rate. Our aim was to describe the early mortality rate and demographic variables in a hip fracture sample population in Spain during the coronavirus pandemic. METHODS: This is a multicenter, observational, retrospective, descriptive study. We collected data from 13 major hospitals in Spain from the beginning of the national state of alarm (declared on March 14, 2020, by the Spanish government) until the end of our study period on April 4, 2020. All patients who were ≥65 years of age, presented to the Emergency Department of the participating hospitals during this period with a diagnosis of proximal femoral fracture, and had a minimum follow-up of 10 days were included in the cohort. In addition to mortality, demographic and other potential prognostic variables were also collected. RESULTS: In this study, 136 patients with a hip fracture were included. Of these patients, 124 underwent a surgical procedure and 12 were managed nonoperatively. The total mortality rate was 9.6%. Sixty-two patients were tested for COVID-19, with 23 patients being positive. The mortality rate for these 23 patients was 30.4% (7 of 23 patients) at a mean follow-up of 14 days. The mortality rate was 10.3% (4 of 39) for patients who had been tested and had a negative result and 2.7% (2 of 74) for patients who had not been tested. Of the 12 patients who were managed nonoperatively, 8 (67%) died, whereas, of the 124 patients who were surgically treated, 5 (4%) died. Results differed among centers. CONCLUSIONS: There is a higher mortality rate in patients with a hip fracture and an associated positive test for COVID-19. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

El polietileno de alto entrecruzamiento no reduce el desgaste en la artroplastia total de rodilla / Cross-linked polyethylene does not reduce wear in total knee arthroplasty

Objetivo: Comparar dos pares de fricción (metal/polietileno de ultra alto peso molecular [UHMWPE], metal/polietileno de alto entrecruzamiento) mediante análisis cuantitativo y cualitativo de partículas de polietileno en líquido sinovial a los 3 años postintervención en pacientes portadores de prótesis total de rodilla (PTR). Material y métodos: Se llevó a cabo un estudio de cohortes prospectivo, aleatorizado, con evaluación ciega incluyendo 25 pacientes a quienes se intervino de PTR de manera bilateral, con 6 meses de diferencia. A los 3 años postintervención, se realizaron artrocentesis de rodilla a 12 pacientes y se analizaron las partículas de polietileno. Resultados: No se hallaron diferencias significativas en el número de partículas generadas por los diferentes insertos de polietileno a los 3 años tras la implantación de una artroplastia total de rodilla (3.000×: x¯ entrecruzado=849,7; x¯ UHMWPE=796,9; p=0,63; 20.000×: x¯ entrecruzado=66,3; x¯ UHMWPE=73,1; p=0,76). Tampoco existen diferencias significativas entre los 2 tipos de inserto, entre la posibilidad de encontrar partículas de forma elongada (χ2=0,19; p=0,66) ni redonda (χ2=1,44; p=0,23). Sin embargo, la probabilidad de encontrar partículas de forma fibrilar es 3,08 veces mayor en el UHMWPE. Conclusiones: El polietileno altamente entrecruzado no reduce significativamente la generación de partículas de polietileno en aquellos pacientes intervenidos mediante una artroplastia total de rodilla, con muestras a 3 años postintervención

Aim: To compare two different types of inserts: Ultra-high molecular weight polyethylene (UHMWPE) and cross-linked polyethylene with a quantitative and qualitative study of polyethylene wear particles in synovial fluid 3 years after total knee arthroplasty. Material and methods: A prospective, randomized, controlled cohort study with blinded evaluation was carried out on 25 patients undergoing staged bilateral total knee replacement, 6 months apart. Knee arthrocentesis was performed on 12 patients 3 years after surgery, and the polyethylene particles were analyzed. Results: No significant differences were found in the number of particles generated by the two different types of inserts at 3 years from total knee arthroplasty (3,000×: x¯ cross-linked=849.7; x¯ UHMWPE=796.9; P=.63; 20,000×: x¯ cross-linked=66.3; x¯ UHMWPE=73.1; P=.76). Likewise, no differences in the probability of finding elongated (χ2=0.19; P=.66) or rounded (χ2=1.44; P=.23) particles in both types of inserts were observed. However, the probability of finding fibrillar particles is 3.08 times greater in UHMWPE. Conclusions: Cross-linked polyethylene does not significantly reduce the generation of polyethylene particles in patients with total knee arthroplasty, 3 years after the surgical procedure

Teaching Patients How to Reduce a Shoulder Dislocation: A Randomized Clinical Trial Comparing the Boss-Holzach-Matter Self-Assisted Technique and the Spaso Method.

BACKGROUND: There are many different techniques for reducing acute anterior dislocations of the shoulder, and their use depends on surgeon preference. The objective of this study was to compare the pain experienced by a patient performing a self-reduction technique with the pain felt during a reduction performed by a trained physician. METHODS: The study was carried out at the emergency department of a tertiary referral center. Patients between 18 and 60 years of age with an acute anterior shoulder dislocation were randomly allocated into 2 groups. In 1 group the emergency doctor actively guided the reduction process with the Spaso technique (Sp group), and in the other group the patient used the Boss-Holzach-Matter (also known as Davos or Aronen) self-reduction technique (BHM group). The pain experienced by the patient during the reduction was recorded by means of a visual analogue scale (VAS) ranging from 0 to 10. Other recorded data included demographic characteristics, reduction time, and success rate. RESULTS: Of 378 patients assessed for eligibility from May 2015 until February 2017, 197 did not meet the inclusion criteria, 58 met exclusion criteria, 22 declined to participate, and 41 withdrew before randomization. Sixty acute anterior shoulder dislocations were randomized into the Sp group (n = 30) or the BHM group (n = 30). The BHM group experienced significantly less pain during reduction than the Sp group (p = 0.047), with mean pain scores of 3.57 (standard deviation [SD] = 2.1]) and 5.26 (SD = 2.9), respectively. No significant difference between groups was found with respect to reduction time (105 seconds [range, 10 to 660 seconds] in the Sp group and 90 seconds [range, 5 to 600 seconds] in the BHM group; p = 0.6) or success rate (67% and 77%, respectively; p = 0.39). CONCLUSIONS: The self-reduction technique results in less pain than, and is as efficient in achieving reduction of anterior shoulder dislocations as, the Spaso technique. These findings favor the use of the self-assisted method as an effective first-line treatment for shoulder dislocations seen in the emergency department as well as its use by patients with recurrent dislocation. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Cross-linked polyethylene does not reduce wear in total knee arthroplasty. / El polietileno de alto entrecruzamiento no reduce el desgaste en la artroplastia total de rodilla.

AIM: To compare two different types of inserts: Ultra-high molecular weight polyethylene (UHMWPE) and cross-linked polyethylene with a quantitative and qualitative study of polyethylene wear particles in synovial fluid 3 years after total knee arthroplasty. MATERIAL AND METHODS: A prospective, randomized, controlled cohort study with blinded evaluation was carried out on 25 patients undergoing staged bilateral total knee replacement, 6 months apart. Knee arthrocentesis was performed on 12 patients 3 years after surgery, and the polyethylene particles were analyzed. RESULTS: No significant differences were found in the number of particles generated by the two different types of inserts at 3 years from total knee arthroplasty (3,000×: x¯ cross-linked=849.7; x¯ UHMWPE=796.9; P=.63; 20,000×: x¯ cross-linked=66.3; x¯ UHMWPE=73.1; P=.76). Likewise, no differences in the probability of finding elongated (χ2=0.19; P=.66) or rounded (χ2=1.44; P=.23) particles in both types of inserts were observed. However, the probability of finding fibrillar particles is 3.08 times greater in UHMWPE. CONCLUSIONS: Cross-linked polyethylene does not significantly reduce the generation of polyethylene particles in patients with total knee arthroplasty, 3 years after the surgical procedure.

Analgesia intravenosa domiciliaria mediante bomba elastomérica como procedimiento ambulatorio de control del dolor en la reparación del ligamento cruzado anterior / Home-based intravenous analgesia with elastomeric pump as an outpatient procedure for pain control after anterior cruciate ligament repair

Objetivo. Hacer un seguimiento del dolor en el posoperatorio inmediato, mediante el uso de bomba elastomérica en la cirugía del ligamento cruzado anterior (LCA). Material y métodos. Trescientos nueve pacientes intervenidos de ligamentoplastia del LCA mediante plastia autóloga de hueso-tendón-hueso. Durante el posoperatorio inmediato se realizó un seguimiento del dolor mediante escala visual analógica (EVA); tanto en la unidad de reanimación posoperatoria, como en la sala de adaptación al medio, y durante las primeras 24-48-72 h en el domicilio. Registramos también la necesidad de medicación de rescate, efectos adversos observados y visitas al servicio de urgencias. Resultados. Se estudió a 309 pacientes (264 varones, 45 mujeres) con una edad media de 33 años (rango: 18-55). El 44,7% de los pacientes reportaron dolor posoperatorio inmediato leve y el 38,5% no tenía dolor. Al alta, el 41,1% de los pacientes reportaron dolor leve y el 57% no tenía dolor. En domicilio, se mantuvieron los valores de dolor leve/moderado, con más del 97% de los pacientes con valores EVA ≤ 3. Se registraron efectos adversos en menos del 3% de los casos. El 8,7% de los casos tuvo que hacer uso en algún momento de medicación analgésica. Menos del 1% presentó prurito mientras llevaban la analgesia intravenosa en el domicilio y menos del 2% presentó problemas relacionados con el dispositivo. Discusión. Actualmente, no hay consenso en cuanto al manejo posoperatorio de las lesiones del LCA, aunque la tendencia es el uso de anestesia multimodal y de sistemas para reducir el dolor posoperatorio. Conclusiones. El uso de bomba elastomérica como procedimiento ambulatorio de control del dolor en la reparación del ligamiento cruzado anterior ha reportado buenos resultados (AU)

Objective. To follow up pain in the immediate postoperative period, using an elastomeric pump in anterior cruciate ligament surgery. Material and methods. 309 patients who had undergone anterior cruciate ligament repair with bone-tendon-bone allograft. Pain control was assessed with a visual analogue scale (VAS) during the immediate postoperative period, in the postoperative care unit, in the recovery room, and after the first 24-48-72hours following home discharge. The need for rescue medication, adverse effects observed and emergency visits were also registered. Results. 309 patients were assessed (264 males, 45 females), mean age 33 (range: 18 - 55). Postoperative pain was mild in 44.7% of patients, and 38.5% were pain-free. At discharge, 41.1% of patients reported mild pain and 57% were pain-free. At home, mild to moderate levels of pain were maintained and over 97% of patients presented VAS values ≤ 3. Fewer than 3% had adverse effects, 8.7% had to use analgesic medication at some point. Pruritus occurred in less than 1% of patients receiving intravenous analgesia at home, and fewer than 2% had device-related complications. Discussion. There is no consensus regarding the postoperative management of anterior cruciate ligament lesions, although most surgeons use multimode anaesthesia and different combinations of analgesics to reduce postoperative pain. Conclusions. The use of an intravenous elastomeric pump as postoperative analgesia for anterior cruciate ligamentoplasty has yielded good results (AU)

Home-based intravenous analgesia with elastomeric pump as an outpatient procedure for pain control after anterior cruciate ligament repair. / Analgesia intravenosa domiciliaria mediante bomba elastomérica como procedimiento ambulatorio de control del dolor en la reparación del ligamento cruzado anterior.

OBJECTIVE: To follow up pain in the immediate postoperative period, using an elastomeric pump in anterior cruciate ligament surgery. MATERIAL AND METHODS: 309 patients who had undergone anterior cruciate ligament repair with bone-tendon-bone allograft. Pain control was assessed with a visual analogue scale (VAS) during the immediate postoperative period, in the postoperative care unit, in the recovery room, and after the first 24-48-72hours following home discharge. The need for rescue medication, adverse effects observed and emergency visits were also registered. RESULTS: 309 patients were assessed (264 males, 45 females), mean age 33 (range: 18 - 55). Postoperative pain was mild in 44.7% of patients, and 38.5% were pain-free. At discharge, 41.1% of patients reported mild pain and 57% were pain-free. At home, mild to moderate levels of pain were maintained and over 97% of patients presented VAS values ≤ 3. Fewer than 3% had adverse effects, 8.7% had to use analgesic medication at some point. Pruritus occurred in less than 1% of patients receiving intravenous analgesia at home, and fewer than 2% had device-related complications. DISCUSSION: There is no consensus regarding the postoperative management of anterior cruciate ligament lesions, although most surgeons use multimode anaesthesia and different combinations of analgesics to reduce postoperative pain. CONCLUSIONS: The use of an intravenous elastomeric pump as postoperative analgesia for anterior cruciate ligamentoplasty has yielded good results.

Transcultural adaptation, validation and assessment of the psychometric properties of the spanish version of the Western Ontario Shoulder Instability Index questionnaire. / Adaptación transcultural, validación y valoración de las propiedades psicométricas, de la versión española del cuestionario Western Ontario Shoulder Instability Index.

OBJECTIVE: The aim of the present study is to present a transcultural adaptation and validation of the Western Ontario Shoulder Instability Index questionnaire into Spanish (Spain), and to assess its psychometric properties. MATERIAL AND METHODS: The transcultural adaptation was conducted according to sequential forward and backward translation approach. A pilot study was subsequently performed to ensure acceptable psychometric properties. The Western Ontario Shoulder Instability Index questionnaire was administered to 79 patients twice within a period of 2 months, and patients were stratified into 3 groups (cohorts). RESULTS: CONCLUSIONS: The Spanish version of the Western Ontario Shoulder Instability Index questionnaire is a valid, reliable tool, and highly sensitive to change to assess patients with shoulder instability.

Consenso SECOT-GEDOS sobre el control del dolor prequirúrgico en artrosis de rodilla y cadera / SECOT-GEDOS consensus on pre-surgical pain management in knee and hip arthrosis

Objetivo: Desarrollar recomendaciones basadas en la mejor evidencia y experiencia sobre el manejo del dolor en pacientes con artrosis de rodilla o cadera e indicación de artroplastia. Métodos: Las recomendaciones se emitieron siguiendo la metodología de grupos nominales. Se seleccionó un grupo director de expertos (5 traumatólogos y un anestesiólogo) que definieron el alcance, usuarios, apartados del documento, posibles recomendaciones, revisiones sistemáticas y se asignaron tareas. Se realizaron 3 revisiones sistemáticas sobre: la eficacia y seguridad de la analgesia prequirúrgica en relación al dolor posquirúrgico; la eficacia y seguridad de la analgesia preventiva, y sobre los factores prequirúrgicos que influyen en el dolor posquirúrgico. Los expertos redactaron los apartados y generaron las recomendaciones correspondientes. El nivel de evidencia y grado de recomendación se clasificaron según el modelo del Center for Evidence Based Medicine de Oxford y el grado de acuerdo por técnica Delphi (2 rondas). El Delphi se amplió a 39 traumatólogos y anestesiólogos. El documento completo circuló entre el grupo director para su última revisión. Resultados: Se generaron 21 recomendaciones. Incluye el manejo farmacológico específico, la evaluación y monitorización de estos pacientes que están en tratamiento, y el tratamiento preventivo del dolor posquirúrgico. Existió consenso mayor del 70% en 19 de ellas. Conclusiones: En el paciente pendiente de artroplastia de cadera o rodilla se debe hacer una correcta evaluación, seguimiento y manejo farmacológico y no farmacológico de los factores que predicen un mal resultado de la intervención, en particular del dolor prequirúrgico. Estas actuaciones pueden mejorar el dolor posquirúrgico y el resultado de la artroplastia (AU)

Objective: To develop recommendations, based on best evidence and experience, on pain management in patients undertaking total knee or hip replacement. Methods: Nominal group methodology was followed. A group of experts was selected (5 orthopedics, 1 anesthesiologist), who defined the scope, users, topics, preliminary recommendations, and 3 systematic reviews: efficacy and safety of pre-surgical analgesia regarding to post-surgical pain, efficacy and safety of pre-emptive analgesia and pre-operative factors of post-operative pain. The level of evidence and grade of recommendation was established using the Oxford Centre for Evidence Based Medicine, and the level of agreement with the Delphi technique (2 rounds). The Delphi was extended to 39 orthopedics and anesthesiologists. The whole document was reviewed by all the experts. Results: A total of 21 recommendations were produced. They include specific pharmacological treatment, as well as the evaluation and monitoring of patients on this treatment, and post-operative pre-emptive treatment. Agreement above 70% was reached in 19 recommendations. Conclusions: In patients undergoing total knee or hip replacement, a proper evaluation, follow-up, pharmacological and non-pharmacological treatment of predictors of poor surgical outcomes should be performed, especially those related to pre-operative pain. This can improve post-operative pain and surgery outcomes (AU)

SECOT-GEDOS consensus on pre-surgical pain management in knee and hip arthrosis.

OBJECTIVE: To develop recommendations, based on best evidence and experience, on pain management in patients undertaking total knee or hip replacement. METHODS: Nominal group methodology was followed. A group of experts was selected (5 orthopedics, 1 anesthesiologist), who defined the scope, users, topics, preliminary recommendations, and 3 systematic reviews: efficacy and safety of pre-surgical analgesia regarding to post-surgical pain, efficacy and safety of pre-emptive analgesia and pre-operative factors of post-operative pain. The level of evidence and grade of recommendation was established using the Oxford Centre for Evidence Based Medicine, and the level of agreement with the Delphi technique (2 rounds). The Delphi was extended to 39 orthopedics and anesthesiologists. The whole document was reviewed by all the experts. RESULTS: A total of 21 recommendations were produced. They include specific pharmacological treatment, as well as the evaluation and monitoring of patients on this treatment, and post-operative pre-emptive treatment. Agreement above 70% was reached in 19 recommendations. CONCLUSIONS: In patients undergoing total knee or hip replacement, a proper evaluation, follow-up, pharmacological and non-pharmacological treatment of predictors of poor surgical outcomes should be performed, especially those related to pre-operative pain. This can improve post-operative pain and surgery outcomes.

Secondary patellar resurfacing in the treatment of patellofemoral pain after total knee arthroplasty.

PURPOSE: This paper reports a prospective review of patients who, between 2004 and 2007, underwent secondary patellar resurfacing (SPR) due to anterior knee pain after a primary total knee arthroplasty (TKA). The aim was to evaluate the clinical outcomes obtained with the SPR and to compare them with radiological findings. METHODS: A total of twenty-seven consecutive patients met the inclusion criteria. There were twenty-three (85%) women and four (15%) men with a median age of 70 years. The patients were evaluated before and after the surgery with the same functional scores and radiological parameters. Bone scintigraphy was also used in the assessment, and a CT-scan was performed in order to evaluate the femoral component rotation. The median time between TKA and SPR was 18 months. RESULTS: With a median follow-up of 23 months, seventeen patients (63%) reported a clear subjective improvement after SPR, and patellofemoral scores (primary outcome measure), KSS and WOMAC (secondary outcome measures) showed a statistically significant improvement following the procedure. There were no significant changes after SPR in the Insall-Salvati ratio, the lateral patellar displacement or the lateral patellar tilt. The mean time between TKA and SPR had no statistically significant effect on outcome. The bone scintigraphy revealed increased patellar uptake in seven cases, but this was not related to subsequent improvement after SPR. Rotational computed tomography showed a median internal rotation of the femoral component of 1º. The complications observed were a patellar component loosening and an acute post-infection. CONCLUSION: No clinical or radiological parameter was found to be related to the final outcome after SPR. There was a discrepancy between functional scale scores and the patient's subjective satisfaction.

Intramedullary versus extramedullary tibial cutting guide in severely obese patients undergoing total knee replacement: a randomized study of 70 patients with body mass index >35 kg/m2.

BACKGROUND: Patients with obesity have an increased risk of osteoarthritis of the knee, which can lead to the need for total knee replacement (TKR). TKR may be more complex in obese patients and the correct orientation of the implant is more difficult. We selected patients with body mass index (BMI) >35 kg/m(2) undergoing TKR and studied the utility of an intramedullary tibial cutting guide in facilitating the correct orientation of the tibial implant. METHODS: Seventy patients with BMI >35 kg/m(2) were selected for a prospective, randomized study. Patients were divided into two groups: In group 1 (n=31), the tibial component was implanted using the aid of a intramedullary tibial guide. In group 2 (n=39), the tibial component was implanted using the aid of an extramedullary tibial cutting guide. RESULTS: The two groups were comparable with respect to age, BMI, and degree of preoperative deformity. Mean age was 69.35 in group 1 and 70.06 in group 2. Group 1 had a mean BMI of 39.84 kg/m(2) and group 2 of 40.05 kg/m(2). Postoperative orientation of the femur and tibia and the mechanical axis were within the normal range in both groups. A statistically significant difference between the two groups was observed in tourniquet time, which was longer in group 2 than in group 1 (p=0.038). CONCLUSION: Two types of guide were compared in correctly orienting the tibial component of the TKR in patients with a BMI >35 kg/m(2). The lesser tourniquet time in the group in which the intramedullary guide was used suggest its usefulness because the positioning and orientation of the tibial cut was carried out more rapidly and anatomical references were not needed for correct orientation, as it is guided by the anatomical axis of the tibia. The use of the intramedullary guide reduces surgical time in these patients.

Knee osteotomy: navigation guided and arthroscopy assisted.

The aim of this work is to describe the procedure used, which combines navigation, arthroscopy and fluoroscopic control, and to evaluate its usefulness in complex osteotomies around the knee. The consolidation of the osteotomy was obtained without complications by obtaining a correct axis of the limb in three spatial planes. This is a precise and reproducible technique. It does not need computer support, associated with specific navigation. Simultaneous arthroscopy also allows the correction of certain intra-articular defects in the same operation, and the precise evaluation of the cartilage's state.

Recursos de osteosíntesis en fémur porótico / Osteosynthesis resources for osteoporotic femur

Objetivos. Exponer dos técnicas quirúrgicas de refuerzo de una osteosíntesis convencional en situaciones especiales de debilidad ósea del fémur, como son las fracturas periprotésicas, las fracturas patológicas y los fracasos de osteosíntesis previas en pacientes de edad avanzada. La debilidad del hueso puede llegar a dificultar la realización de osteosíntesis estables en fracturas de fémur porque impide el correcto anclaje del material, ya sean agujas, cerclajes o especialmente tornillos. Material y método. Se evaluaron 13 pacientes (media de edad de 78,3 años), 9 de los cuales sufrieron fracturas periprotésicas de fémur, dos fracasos de osteosíntesis previas, un caso de pseudoartrosis tras una fractura periprotésica y una fractura diafisaria en un fémur muy osteoporótico, en los cuales se han utilizado dos técnicas de refuerzo del hueso: el cementado endomedular y el implante de contraplacas atornilladas de aloinjerto óseo congelado. Resultados. Se realizó un seguimiento de estos pacientes en un período que oscila entre 12 y 72 meses (media de 26,2 meses). En un caso se produjo una pseudoartrosis de la fractura por ocupación accidental del foco de fractura por el cemento acrílico. En los 12 casos restantes se consiguió la consolidación. Conclusiones. El cementado endomedular y la utilización de contraplacas atornilladas de aloinjerto óseo son dos recursos técnicos útiles en situaciones especiales en las que es necesario realizar una osteosíntesis estable sobre un hueso muy débil (AU)

Use of bone allograft in tibial plateau fractures.

To determine the behaviour of bone allografts in the treatment of tibial plateau fractures, 20 recipients of frozen bone allograft for a depressed tibial plateau fracture were studied. Incorporation of grafts took place in all cases, and no complication secondary to the allograft use has been detected. To avoid donor site morbidity associated with harvesting iliac crest, the use of frozen bone allograft is a good alternative in the treatment of depressed tibial plateau fractures.

[Image of pseudocapture caused by micro-dislodgment of the electrode in a VDD pacemaker]. / Imagen de seudocaptura por microdesplazamiento del electrodo en un marcapasos VDD.

The new AV sequential pacemakers have improved the suitability for the election of the best pacing mode for each patient. The complexity of the systems may mask some dysfunctions. In the presented case, a failure to capture due to micro-dislodgment, may have been missed in a simple pacemaker control, because of the combination of several factors: the presence of normal AV conduction at that moment, the concordance between the pacemaker stimulus and the conducted QRS complex and the similar morphology of the conducted and paced QRS complex.