Gentamicincoated tibial nail is an effective prevention method for fracture-related infections in open tibial fractures.

Fracture-related infection (FRI) is a common complication following open tibia fracture (OTF), especially in patients with high-energy trauma or comorbidities. The use of gentamicin-coated nail (GCN) has been proposed as a local adjuvant to prevent FRI in high-risk patients. HYPOTHESIS: The incidence of FRI is expected to be lower in OTF treated with a GCN, alongside with no detrimental effects on fracture healing time. OBJECTIVES: This study aimed to evaluate the effectiveness of GCNs as a definitive fixation method and prophylaxis for FRI in OTFs. Secondary outcomes included non-union rates and time to healing. METHODS: The study design was a mixed cohort, including a prospective group of patients treated with GCN (Expert Tibial Nail PROtect™, Depuy Synthes, Johnson&Johnson Company Inc, New Jersey, USA) and a retrospectively evaluated group treated with non-gentamicin-coated nail (NGCN). Patients with at least 12 months of follow-up were included. The treatment protocol consisted of timely administration of antibiotics, surgical debridement, and early soft-tissue coverage. Exclusion criteria included protocol infringement, traumatic amputation, and loss of follow-up. Statistical analysis was performed using Stata v14.0, with a significance level of p < 0.05. RESULTS: The study included 243 patients, 104 in GCN group and 139 NGCN group. External Fixator use was higher in the NGCN group, but this did not significantly affect the FRI rate. GCN use was associated with a significantly lower incidence of FRI (2.88% GCN group vs. 15.83% NGCN group, OR 0.16, p < 0.01). Furthermore, GCN use was found to be a protective factor against tibial non-union (OR 0.41, p = 0.03). There were no adverse effects attributed to locally administered gentamycin. The NGCN cohort had a higher incidence of polytrauma, although the difference was not statistically significant. A longer time to heal as well as more FRI and Non-union according to the progression in Gustilo-Anderson classification was observed in the GCN group. CONCLUSION: Our findings suggest that GCN is an effective prophylactic method to reduce the risk of FRI in open tibial fractures at 12-month follow-up, as well as, probably derived from this protective effect, leading to lower fracture consolidation times when compared with cases treated without GCN.

Resection and reconstruction of the proximal femur with revision stems: a cost-effective alternative.

Background: Modular oncologic megaprosthesis is the standard method for reconstruction after resection of tumors of the proximal femur. These implants have been utilized for either primary tumors or metastatic disease of bone and multiple myeloma. Fixation is based on either cemented or cementless stems, and a collar supporting the body of the prosthesis. For those patients with advanced disease and/or limited life span, a judicious approach should balance the functional expectations, prognosis, and the issue of cost of the surgical procedure and the implant that is selected. Methods: Based on the principles of distal fixation of tapered stems, the authors have utilized implants originally designed for hip revision surgery to reconstruct the proximal femur in 19 patients, after resection because of metastases, multiple myeloma and some aggressive primary tumors. The essentials of the technique consist of distal fixation in the remaining isthmus of the femur by means of tapered stems, impacted in such a way to achieve solid primary fixation, balanced with accurate leg length restoration. Proximally, the implant remains devoid of bone coverage. Results: In this retrospective study, proper distal fixation, leaving the proximal part of the implant uncovered with bone, has resulted in good functional results in mid-term follow-up of patients. Primary fixation has led to secondary bone ongrowth and remodeling, providing secondary fixation. Complications such as instability, loosening and infection are comparable with those associated to the traditional management with mega prosthesis. Conclusions: The utilization of tapered stems for distal fixation after proximal femoral resections has shown reliable results after mid-term follow-up. The method might be considered as a cost-effective alternative for selected patients.

Modelo predictivo de la no unión de tibia / Tibia non union predictive model

OBJETIVOS: Estimar un modelo predictivo para la no-unión en pacientes que presentan fractura de tibia. MATERIALES Y MÉTODOS: Estudio de cohorte retrospectivo, en pacientes con fractura de tibia operadas entre 2012 y 2018, con un mínimo de 12 meses de seguimiento, excluyendo amputaciones traumáticas. Realizamos un modelo de regresión logística con 13 variables descritas en la literatura. Se descartaron las variables estadísticamente no significativas y las que no causaban efecto de confusión. Se evaluó la bondad de ajuste mediante el test de Hosmer-Lemeshow y la discriminación del modelo con la curva ROC. RESULTADOS: Se incluyeron 411 fracturas de tibia, las variables estadísticamente significativas fueron: exposición ósea OR » 2,57(IC:1,15­5,75, p » 0,022), diabetes OR » 3,29 (IC:1,37­7,91, p » 0,008) y uso de tutor externo OR » 1,77(IC:0,81­3,85), el que tuvo efecto de confusión. La bondad de ajuste demostró que los datos se ajustan adecuadamente al modelo (p » 0,35). La curva ROC demuestra un 70,91% de poder discriminatorio. Al evaluar aisladamente las fracturas expuestas, no hubo asociación estadísticamente significativa con ninguna variable. DISCUSIÓN: Al evaluar el modelo, obtuvimos una asociación estadísticamente significativa entre: no unión, exposición ósea, diabetes y uso de tutor externo, información concordante con la literatura. Al estudiar el subgrupo de fracturas expuestas, las demás variables son estadísticamente no significativas. Eso refleja que la exposición ósea es la variable que confiere mayor riesgo. El seguimiento adecuado de esos pacientes es fundamental dado este alto riesgo de evolucionar con no-unión. CONCLUSIÓN: En nuestra serie, la exposición ósea es el factor de riesgo más importante para presentar no unión de tibia.

OBJECTIVES: Estimate a predictive model for non-union in patients presenting with a tibial fracture. MATERIALS AND METHODS: Retrospective cohort study in patients with tibia fractures operated between 2012 and 2018, with a minimum follow-up of 12 months, excluding traumatic amputations. We performed a multivariate logistic regression model with 13 variables described in the literature. The variables that were statistically non-significant and those variables that do not cause confusion, were discarded. Goodness of fit was evaluated using the Hosmer-Lemeshow test and the discrimination of the model with the ROC curve. RESULTS: 411 tibial fractures were included, the statistically significant variables were: bone exposure OR » 2.57(CI:1.15­5.75, p » 0.022), diabetes OR » 3.29(CI:1.37­7.91, p » 0.008) and use of external fixation OR » 1.77(CI:0.81­3.85), being included in the model because of its confounding effect. Goodness of fit demonstrates that the data fit the model adequately(p » 0.35). The ROC curve demonstrates 70.91% discriminatory power. When evaluating the exposed fractures in isolation, there was no statistically significant association with any variable. DISCUSSION: When evaluating the model, we obtained a statistically significant association between non-union, bone exposure, diabetes and use of external fixation, being consistent with the literature. When studying the subset of exposed fractures, the other variables are statistically non-significant. This reflects that bone exposure is the variable that confers the greatest risk. Proper follow-up of these patients is essential given this high risk of evolving with non-union. CONCLUSION: In our series, bone exposure is the most important risk factor for presenting tibial non-union.

Cirugía asistida por computador en tumores óseos: principios generales / Computer assisted surgery in bone tumours: general principles

La mayoría de los tumores óseos primarios pueden ser tratados mediante una resección amplia —muchas veces asociada a terapias adyuvantes— sin comprometer la sobrevida del paciente. La posibilidad de una resección conservadora depende de la localización y tamaño del tumor y de las partes blandas circundantes. Una cuidadosa evaluación de estudios imagenológicos permite al cirujano elaborar un plan quirúrgico que permita una resección con márgenes adecuados, al mismo tiempo que conservar la mayor cantidad de tejido sano, de modo de obtener una extremidad funcional. A veces, la ejecución quirúrgica de lo planeado se hace muy difícil, y la precisión de esta puede resultar afectada. La cirugía guiada por computador se ha constituido en una herramienta útil en estas situaciones. Está basada en la creación de un plan virtual en 3 dimensiones mediante el procesamiento de imágenes de tomografía computada (TC) y resonancia nuclear magnética (RNM). Este plan puede ser reproducido en el escenario quirúrgico mediante la correspondencia entre este escenario virtual y la anatomía real del paciente. Esta tecnología puede permitir una mayor precisión en la ejecución de osteotomías en zonas difíciles como la pelvis, minimizando la resección innecesaria de tejido sano, pero manteniendo un margen oncológico adecuado. Describiremos los principios y el razonamiento que fundamentan el uso de la cirugía guiada por computador en la cirugía de tumores óseos, la cual se ha constituido en una herramienta útil para el manejo de situaciones clínicas específicas...

The majority of primary bone tumours can be effectively treated with wide resection —frequently associated with adjuvant therapy— without compromising the outcome of the patient. The feasibility of limb-sparing surgery in a particular scenario is dependent on the location and size of the tumour, as well as the involvement of the host bone and surrounding soft tissues. Careful evaluation of imaging studies allows the surgeon to plan the resection with adequate margins, while preserving as much normal tissues as possible, in order to achieve a functional limb. At times, the surgical execution of what was planned as resection becomes very difficult, and precision may be less than optimal. Computer-guided surgery has become a useful tool in these situations. It is based on the creation of a three-dimensional virtual plan by means of image processing from computed tomography (CT) and magnetic resonance (MRI) of the clinical situation. This plan is reproduced in the surgical field by means of the interaction between this virtual scenario and the actual anatomy of the patient. This technology could allow better precision in the execution of osteotomies in difficult areas, such as the pelvis, minimising unnecessary resection of normal tissue, while maintaining wide margins. A description is presented of the principles and rationale of computer-guided surgery for bone tumours, which has become a useful tool for the management of selected clinical situations...